Free DISC-002 Form Interrogatories­Employment Law - California


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DISC-002
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address):

TELEPHONE NO.: E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name):

FAX NO. (Optional):

SUPERIOR COURT OF CALIFORNIA, COUNTY OF

SHORT TITLE:

FORM INTERROGATORIES ­ EMPLOYMENT LAW
Asking Party: Answering Party: Set No.:

CASE NUMBER:

Sec. 1. Instructions to All Parties (a) Interrogatories are written questions prepared by a party to an action that are sent to any other party in the action to be answered under oath. The interrogatories below are form interrogatories approved for use in employment cases. (b) For time limitations, requirements for service on other parties, and other details, see Code of Civil Procedure sections 2030.010­2030.410 and the cases construing those sections. (c) These form interrogatories do not change existing law relating to interrogatories nor do they affect an answering party's right to assert any privilege or make any objection. Sec. 2. Instructions to the Asking Party (a) These form interrogatories are designed for optional use by parties in employment cases. (Separate sets of interrogatories, Form Interrogatories--General (form DISC-001) and Form Interrogatories--Limited Civil Cases (Economic Litigation) (form DISC-004) may also be used where applicable in employment cases.) (b) Insert the names of the EMPLOYEE and EMPLOYER to whom these interrogatories apply in the definitions in sections 4(d) and (e) below. (c) Check the box next to each interrogatory that you want the answering party to answer. Use care in choosing those interrogatories that are applicable to the case. (d) The interrogatories in section 211.0, Loss of Income Interrogatories to Employer, should not be used until the employer has had a reasonable opportunity to conduct an investigation or discovery of the employee's injuries and damages. (e) Additional interrogatories may be attached. Sec. 3. Instructions to the Answering Party (a) You must answer or provide another appropriate response to each interrogatory that has been checked below. (b) As a general rule, within 30 days after you are served with these interrogatories, you must serve your responses on the asking party and serve copies of your responses on all other parties to the action who have appeared. See Code of Civil Procedure sections 2030.260­2030.270 for details.
Form Approved for Optional Use Judicial Council of California DISC-002 [Rev. January 1, 2009]

(c) Each answer must be as complete and straightforward as the information reasonably available to you permits. If an interrogatory cannot be answered completely, answer it to the extent possible. (d) If you do not have enough personal knowledge to fully answer an interrogatory, say so, but make a reasonable and good faith effort to get the information by asking other persons or organizations, unless the information is equally available to the asking party. (e) Whenever an interrogatory may be answered by referring to a document, the document may be attached as an exhibit to the response and referred to in the response. If the document has more than one page, refer to the page and section where the answer to the interrogatory can be found. (f) Whenever an address and telephone number for the same person are requested in more than one interrogatory, you are required to furnish them in answering only the first interrogatory asking for that information.

(g) If you are asserting a privilege or making an objection to an interrogatory, you must specifically assert the privilege or state the objection in your written response. (h) Your answers to these interrogatories must be verified, dated, and signed. You may wish to use the following form at the end of your answers: I declare under penalty of perjury under the laws of the State of California that the foregoing answers are true and correct.

(DATE)

(SIGNATURE)

Sec. 4. Definitions Words in BOLDFACE CAPITALS in these interrogatories are defined as follows: (a) PERSON includes a natural person, firm, association, organization, partnership, business, trust, limited liability company, corporation, or public entity.
Page 1 of 8 Code of Civil Procedure, §§ 2030.010­2030.410, 2033.710 www.courtinfo.ca.gov American LegalNet, Inc. www.FormsWorkflow.com

