Were you fired?
YesNo

When were you fired?

What reason were you given for termination?

If you think the reason for termination is wrong, what do you feel is the real reason for termination?

When did you resign?

Why did you resign?

Have you been harassed or discriminated against because of your membership in a protected class (race, religion, creed, color, national origin, ancestry, physical disability, mental disability, medical condition, marital status, gender, gender identity, age, sexual orientation or military and veteran status)?
YesNo

Please briefly describe the harassment and/or discrimination.

Who harassed and/or discriminated against you (identify name & job title)?

When was the last time that you were harassed and/or discriminated against?

Please briefly describe the retaliation.

Who retaliated against you?