Law Office of
Clayton C. Ikei

Directions:

The form is a list of questions which our firm uses to screen potential clients. The screening process helps us to determine if you have the type of case which we handle. It also helps us determine if we have a potential conflict of interest in handling your case. If we do, we cannot ethically represent you. Please understand that simply submitting a questionnaire does not, as a matter of course, mean that the firm does represent you or will be able to represent you. The purpose of this questionnaire is only to help us to determine if we are able to do so.

Our firm processes intakes in several ways: via telephone, via mail and via e-mail. If you wish to submit your questionnaire by telephone, please have this form with you when you call it will help you to answer questions as we go through them. Alternatively, you can print out the form and mail it to us at the above address or fax it to us at the above number. If you wish to contact our office via e-mail, please use the form as a guideline for the information that you should submit to us.

Our firm keeps information submitted to us by potential clients confidential. You should use your own judgment about how to submit that information to us. If you have confidential or sensitive information you may prefer to contact us by telephone or by facsimile. If you chose to submit information via e-mail, we are not responsible if the information is intercepted while in transit over the Internet.

TIPS
Some things to keep in mind as you fill in the form:
Please be as brief as possible, but also be specific. You do not need to try to win your case, but do give us enough information to understand it thoroughly.

Please include dates as much as possible ... if you can only remember the month and the year, that is better than leaving items without any date.

If you do not understand something, please contact us and we will attempt to explain it to you.

We ask your race and age and gender because that information can affect the type of claim you can make. When you refer to other people, please include their race, age and gender if you know them if you claim you are being harassed because of your race, it helps us to know if the person doing it is of a different race than you.

                           INTAKE QUESTIONNAIRE

Name: __________________________________________________________
Address:_________________________________________________________
Home phone:__________Pager/Cell phone:__Work phone:______________


Okay to call you at work? ( )YES ( ) NO

E-mail address: _________________________________________________
Referred by: ____________________________________________________
Employer:________________________________________________________
Type of business: _______________________________________________
Position/ Duties: _______________________________________________
Length of employment: __________ Last salary: ____________

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NATURE OF CASE
( ) Race | ( ) Religion
( ) Gender | ( ) Age
( ) Sexual harassment | ( ) Other
Please explain Other: _____________________________________

Race:________________ Gender: ( ) Male ( ) Female Age: ______
Ethnic Background: _____________________________________________
Statement of Facts: __________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Date occurred: _____________________________________________

Have you been terminated? ( ) YES ( )NO
Reason(s) you were given: ____________________________________
Are you a union employee? ( ) YES ( )NO
Name of union:_____________________________________________
Do you have an employment contract? ( ) YES ( )NO
Does your company have a policy manual? ( ) YES ( )NO
Have you filed a grievance? ( ) YES ( )NO
If yes, date it was filed:_________________________________
Outcome: __________________________________________________

Have you contacted or made complaints with any of the following:
( )Formal complaint with your Agency (federal employees)
( )Federal Equal Employment Opportunity Commission (EEOC)
( )Hawaii Civil Rights Commission (HCRC)
( )Other Agency
Please specify:__________________________________________