FORM INTERROGATORIES­EMPLOYMENT LAW

DISC-002
(b) YOU OR ANYONE ACTING ON YOUR BEHALF includes you, your agents, your employees, your insurance companies, their agents, their employees, your attorneys, your accountants, your investigators, and anyone else acting on your behalf. (c) EMPLOYMENT means a relationship in which an EMPLOYEE provides services requested by or on behalf of an EMPLOYER, other than an independent contractor relationship. (d) EMPLOYEE means a PERSON who provides services in an EMPLOYMENT relationship and who is a party to this lawsuit. For purposes of these interrogatories, EMPLOYEE refers to (insert name): Sec. 5. Interrogatories The following interrogatories for employment law cases have been approved by the Judicial Council under Code of Civil Procedure section 2033.710: CONTENTS 200.0 Contract Formation 201.0 Adverse Employment Action 202.0 Discrimination Interrogatories to Employee 203.0 Harassment Interrogatories to Employee 204.0 Disability Discrimination 205.0 Discharge in Violation of Public Policy 206.0 Defamation 207.0 Internal Complaints 208.0 Governmental Complaints 209.0 Other Employment Claims by Employee or Against Employer 210.0 Loss of income Interrogatories to Employee 211.0 Loss of income Interrogatories to Employer 212.0 Physical, Mental, or Emotional Injuries-- Interrogatories to Employee 213.0 Other Damages Interrogatories to Employee 214.0 Insurance 215.0 Investigation 216.0 Denials and Special or Affirmative Defenses 217.0 Response to Request for Admissions 200.0 Contract Formation 200.1 Do you contend that the EMPLOYMENT relationship was at "at will"? If so: (a) state all facts upon which you base this contention; state the name, ADDRESS, and telephone (b) number of each PERSON who has knowledge of those facts; and (c) identify all DOCUMENTS that support your contention.

(If no name is inserted, EMPLOYEE means all such PERSONS.) (e) EMPLOYER means a PERSON who employs an EMPLOYEE to provide services in an EMPLOYMENT relationship and who is a party to this lawsuit. For purposes of these interrogatories, EMPLOYER refers to (insert name):

(If no name is inserted, EMPLOYER means all such PERSONS.) (f) ADVERSE EMPLOYMENT ACTION means any TERMINATION, suspension, demotion, reprimand, loss of pay, failure or refusal to hire, failure or refusal to promote, or other action or failure to act that adversely affects the EMPLOYEE'S rights or interests and which is alleged in the PLEADINGS. (g) TERMINATION means the actual or constructive termination of employment and includes a discharge, firing, layoff, resignation, or completion of the term of the employment agreement. (h) PUBLISH means to communicate orally or in writing to anyone other than the plaintiff. This includes communications by one of the defendant's employees to others. (Kelly v. General Telephone Co. (1982) 136 Cal.App.3d 278, 284.) (i) PLEADINGS means the original or most recent amended version of any complaint, answer, cross-complaint, or answer to cross-complaint. (j) BENEFIT means any benefit from an EMPLOYER, including an "employee welfare benefit plan" or employee pension benefit plan" within the meaning of Title 29 United States Code section 1002(1) or (2) or ERISA. (k) HEALTH CARE PROVIDER includes any PERSON referred to in Code of Civil Procedure section 667.7(e)(3). (l) DOCUMENT means a writing, as defined in Evidence Code section 250, and includes the original or a copy of handwriting, typewriting, printing, photostats, photographs, electronically stored information, and every other means of recording upon any tangible thing and form of communicating or representation, including letters, words, pictures, sounds, or symbols, or combinations of them. (m) ADDRESS means the street address, including the city, state, and zip code.
DISC-002 [Rev. January 1, 2009]

200.2 Do you contend that the EMPLOYMENT relationship was not "at will"? If so: (a) (b) state all facts upon which you base this contention; state the name, ADDRESS, and telephone number of each PERSON who has knowledge of those facts; and identify all DOCUMENTS that support your contention.

