Security Officer Medical

LABOR AND EMPLOYMENT INTAKE QUESTIONNAIRE

EMPLOYEE INFORMATION

PERSONAL INFORMATION

Last Name: white

First Name: ronald

MI:k

Street or Mailing Address:

Apt or Unit#:

City: leesburg

County: lake

State: fl

Zip:

34748

Cell:270-***-****

Home: none

Work: none

Email Address: **********@*****.***

Date of Birth: 10/24/1952

Race: white

Nationality:

white

EMPLOYER INFORMATION

Name of Company: alliance

Address/Location:alliance contract though leesburg hospital

City, State, Zip: leesburg fl 34748

Telephone Number:

Fax Number:

Rate of Pay: 9 an hour

Position:security officer

Schedule/How Many Hours a Week Worked on Average? 40 plus

Approximate number of employees:15 around

Name of Owner/Manager:

Other Locations: Yes yes No

If yes, list location(s): village hospital

Are you invested in a corporate pension plan through your employer? Yes No no

Please check the category or categories under which you feel you were discriminated:

Age Discrimination Race Discrimination

National origin discrimination Discrimination based on color

Sex (Gender) discrimination Sexual Harassment

Religious discrimination yes Disability Discrimination

Retaliation for complaining of unlawful conduct or discrimination

Violation of FMLA (Family Medical Leave Act)

Retaliation for filing a valid worker’s compensation claim

Sexual Orientation discrimination

Whistleblower Pregnancy discrimination

Overtime Pay FILL OUT BACK PAGE IF OVERTIME OR WAGES APPLIES Unpaid Wages

Other (please explain):

How long have worked for the employer:

Never got on

DATES OF EMPLOYMENT

Date of Hire:

Date of Fire:

Are you currently employed by the company? no

If not, did you quit or did they terminate you:

Date of last discrimination:

WHAT HAPPENED THAT MAKES YOU FEEL YOU WERE WRONGFULLY TREATED? PLEASE BE SPECIFIC AND DETAILED:

(Provide a timeline of events, including, dates, times, names, etc.) If you need more space, please use a separate sheet and be sure to attach. You can type directly into this form.

I went for interview around October 10th 2018.got a call from PAT hes the one that hires.i went for interview with JEFF he ask me for me for my blue card I got when I went though 40 hour class in Ocala fl. Drivers licence social security card. An told me welcome aboard. Like I got the job. Told me to call RENEE an she tell me when to start .i call her no reply waited few days no reply from her .i call PAT no reply.i call RYAN KING over all the sercuity. No reply. Yes I do believe my handicap stop me from getting the job. I have ork all my life nothing ever stop me.how would you fill. Not a good filling.i got another job not security. But a great job an great people. They have no right to discriminate. I even had some security guys tell me welcome aboard they said if I went though interview I should have got the job. They hire about 12 behind me with no trouble.

.

Have you filed a complaint? If so with whom?

a. Supervisor

b. HR

c. EEOC or FCHR: no I wated legal advise an legal lawy

If a complaint was filed, did the discrimination occur again after filing a complaint? Please explain (attach copy if written):

If a complaint was filed with the EEOC did you receive the Right to Sue Letter? If so what is the date on the letter? (Please provide a copy with this form)

Did the EEOC find Cause?

If so, what is the Cause? (Please attach letter)

**ONLY ANSWER THIS PORTION IF YOU ARE ALLEGING A VIOLATION OF FAMILY AND MEDICAL LEAVE ACT (FMLA) **

IF YOU ALLEGE OR HAVE A VIOLATION OF THE FAMILY AND MEDICAL LEAVE ACT (FMLA), PLEASE ANSWER THE FOLLOWING:

Have you been there one (1) year?

What is/was your reason for taking FMLA?

What date did your leave start?

What date did you return or get fired?

Were you full time?

Were you an employee in good standing? (Any warnings, Write-ups, Suspensions, etc.) If so, please explain in detail:

ONLY FILL OUT THE BELOW IF YOU ARE SEEKING ASSISTANCE FOR OVERTIME OR UNPAID WAGE CLAIMS

During the last three (3) years, what was your work schedule (hours you actually worked)?

Day Start Time Stop Time Total Hours Comments

Sundays

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

Saturdays

Total Hours Per Week (Approximate):

1. List every job title you had while you worked unpaid (or underpaid) overtime hours.

2. Please describe the nature and duties of each of the job titles you listed above.

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