What protected characteristics do you believe is the basis for the pay discrimination?: (select all that apply)
genderraceagesexual orientationnational origingender identity

Do you know what others in similar roles are paid?
YesNo

Comparisons Name (name of person in similar role)

Comparisons Job Title

Comparisons Annual Compensation

Comparisons Annual Bonuses

Comparisons Demographic

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?

Have you discussed your pay with management or HR?
YesNo

Company representative with whom you discussed your pay?

When did you discuss your pay with Management or HR?

What was Management / HR response?

Do you have access to pay stubs, offer letters, or performance reviews?
YesNo

Can you provide job descriptions for your role and those of comparisons?
YesNo

Do you have written or verbal statements suggesting bias or unfair treatment?
YesNo

Have you filed any internal complaints?
YesNo