(c)

200.3 Do you contend that the EMPLOYMENT relationship was governed by any agreement--written, oral, or implied? If so: (a) state all facts upon which you base this contention; state the name, ADDRESS, and telephone (b) number of each PERSON who has knowledge of those facts; and (c) identify all DOCUMENTS that support your contention.
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FORM INTERROGATORIES­EMPLOYMENT LAW

DISC-002
200.4 Was any part of the parties' EMPLOYMENT relationship governed in whole or in part by any written rules, guidelines, policies, or procedures established by the EMPLOYER? If so, for each DOCUMENT containing the written rules, guidelines, policies, or procedures: (a) (b) (c) state the date and title of the DOCUMENT and a general description of its contents; state the manner in which the DOCUMENT was communicated to employees; and state the manner, if any, in which employees acknowledged either receipt of the DOCUMENT or knowledge of its contents. 201.2 Are there any facts that would support the EMPLOYEE'S TERMINATION that were first discovered after the TERMINATION? If so: (a) state the specific facts; (b) state when and how EMPLOYER first learned of each specific fact; state the name, ADDRESS, and telephone number of (c) each PERSON who has knowledge of the specific facts; and (d) identify all DOCUMENTS that evidence these specific facts. 201.3 Were there any other ADVERSE EMPLOYMENT ACTIONS, including (the asking party should list the ADVERSE EMPLOYMENT ACTIONS):

200.5 Was any part of the parties' EMPLOYMENT relationship covered by one or more collective bargaining agreements or memorandums of understanding between the EMPLOYER (or an association of employers) and any labor union or employee association? If so, for each collective bargaining agreement or memorandum of understanding, state: (a) the names and ADDRESSES of the parties to the collective bargaining agreement or memorandum of understanding; the beginning and ending dates, if applicable, of the collective bargaining agreement or memorandum of understanding; and which parts of the collective bargaining agreement or memorandum of understanding, if any, govern (1) any dispute or claim referred to in the PLEADINGS and (2) the rules or procedures for resolving any dispute or claim referred to in the PLEADINGS.

(b)

If so, for each action, provide the following: (a) all reasons for each ADVERSE EMPLOYMENT ACTION; the name, ADDRESS, and telephone number of (b) each PERSON who participated in making each ADVERSE EMPLOYMENT ACTION decision; (c) the name, ADDRESS, and telephone number of each PERSON who provided any information relied upon in making each ADVERSE EMPLOYMENT ACTION decision; and the identity of all DOCUMENTS relied upon in making each ADVERSE EMPLOYMENT ACTION decision.

(c)

(d)

200.6 Do you contend that the EMPLOYEE and the EMPLOYER were in a business relationship other than an EMPLOYMENT relationship? If so, for each relationship: (a) state the names of the parties to the relationship; (b) identify the relationship; and (c) state all facts upon which you base your contention that the parties were in a relationship other than an EMPLOYMENT relationship. 201.0 Adverse Employment Action

201.4 Was the TERMINATION or any other ADVERSE EMPLOYMENT ACTIONS referred to in Interrogatories 201.1 through 201.3 based in whole or in part on the EMPLOYEE'S job performance? If so, for each action: identify the ADVERSE EMPLOYMENT ACTION; (a) (b) identify the EMPLOYEE'S specific job performance that played a role in that ADVERSE EMPLOYMENT ACTION; identify any rules, guidelines, policies, or procedures that were used to evaluate the EMPLOYEE'S specific job performance; state the names, ADDRESSES, and telephone numbers of all PERSONS who had responsibility for evaluating the specific job performance of the EMPLOYEE; state the names, ADDRESSES, and telephone numbers of all PERSONS who have knowledge of the EMPLOYEE'S specific job performance that played a role in that ADVERSE EMPLOYMENT ACTION; and describe all warnings given with respect to the EMPLOYEE'S specific job performance.
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(c) 201.1 Was the EMPLOYEE involved in a TERMINATION? If so: (a) state all reasons for the EMPLOYEE'S TERMINATION; (b) state the name, ADDRESS, and telephone number of each PERSON who participated in the TERMINATION decision; (c) state the name, ADDRESS, and telephone number of each PERSON who provided any information relied upon in the TERMINATION decision; and identify all DOCUMENTS relied upon in the (d) TERMINATION decision.
DISC-002 [Rev. January 1, 2009]

