Questionnaire - EEOC v Prestige Care Settlement

EEOC v Prestige Care, Inc.

EEOC v Prestige Care Settlement

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U.S. Equal Employment Opportunity Commission v. Prestige Care, Inc. et al., Case No. 1:17-cv-01299-AWI-SAB (E.D. Cal.)

QUESTIONNAIRE

IT IS IMPORTANT THAT YOU READ THESE INSTRUCTIONS BEFORE COMPLETING THIS CLAIM FORM

COMPLETION OF THIS QUESTIONNAIRE DOES NOT GUARANTEE THAT MONETARY RELIEF WILL BE PROVIDED TO YOU.

Please complete this questionnaire if you are seeking monetary relief in connection with the Settlement of claims of disability discrimination under the Americans with Disabilities Act (“ADA”) brought by the U.S. Equal Employment Opportunity Commission (“EEOC”) against Prestige Care, Inc., Prestige Senior Living, LLC, and related nursing facilities and assisted living facilities (collectively, “Prestige”). Please read each question carefully and answer completely and truthfully. At the end of this form, you will be asked to sign to verify that the information you provide is correct.

By completing this questionnaire, you are agreeing to participate in the claims process for the administration of the Settlement fund established by the settlement between the EEOC and Prestige. If you are provided monetary relief in this process, you may incur and be responsible for taxes under local, state and/or federal law. You are encouraged to consult a tax professional concerning the tax implications if you are awarded money through the claims process.

If you have any questions regarding this matter, please direct your questions to 1-800-578-9164 or via email at PrestigeCareSettlement@atticusadmin.com. Please allow five (5) business days for them to respond to your inquiry.
If you would like to view and download the questionnaire click HERE
ClaimFormNo
Claimant ID*
Full Legal Name*
First Middle Last
Date of Birth*
Month
Day
Year
Social Security No.*
Home Address*
Street Address Address Line 2 City State Zip Code
Personal email address*

(do not provide a work email address)
Primary Phone Number*
Cell phone number
To your knowledge, did you work for Prestige Care, Inc., Prestige Senior Living, LLC, a related nursing facility, and/or a related assisted living facility between January 2011 and December 2018?
- Yes
- No
- I worked for a nursing facility and/or an assisted living facility between January 2011 and December 2018, but I don’t know if it was related to Prestige Care, Inc. or Prestige Senior Living, LLC.
The name(s) of the facility(ies):
What was your last job title while working for Prestige? Please provide a brief description of your job duties for that position.
What was your last rate of pay while working for Prestige? (Please approximate to the best of your recollection if you do not remember the exact rate of pay.)
Was the reason you left employment with Prestige related to a physical or mental impairment?*
- Yes
- No
Please describe each impairment that was related to the reason you left employment with Prestige:
Were you on leave from work (such as medical leave, sick leave, or disability leave) due to a physical or mental impairment at the time your employment with Prestige ended?*
- Yes
- No
please describe each impairment which caused you to be on leave from work at the time your employment with Prestige ended:
do you believe you could have remained employed or returned to work with Prestige if Prestige had accommodated your impairment(s)? (Examples of accommodations may include temporary leave, temporary light duty, job restructuring, part-time or modified work schedules, reassignment to a vacant position, acquisition or modifications of equipment or devices, and other similar accommodations for individuals with disabilities.)
- Yes
- No
please describe the accommodation(s) that you believe would have allowed to remain employed (or return to work) with Prestige?
Were you unemployed for a period of time after leaving your employment with Prestige?*
- Yes
- No
For approximately how long:
If the reason your employment with Prestige ended was related to a physical or mental impairment, or if you were on leave due a physical or mental impairment at the time your employment with Prestige ended, please describe the impact that loss of employment had on you personally. (This includes all types of impact, such as emotional, psychological, financial, professional, physical, and medical impact, etc. If you suffered physical or psychological effects (e.g., unusual stress, anxiety, sleep problems, headaches, stomach problems, depression, sadness, weight loss or gain, hair loss, grinding teeth, loss of self-esteem, humiliation, etc.), please describe them.)
20. I wish to participate in the claims process for the Settlement fund established by the settlement between the EEOC and Prestige.*
- Yes
- No
Typed signature*
Signature Acknowledgment*
- I state that the above answers are correct to the best of my knowledge. I do not know of any reason that I am ineligible to participate in this claims process or receive monetary relief from the Settlement fund in this matter.
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Unique ID
Name
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