SEXUAL MISCONDUCT BY A PROFESSIONAL INQUIRY FORM*

About Wrongful Discharge/Discrimination Cases

About Serious Personal Injury or Wrongful Death Cases

You may Email by clicking on the submit button below or print this form to mail or fax to us:

Burkhalter, Rayson & Associates, P.C.

P.O. Box 2777

Knoxville, TN 37901-2777

Fax No.: (865) 524-0172

*There is no charge for us to review this inquiry and on most cases, we do not get paid unless we win.

Also, if you feel uncomfortable filling out this form, please give a brief description, and we will be in contact.

To request more information, please complete the form below.
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*Email:*

*Your Name:*

*Date:*

Name of employer: (This name can be withheld at this time, if you prefer.)

Name, title, and location of person you accuse of sexual misconduct: (If you prefer not to identify the professional at this time, it is okay to leave the name blank.)

Does this person work for anyone? If so, name of the employer?

Description of misconduct:

When did this misconduct occur?

Did you have a professional relationship with this person? If so, please complete (a) through (c):

(a) Please describe the professional relationship

(b) When did the relationship begin, and when and how did it end?

(c) When and how did the sexual misconduct begin and end?

Are there any witnesses or other documentary evidence that will corroborate the sexual misconduct? If so, who (or what) will the witnesses testify to?

What were the injuries caused to you by the sexual misconduct?

Did you complain about the sexual misconduct? If so, to whom, when, and describe what happened:

Did you incur a financial injury as a result of the misconduct? If so, please explain:

Were you retaliated against for complaining?Select1:

*When is the best time to contact you, and how would you prefer we contact you?*

*Your home phone number:*

Work phone number:

Other phone number:

*Your address ( street, city, st and zip ):*

*When and how did you hear about us?*

Your information is being sent directly to Burkhalter, Rayson & Associates, P.C., and by law, all communications to us are 100% confidential.