(d)

(e)

(f)

FORM INTERROGATORIES­EMPLOYMENT LAW

DISC-002
201.5 Was any PERSON hired to replace the EMPLOYEE after the EMPLOYEE'S TERMINATION or demotion? If so, state the PERSON'S name, job title, qualifications, ADDRESS and telephone number, and the date the PERSON was hired. 201.6 Has any PERSON performed any of the EMPLOYEE'S former job duties after the EMPLOYEE'S TERMINATION or demotion? If so: state the PERSON'S name, job title, (a) ADDRESS, and telephone number; (b) identify the duties; and (c) state the date on which the PERSON started to perform the duties. 201.7 If the ADVERSE EMPLOYMENT ACTION involved the failure or refusal to select the EMPLOYEE (for example, for hire, promotion, transfer, or training), was any other PERSON selected instead? If so, for each ADVERSE EMPLOYMENT ACTION, state the name, ADDRESS, and telephone number of each PERSON selected; the date the PERSON was selected; and the reason the PERSON was selected instead of the EMPLOYEE. 202.0 Discrimination--Interrogatories to Employee (c) identify each characteristic (for example, gender, race, age, etc.) on which you base your claim of harassment; state all facts upon which you base your contention that you were unlawfully harassed; state the name, ADDRESS, and telephone number of each PERSON with knowledge of those facts; and identify all DOCUMENTS evidencing those facts. Disability Discrimination

(d) (e)

(f) 204.0

204.1 Name and describe each disability alleged in the PLEADINGS. 204.2 Does the EMPLOYEE allege any injury or illness that arose out of or in the course of EMPLOYMENT? If so, state: the nature of such injury or illness; (a) (b) how such injury or illness occurred; (c) the date on which such injury or illness occurred; whether EMPLOYEE has filed a workers' (d) compensation claim. If so, state the date and outcome of the claim; and (e) whether EMPLOYEE has filed or applied for disability benefits of any type. If so, state the date, identify the nature of the benefits applied for, and the outcome of any such application. 204.3 Were there any communications between the EMPLOYEE (or the EMPLOYEE'S HEALTH CARE PROVIDER) and the EMPLOYER about the type or extent of any disability of EMPLOYEE? If so: state the name, ADDRESS, and telephone (a) number of each person who made or received the communications; (b) state the name, ADDRESS, and telephone number of each PERSON who witnessed the communications; describe the date and substance of the communications; and identify each DOCUMENT that refers to the communications.

202.1 Do you contend that any ADVERSE EMPLOYMENT ACTIONS against you were discriminatory? If so: (a) (b) identify each ADVERSE EMPLOYMENT ACTION that involved unlawful discrimination; identify each characteristic (for example, gender, race, age, etc.) on which you base your claim or claims of discrimination; state all facts upon which you base each claim of discrimination; state the name, ADDRESS, and telephone number of each PERSON with knowledge of those facts; and identify all DOCUMENTS evidencing those facts.

(c) (d) (e)

(c) (d)

202.2 State all facts upon which you base your contention that you were qualified to perform any job which you contend was denied to you on account of unlawful discrimination. 203.0 Harassment--Interrogatories to Employee

203.1 Do you contend that you were unlawfully harassed in your employment? If so: (a) state the name, ADDRESS, telephone number, and employment position of each PERSON whom you contend harassed you; for each PERSON whom you contend harassed you, describe the harassment;

204.4 Did the EMPLOYER have any information about the type, existence, or extent of any disability of EMPLOYEE other than from communications with the EMPLOYEE or the EMPLOYEE'S HEALTH CARE PROVIDER? If so, state the sources and substance of that information and the name, ADDRESS, and telephone number of each PERSON who provided or received the information. 204.5 Did the EMPLOYEE need any accommodation to perform any function of the EMPLOYEE'S job position or need a transfer to another position as an accommodation? If so, describe the accommodations needed.
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(b)

