DISC-002

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

TELEPHONE NO.:

FAX NO. (Optional):

E-MAIL ADDRESS (Optional):
ATTORNEY FOR (Name):

SUPERIOR COURT OF CALIFORNIA, COUNTY OF

SHORT TITLE OF CASE:

FORM INTERROGATORIES—EMPLOYMENT LAW CASE NUMBER:

Asking Party:
Answering Party:
Set No.:

Sec. 1. Instructions to All Parties (c) Each answer must be as complete and straightforward as the
information reasonably available to you permits. If an
(a) Interrogatories are written questions prepared by a party to an
interrogatory cannot be answered completely, answer it to the
action that are sent to any other party in the action to be
extent possible.
answered under oath. The interrogatories below are form
interrogatories approved for use in employment cases.
(d) If you do not have enough personal knowledge to fully answer
(b) For time limitations, requirements for service on other parties, an interrogatory, say so, but make a reasonable and good
and other details, see Code of Civil Procedure sections faith effort to get the information by asking other persons or
2030.010–2030.410 and the cases construing those sections. organizations, unless the information is equally available to
(c) These form interrogatories do not change existing law relating the asking party.
to interrogatories nor do they affect an answering party’s right
to assert any privilege or make any objection. (e) Whenever an interrogatory may be answered by referring to a
document, the document may be attached as an exhibit to the
Sec. 2. Instructions to the Asking Party response and referred to in the response. If the document has
(a) These form interrogatories are designed for optional use by more than one page, refer to the page and section where the
parties in employment cases. (Separate sets of answer to the interrogatory can be found.
interrogatories, Form Interrogatories—General (form
DISC-001) and Form Interrogatories—Limited Civil Cases (f) Whenever an address and telephone number for the same
(Economic Litigation) (form DISC-004) may also be used person are requested in more than one interrogatory, you are
where applicable in employment cases.) required to furnish them in answering only the first
(b) Insert the names of the EMPLOYEE and EMPLOYER to interrogatory asking for that information.
whom these interrogatories apply in the definitions in sections
(g) If you are asserting a privilege or making an objection to an
4(d) and (e) below.
interrogatory, you must specifically assert the privilege or
(c) Check the box next to each interrogatory that you want the state the objection in your written response.
answering party to answer. Use care in choosing those
interrogatories that are applicable to the case. (h) Your answers to these interrogatories must be verified, dated,
(d) The interrogatories in section 211.0, Loss of Income and signed. You may wish to use the following form at the end
Interrogatories to Employer, should not be used until the of your answers:
employer has had a reasonable opportunity to conduct an
investigation or discovery of the employee’s injuries and I declare under penalty of perjury under the laws of the State of
damages. California that the foregoing answers are true and correct.
(e) Additional interrogatories may be attached.
Sec. 3. Instructions to the Answering Party (Date) (SIGNATURE)

(a) You must answer or provide another appropriate response to Sec. 4. Definitions
each interrogatory that has been checked below. Words in BOLDFACE CAPITALS in these interrogatories are
(b) As a general rule, within 30 days after you are served with defined as follows:
these interrogatories, you must serve your responses on the
asking party and serve copies of your responses on all other (a) PERSON includes a natural person, firm, association,
parties to the action who have appeared. See Code of Civil organization, partnership, business, trust, limited liability
Procedure sections 2030.260–2030.270 for details. company, corporation, or public entity.
Page 1 of 8
Form Approved for Optional Use Code of Civil Procedure, §§
Judicial Council of California FORM INTERROGATORIES–EMPLOYMENT LAW 2030.010–2030.410, 2033.710
DISC-002 [Rev. January 1, 2009] www.courts.ca.gov
 DISC-002
(b) YOU OR ANYONE ACTING ON YOUR BEHALF includes Sec. 5. Interrogatories
you, your agents, your employees, your insurance
companies, their agents, their employees, your attorneys, The following interrogatories for employment law cases have
your accountants, your investigators, and anyone else acting been approved by the Judicial Council under Code of Civil
on your behalf. Procedure section 2033.710:

(c) EMPLOYMENT means a relationship in which an CONTENTS

EMPLOYEE provides services requested by or on behalf of 200.0 Contract Formation
an EMPLOYER, other than an independent contractor
201.0 Adverse Employment Action
relationship.
(d) EMPLOYEE means a PERSON who provides services in an 202.0 Discrimination Interrogatories to Employee
EMPLOYMENT relationship and who is a party to this lawsuit. 203.0 Harassment Interrogatories to Employee
For purposes of these interrogatories, EMPLOYEE refers to
(insert name): 204.0 Disability Discrimination
205.0 Discharge in Violation of Public Policy

(If no name is inserted, EMPLOYEE means all such 206.0 Defamation

PERSONS.) 207.0 Internal Complaints
(e) EMPLOYER means a PERSON who employs an 208.0 Governmental Complaints
EMPLOYEE to provide services in an EMPLOYMENT
relationship and who is a party to this lawsuit. For purposes 209.0 Other Employment Claims by Employee or Against
of these interrogatories, EMPLOYER refers to (insert name): Employer
210.0 Loss of income Interrogatories to Employee

