Lost Earnings Evaluation: Discrimination

Plaintiff's Information

First Name: Last Name:

Street Address:

City: State: Zip Code:

Phone: (i.e. 702-263-8044)

Email:

Demographic Information

Date of Birth: (i.e. YYYY/MM/DD)

Race: Please Choose African American Asian Caucasian Hispanic Origin Native American Descent Others Citizenship: Please Choose Natural Born U.S. Naturalized Others

If Others, please specify:

Gender: Choose Female Male Marital Status: Please Choose Single Married Widowed

Highest grade of school completed/degrees received: Please Choose Did not graduate highschool G.E.D. Highschool 2-yr College 4-yr University Master's Doctorate

Children?

Date of termination: (i.e. YYYY/MM/DD)

Last Day Working: (i.e. YYYY/MM/DD)

Additional Information

Please limit to less than 200 words... Also, specify dates and period unemployed and if applicable date of reemployment. Applicable additional information may include but not limited to the following: 1. Earnings history (pre & post incident) 2. Fringe benefits (pre & post incident) 3. Incidental cost in job search 4. Job relocation or retraining cost 5. Relevant deposition documents

Prognosis for Reemployment

Has the victim retuned to work? Choose YES NO

Are there any pre-existing medical conditions or disabilities?

Does the medical conditions or disabilities restrict any type or amount of work the victim can perform?

Has the victim started any vocational training and or rehabilitation? Choose YES NO

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