DISC-002 [Rev. January 1, 2009]

FORM INTERROGATORIES­EMPLOYMENT LAW

DISC-002
204.6 Were there any communications between the EMPLOYEE (or the EMPLOYEE'S HEALTH CARE PROVIDER) and the EMPLOYER about any possible accommodation of EMPLOYEE? If so, for each communication: state the name, ADDRESS, and telephone (a) number of each PERSON who made or received the communication; (b) state the name, ADDRESS, and telephone number of each PERSON who witnessed the communication; describe the date and substance of the communication; and identify each DOCUMENT that refers to the communication. (d) state whether, at the time the statement was PUBLISHED, the PERSON who PUBLISHED the statement believed it to be true; and state all facts upon which the PERSON who published the statement based the belief that it was true. 206.2 State the name and ADDRESS of each agent or employee of the EMPLOYER who responded to any inquiries regarding the EMPLOYEE after the EMPLOYEE'S TERMINATION. 206.3 State the name and ADDRESS of the recipient and the substance of each post-TERMINATION statement PUBLISHED about EMPLOYEE by any agent or employee of EMPLOYER. 207.0 Internal Complaints 207.1 Were there any internal written policies or regulations of the EMPLOYER that apply to the making of a complaint of the type that is the subject matter of this lawsuit? If so: (a) state the title and date of each DOCUMENT containing the policies or regulations and a general description of the DOCUMENT'S contents; (b) (c) state the manner in which the DOCUMENT was communicated to EMPLOYEES; state the manner, if any, in which EMPLOYEES acknowledged receipt of the DOCUMENT or knowledge of its contents, or both; state, if you contend that the EMPLOYEE failed to use any available internal complaint procedures, all facts that support that contention; and state, if you contend that the EMPLOYEE'S failure to use internal complaint procedures was excused, all facts why the EMPLOYEE'S use of the procedures was excused.

(e)

(c) (d)

204.7 What did the EMPLOYER consider doing to accommodate the EMPLOYEE? For each accommodation considered: (a) describe the accommodation considered; (b) state whether the accommodation was offered to the EMPLOYEE; (c) state the EMPLOYEE'S response; or if the accommodation was not offered, state all the (d) reasons why this decision was made; (e) state the name, ADDRESS, and telephone number of each PERSON who on behalf of EMPLOYER made any decision about what accommodations, if any, to make for the EMPLOYEE; and state the name, ADDRESS, and telephone number of each PERSON who on behalf of the EMPLOYER made or received any communications about what accommodations, if any, to make for the EMPLOYEE.

(f)

(d)

205.0 Discharge in Violation of Public Policy 205.1 Do you contend that the EMPLOYER took any ADVERSE EMPLOYMENT ACTION against you in violation of public policy? If so: (a) identify the constitutional provision, statute, regulation, or other source of the public policy that you contend was violated; and (b) state all facts upon which you base your contention that the EMPLOYER violated public policy. 206.0 Defamation 206.1 Did the EMPLOYER'S agents or employees PUBLISH any of the allegedly defamatory statements identified in the PLEADINGS? If so, for each statement: identify the PUBLISHED statement; (a) state the name, ADDRESS, telephone number, and (b) job title of each person who PUBLISHED the statement; (c) state the name, ADDRESS, and telephone number of each person to whom the statement was PUBLISHED; (e)

207.2 Did the EMPLOYEE complain to the EMPLOYER about any of the unlawful conduct alleged in the PLEADINGS? If so, for each complaint: (a) state the date of the complaint; (b) state the nature of the complaint; (c) state the name and ADDRESS of each PERSON to whom the complaint was made; (d) state the name, ADDRESS, telephone number, and job title of each PERSON who investigated the complaint; state the name, ADDRESS, telephone number, (e) and job title of each PERSON who participated in making decisions about how to conduct the investigation;

