SEXUAL HARASSMENT INQUIRY FORM*

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

To request more information, please complete the form below.
*Bold fields are required*

*Email:*

*Your Name:*

*Date*

*Name of employer:*

*Approximate number of employees:*

*Date of hire:*

*Name and title of the sexual harasser:*

*Was the harasser your supervisor? Explain.*

*Please describe the nature of the harassment:*

*How have you been damaged by the harassment? Please describe the injuries:*

*Did you complain about the sexual harassment? If so, to whom, when, and explain what happened.*

*Were you retaliated against for complaining?*

*Were you terminated?*

Date of termination (if applicable):

*Last job title (or position):*

*Reason given for termination:*

*Reason (or reasons) why you feel you were terminated:*

*Union member?*

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

*Your phone number:*

Work phone number:

Other phone number:

*Your mailing 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.

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