Genetic Information Privacy Act Violations in the Workplace

Your Name: *

First

Last

Email: *

Phone: *

City: *

State: *

Zip Code: *

Former or current Illinois resident? *

Yes
No

If former, what month and year did you move out of Illinois? *

Name of employer: *

Month/Year you were hired: *

Are you a current or former employee? *

Current
Former

If former, month/year you left the company: *

Did you perform your work in Illinois? *

Yes
No

City of employer/location where you worked: *

What is/was your title? *

What were your job duties? *

Did you have a pre-employment physical exam by a physician, nurse or medical professional? *

Yes
No

If yes, by the company’s doctor (employed by the company) or your own doctor? *

Yes
No

Did they ask you about family medical history? *

Yes
No

Approximate month and year of the physical exam? *

Did HR, a hiring manager or your boss ever ask you about your family medical history? *

Yes
No

If yes, did they ask verbally or in writing? *

Yes
No

If verbally, what did your employer say? Do you remember what they asked you about family medical history?

If in writing, (i.e. questionnaire), did YOU fill out the answer to the family medical history question or did the HR manager/hiring person?

Myself
HR manager/hiring person

Did you answer their question about family medical history?

Yes
No

Approximate month/year you were asked this question by HR or a hiring manager:

When was the last (most recent) time you asked about family medical history by your employer (month & year)? *

Were you ever injured on the job while working at this company? *

Yes
No

If yes, were you asked about family medical history at that time? *

Yes
No

Approximate month/year you were asked this question after your injury: *

Did you quit or were you fired? *

Quit
Fired

If you were fired -WHY? *

Was there tension? If so, why?

Please check the box below if you agree to the following: *

By clicking here and signing in the box below, I agree, and it is my intent, to electronically sign and agree to the below engagement letter terms. By submitting this e-document in this way, I understand that it is the legal equivalent of having placed my handwritten signature on the engagement letter terms, and am affirming my intent to be bound thereby.

Thank you for choosing our firm. Please find below a Lawyer-Client Agreement (“Agreement”) setting out the terms under which Siri & Glimstad LLP (the “Attorneys”) may represent you (“You”):

1. Scope of Representation. Upon confirmation in writing that the Attorneys have reviewed your information and can agree to represent you in this matter, you hereby engage Attorneys to represent you against the individual(s) or entity(ies) you have identified in the foregoing form as having requested your family medical history (“Defendants”) in violation of the Illinois Genetic Information Privacy Act (the “Claim”). You understand that the Claim may be brought and/or resolved either on an individual basis or on a class basis. This potential representation will not be for any other matter, unless we agreed to that representation in writing, nor will it require Attorneys to file any appeal.

2. Attorneys’ Fees. Your representation will be handled strictly on a contingent fee basis. We will seek payment of our fees and costs from the Defendants or out of any amount recovered. If there is no recovery, you will not owe Attorneys anything. Attorneys will be entitled to receive forty percent (40%) (or a lesser percentage if required by law) plus costs from any and all funds obtained from Defendants (which may include any attorney’s fees awarded by the Court).

3. Duties of Attorneys. Attorneys shall take all steps in connection with the Claim which, in the opinion of Attorneys, are required to protect or advance Your interests. Attorneys shall take reasonable steps to keep you informed of the progress of the Claim.

4. Cooperation. You agree to cooperate with Attorneys regarding the Claim and respond to reasonable requests from Attorneys related to the Claim. Your failure to cooperate may require Attorneys to withdraw as your attorneys.

5. Miscellaneous:

(a) Additional Attorneys. Attorneys may associate or affiliate with additional attorneys to assist in the Claim, which additional attorneys shall be included in the reference to “Attorneys” in this Agreement.

(b) Termination. Attorneys may withdraw from this Agreement and/or from representing you regarding the Claim to the extent permitted by law. If Attorneys can resolve the Claim as part of a class, you understand and agree that Attorneys are permitted to withdraw as your individual counsel. If you choose to discharge the Attorneys, the Attorneys will be entitled to fees as provided in Section 2 above on a quantum meruit basis and you will be responsible for all costs previously expended.

(c) Attorneys' Lien. Attorneys shall have a lien for their attorneys’ fees and costs on any amount you recover as a result of the Claim. An effect of such a lien is that Attorney may be able to compel payment of fees and costs from any such funds recovered on behalf of you even if Attorney has been discharged or withdrawn before the end of the case.

(d) No Guarantee. Attorneys cannot and do not make any guarantee of success regarding the Claim. No statement made prior to the execution of this document shall be deemed or construed as a promise or guarantee of success.

(e) Arbitration & Governing Law. Any dispute arising under or relating to the terms of this Agreement or Attorneys’ representation hereunder shall be submitted to binding arbitration before the American Arbitration Association or some other arbitral body as may be required by law.

(f) Storage and Use of Electronic Data: You are aware of and consent to the retention, maintenance, and storage of client information and records relating to this matter in the following forms and locations: Paper (in office and/or storage files); electronic (e.g., computer, handheld devices for email, fax, and via the Internet using cloud storage); or other like mediums. We will endeavor to take reasonable steps necessary to preserve and maintain the confidentiality of all your information and records, however, you recognize and agree that such information and records may be subject to unauthorized access outside our control, and agree to hold us harmless from any breaches of confidentiality of your information and records that we do not directly cause.

(g) Complete Agreement. This is the complete agreement between you and the Attorneys regarding the matters addressed herein.

(h) No Tax Advice. Attorneys have not been retained to provide you with any tax advice. To be sure you understand and are certain of all the potential tax consequences, you should consult with tax advisors regarding these matters.
(i) Severability. If any provision of this Agreement is held in whole or in part to be unenforceable for any reason, the remainder of that provision and of the entire Agreement will be severable and remain in effect
(j) Consent. By signing this agreement, you affirm you have read and consent to the terms of this Agreement. Attorneys shall not become your attorneys nor have an obligation to begin the representation until Attorneys have confirmed to you in writing that they agree to this representation.

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Submitting this form does not create an attorney-client relationship between you and the attorneys of Siri & Glimstad LLP. We may collect, use, and process your data according to the terms of our Privacy Policy.

Genetic Information Privacy Act Violations in the Workplace

Did your past, current or prospective employer in Illinois ask you about your FAMILY medical history?

If yes, YOU MAY BE ENTITLED TO COMPENSATION!
NO COST FOR REPRESENTATION!

Genetic Information Privacy Act Violations in the Workplace

Did your past, current or prospective employer in Illinois ask you about your FAMILY medical history?

If yes, YOU MAY BE ENTITLED TO COMPENSATION!NO COST FOR REPRESENTATION!

If yes, YOU MAY BE ENTITLED TO COMPENSATION!
NO COST FOR REPRESENTATION!