DISC-002 [Rev. January 1, 2009]

FORM INTERROGATORIES­EMPLOYMENT LAW

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DISC-002
(f) state the name, ADDRESS, telephone number, and job title of each PERSON who was interviewed or who provided an oral or written statement as part of the investigation of the complaint; state the nature and date of any action taken in response to the complaint; state whether the EMPLOYEE who made the complaint was made aware of the actions taken by the EMPLOYER in response to the complaint, and, if so, state how and when; identify all DOCUMENTS relating to the complaint, the investigation, and any action taken in response to the complaint; and state the name, ADDRESS, and telephone number of each PERSON who has knowledge of the EMPLOYEE'S complaint or the EMPLOYER'S response to the complaint. (d) state the name, ADDRESS, telephone number, and job title of each PERSON who was interviewed or who provided an oral or written statement as part of the investigation.

(g) (h)

209.0 Other Employment Claims by Employee or Against Employer 209.1 Except for this action, in the past 10 years has the EMPLOYEE filed a civil action against any employer regarding the EMPLOYEE'S employment? If so, for each civil action: (a) state the name, ADDRESS, and telephone number of each employer against whom the action was filed; (b) (c) state the court, names of the parties, and case number of the civil action; state the name, ADDRESS, and telephone number of any attorney representing the EMPLOYEE; and state whether the action has been resolved or is pending.

(i)

(j)

208.0 Governmental Complaints (d) 208.1 Did the EMPLOYEE file a claim, complaint, or charge with any governmental agency that involved any of the material allegations made in the PLEADINGS? If so, for each claim, complaint, or charge: (a) state the date on which it was filed; (b) state the name and ADDRESS of the agency with which it was filed; (c) state the number assigned to the claim, complaint, or charge by the agency; (d) (e) (f) state the nature of each claim, complaint, or charge made; state the date on which the EMPLOYER was notified of the claim, complaint, or charge; state the name, ADDRESS, and telephone number of all PERSONS within the governmental agency with whom the EMPLOYER has had any contact or communication regarding the claim, complaint, or charge; state whether a right to sue notice was issued and, if so, when; and state whether any findings or conclusions regarding the complaint or charge have been made, and, if so, the date and description of the agency's findings or conclusions.

209.2 Except for this action, in the past 10 years has any employee filed a civil action against the EMPLOYER regarding his or her employment? If so, for each civil action: state the name, ADDRESS, and telephone (a) number of each employee who filed the action; (b) state the court, names of the parties, and case number of the civil action; (c) state the name, ADDRESS, and telephone number of any attorney representing the EMPLOYER; and (d) state whether the action has been resolved or is pending. 210.0 Loss of Income--Interrogatories to Employee 210.1 Do you attribute any loss of income, benefits, or earning capacity to any ADVERSE EMPLOYMENT ACTION? (If your answer is "no," do not answer Interrogatories 210.2 through 210.6.) 210.2 State the total amount of income, benefits, or earning capacity you have lost to date and how the amount was calculated. 210.3 Will you lose income, benefits, or earning capacity in the future as a result of any ADVERSE EMPLOYMENT ACTION? If so, state the total amount of income, benefits, or earning capacity you expect to lose, and how the amount was calculated. 210.4 Have you attempted to minimize the amount of your lost income? If so, describe how; if not, explain why not.

(g) (h)

208.2 Did the EMPLOYER respond to any claim, complaint, or charge identified in Interrogatory 208.1? If so, for each claim, complaint, or charge: (a) state the nature and date of any investigation done or any other action taken by the EMPLOYER in response to the claim, complaint, or charge: state the name, ADDRESS, telephone number, and (b) job title of each person who investigated the claim, complaint, or charge; (c) state the name, ADDRESS, telephone number, and job title of each PERSON who participated in making decisions about how to conduct the investigation; and

DISC-002 [Rev. January 1, 2009]

FORM INTERROGATORIES­EMPLOYMENT LAW

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DISC-002
210.5 Have you purchased any benefits to replace any benefits to which you would have been entitled if the ADVERSE EMPLOYMENT ACTION had not occurred? If so, state the cost for each benefit purchased. 210.6 Have you obtained other employment since any ADVERSE EMPLOYMENT ACTION? If so, for each new employment: (a) state when the new employment commenced; (b) state the hourly rate or monthly salary for the new employment; and (c) state the benefits available from the new employment. Loss of Income--Interrogatories to Employer [See instruction 2(d).] 212.0 Physical, Mental, or Emotional Injuries-- Interrogatories to Employee 212.1 Do you attribute any physical, mental, or emotional injuries to the ADVERSE EMPLOYMENT ACTION? (If your answer is "no," do not answer Interrogatories 212.2 through 212.7.) 212.2 Identify each physical, mental, or emotional injury that you attribute to the ADVERSE EMPLOYMENT ACTION and the area of your body affected. 212.3 Do you still have any complaints of physical, mental, or emotional injuries that you attribute to the ADVERSE EMPLOYMENT ACTION? If so, for each complaint state: a description of the injury; (a) whether the complaint is subsiding, remaining (b) the same, or becoming worse; and (c) the frequency and duration. 212.4 Did you receive any consultation or examination (except from expert witnesses covered by Code of Civil Procedure section 2034) or treatment from a HEALTH CARE PROVIDER for any injury you attribute to the ADVERSE EMPLOYMENT ACTION? If so, for each HEALTH CARE PROVIDER state: (a) 211.2 Do you contend that the EMPLOYEE has not made reasonable efforts to minimize the amount of the EMPLOYEE'S lost income? If so: (a) (b) describe what more EMPLOYEE should have done; state the names, ADDRESSES, and telephone numbers of all PERSONS who have knowledge of the facts that support your contention; and (b) (c) (d) the name, ADDRESS, and telephone number; the type of consultation, examination, or treatment provided; the dates you received consultation, examination, or treatment; and the charges to date.

211.0

211.1 Identify each type of BENEFIT to which the EMPLOYEE would have been entitled, from the date of the ADVERSE EMPLOYMENT ACTION to the present, if the ADVERSE EMPLOYMENT ACTION had not happened and the EMPLOYEE had remained in the same job position. For each type of benefit, state the amount the EMPLOYER would have paid to provide the benefit for the EMPLOYEE during this time period and the value of the BENEFIT to the EMPLOYEE.

identify all DOCUMENTS that support your contention and state the name, ADDRESS, and telephone number of the PERSON who has each DOCUMENT. 211.3 Do you contend that any of the lost income claimed by the EMPLOYEE, as disclosed in discovery thus far in this case, is unreasonable or was not caused by the ADVERSE EMPLOYMENT ACTION? If so: (a) state the amount of claimed lost income that you dispute; (b) state all facts upon which you base your contention; (c) (c) state the names, ADDRESSES, and telephone numbers of all PERSONS who have knowledge of the facts; and identify all DOCUMENTS that support your contention and state the name, ADDRESS, and telephone number of the PERSON who has each DOCUMENT.

212.5 Have you taken any medication, prescribed or not, as a result of injuries that you attribute to the ADVERSE EMPLOYMENT ACTION? If so, for each medication state: the name of the medication; (a) (b) (c) (d) (e) the name, ADDRESS and telephone number of the PERSON who prescribed or furnished it; the date prescribed or furnished; the dates you began and stopped taking it; and the cost to date.

(d)

212.6 Are there any other medical services not previously listed in response to interrogatory 212.4 (for example, ambulance, nursing, prosthetics) that you received for injuries attributed to the ADVERSE EMPLOYMENT ACTION? If so, for each service state: (a) the nature; (b) the date; (c) the cost; and (d) the name, ADDRESS, and telephone number of each HEALTH CARE PROVIDER.

DISC-002 [Rev. January 1, 2009]

FORM INTERROGATORIES­EMPLOYMENT LAW

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DISC-002
212.7 Has any HEALTH CARE PROVIDER advised that you may require future or additional treatment for any injuries that you attribute to the ADVERSE EMPLOYMENT ACTION? If so, for each injury state: (a) the name and ADDRESS of each HEALTH CARE PROVIDER; (b) (c) the complaints for which the treatment was advised; and the nature, duration, and estimated cost of the treatment. 215.0 Investigation 215.1 Have YOU OR ANYONE ACTING ON YOUR BEHALF interviewed any individual concerning the ADVERSE EMPLOYMENT ACTION? If so, for each individual state: (a) the name, ADDRESS, and telephone number of the individual interviewed; (b) the date of the interview; and the name, ADDRESS, and telephone number (c) of the PERSON who conducted the interview. 215.2 Have YOU OR ANYONE ACTING ON YOUR BEHALF obtained a written or recorded statement from any individual concerning the ADVERSE EMPLOYMENT ACTION? If so, for each statement state: (a) the name, ADDRESS, and telephone number of the individual from whom the statement was obtained; (b) (c) (d) the name, ADDRESS, and telephone number of the individual who obtained the statement; the date the statement was obtained; and the name, ADDRESS, and telephone number of each PERSON who has the original statement or a copy.

213.0 Other Damages--Interrogatories to Employee 213.1 Are there any other damages that you attribute to the ADVERSE EMPLOYMENT ACTION? If so, for each item of damage state: (a) the nature; the date it occurred; (b) the amount; and (c) (d) the name, ADDRESS, and telephone number of each PERSON who has knowledge of the nature or amount of the damage. 213.2 Do any DOCUMENTS support the existence or amount of any item of damages claimed in Interrogatory 213.1 ? If so, identify the DOCUMENTS and state the name, ADDRESS, and telephone number of the PERSON who has each DOCUMENT. 214.0 Insurance 214.1 At the time of the ADVERSE EMPLOYMENT ACTION, was there in effect any policy of insurance through which you were or might be insured in any manner for the damages, claims, or actions that have arisen out of the ADVERSE EMPLOYMENT ACTION? If so, for each policy state: (a) (b) (c) (d) (e) (f) the kind of coverage; the name and ADDRESS of the insurance company; the name, ADDRESS, and telephone number of each named insured; the policy number; the limits of coverage for each type of coverage contained in the policy; whether any reservation of rights or controversy or coverage dispute exists between you and the insurance company; and the name, ADDRESS, and telephone number of the custodian of the policy.

216.0 Denials and Special or Affirmative Defenses 216.1 Identify each denial of a material allegation and each special or affirmative defense in your PLEADINGS and for each: (a) state all facts upon which you base the denial or special or affirmative defense; (b) state the names, ADDRESSES, and telephone numbers of all PERSONS who have knowledge of those facts; and identify all DOCUMENTS and all other tangible things, that support your denial or special or affirmative defense, and state the name, ADDRESS, and telephone number of the PERSON who has each DOCUMENT.

(c)

217.0 Response to Request for Admissions 217.1 Is your response to each request for admission served with these interrogatories an unqualified admission? If not, for each response that is not an unqualified admission: (a) state the number of the request; state all facts upon which you base your (b) response; (c) state the names, ADDRESSES, and telephone numbers of all PERSONS who have knowledge of those facts; and identify all DOCUMENTS and other tangible things that support your response and state the name, ADDRESS, and telephone number of the PERSON who has each DOCUMENT or thing.

(g)

214.2 Are you self-insured under any statute for the damages, claims, or actions that have arisen out of the ADVERSE EMPLOYMENT ACTION? If so, specify the statute.

(d)

DISC-002 [Rev. January 1, 2009]

FORM INTERROGATORIES­EMPLOYMENT LAW

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