(If no name is inserted, EMPLOYER means all such 211.0 Loss of income Interrogatories to Employer
PERSONS.) 212.0 Physical, Mental, or Emotional Injuries—Interrogatories to
(f) ADVERSE EMPLOYMENT ACTION means any Employee
TERMINATION, suspension, demotion, reprimand, loss of 213.0 Other Damages Interrogatories to Employee
pay, failure or refusal to hire, failure or refusal to promote, or
other action or failure to act that adversely affects the 214.0 Insurance
EMPLOYEE’S rights or interests and which is alleged in the 215.0 Investigation
PLEADINGS .
216.0 Denials and Special or Affirmative Defenses
(g) TERMINATION means the actual or constructive termination
of employment and includes a discharge, firing, layoff, 217.0 Response to Request for Admissions
resignation, or completion of the term of the employment 200.0 Contract Formation
agreement.
200.1 Do you contend that the EMPLOYMENT relationship
(h) PUBLISH means to communicate orally or in writing to was at “at will”? If so:
anyone other than the plaintiff. This includes communications
by one of the defendant’s employees to others. (Kelly v. (a) state all facts upon which you base this contention;
General Telephone Co. (1982) 136 Cal.App.3d 278, 284.) (b) state the name, ADDRESS, and telephone number of
(i) PLEADINGS means the original or most recent amended each PERSON who has knowledge of those facts; and
version of any complaint, answer, cross-complaint, or answer
to cross-complaint. (c) identify all DOCUMENTS that support your contention.

(j) BENEFIT means any benefit from an EMPLOYER, including 200.2 Do you contend that the EMPLOYMENT relationship
an “employee welfare benefit plan” or employee pension was not “at will”? If so:
benefit plan” within the meaning of Title 29 United States (a) state all facts upon which you base this contention;
Code section 1002(1) or (2) or ERISA.
(b) state the name, ADDRESS, and telephone number of
(k) HEALTH CARE PROVIDER includes any PERSON referred
each PERSON who has knowledge of those facts; and
to in Code of Civil Procedure section 667.7(e)(3).
(l) DOCUMENT means a writing, as defined in Evidence Code (c) identify all DOCUMENTS that support your contention.
section 250, and includes the original or a copy of 200.3 Do you contend that the EMPLOYMENT relationship
handwriting, typewriting, printing, photostats, photographs, was governed by any agreement—written, oral, or implied?
electronically stored information, and every other means of If so:
recording upon any tangible thing and form of communicating
or representation, including letters, words, pictures, sounds, (a) state all facts upon which you base this contention;
or symbols, or combinations of them. (b) state the name, ADDRESS, and telephone number of
(m) ADDRESS means the street address, including the city, state, each PERSON who has knowledge of those facts; and
and zip code. (c) identify all DOCUMENTS that support your contention.

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200.4 Was any part of the parties’ EMPLOYMENT 201.2 Are there any facts that would support the
relationship governed in whole or in part by any written EMPLOYEE’S TERMINATION that were first discovered
rules, guidelines, policies, or procedures established by the after the TERMINATION? If so:
EMPLOYER? If so, for each DOCUMENT containing the
(a) state the specific facts;
written rules, guidelines, policies, or procedures:
(b) state when and how EMPLOYER first learned of each
(a) state the date and title of the DOCUMENT and a specific fact;
general description of its contents;
(c) state the name, ADDRESS, and telephone number of
(b) state the manner in which the DOCUMENT was each PERSON who has knowledge of the specific facts;
communicated to employees; and and
(c) state the manner, if any, in which employees (d) identify all DOCUMENTS that evidence these specific
acknowledged either receipt of the DOCUMENT or facts.
knowledge of its contents.
201.3 Were there any other ADVERSE EMPLOYMENT
200.5 Was any part of the parties’ EMPLOYMENT ACTIONS, including (the asking party should list the
relationship covered by one or more collective bargaining ADVERSE EMPLOYMENT ACTIONS):
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 If so, for each action, provide the following:
understanding; (a) all reasons for each ADVERSE EMPLOYMENT
ACTION;
(b) the beginning and ending dates, if applicable, of the
collective bargaining agreement or memorandum of (b) the name, ADDRESS, and telephone number of each
understanding; and PERSON who participated in making each ADVERSE
EMPLOYMENT ACTION decision;
(c) which parts of the collective bargaining agreement or
memorandum of understanding, if any, govern (1) any (c) the name, ADDRESS, and telephone number of each
dispute or claim referred to in the PLEADINGS and (2) PERSON who provided any information relied upon in
the rules or procedures for resolving any dispute or making each ADVERSE EMPLOYMENT ACTION
claim referred to in the PLEADINGS . decision; and

200.6 Do you contend that the EMPLOYEE and the (d) the identity of all DOCUMENTS relied upon in making
EMPLOYER were in a business relationship other than an each ADVERSE EMPLOYMENT ACTION decision.
EMPLOYMENT relationship? If so, for each relationship: 201.4 Was the TERMINATION or any other ADVERSE
EMPLOYMENT ACTIONS referred to in Interrogatories
(a) state the names of the parties to the relationship;
201.1 through 201.3 based in whole or in part on the
(b) identify the relationship; and EMPLOYEE'S job performance? If so, for each action:
(c) state all facts upon which you base your contention (a) identify the ADVERSE EMPLOYMENT ACTION;
that the parties were in a relationship other than an (b) identify the EMPLOYEE'S specific job performance that
EMPLOYMENT relationship. played a role in that ADVERSE EMPLOYMENT
ACTION;
201.0 Adverse Employment Action
(c) identify any rules, guidelines, policies, or procedures
201.1 Was the EMPLOYEE involved in a TERMINATION? that were used to evaluate the EMPLOYEE’S specific
If so: job performance;
(a) state all reasons for the EMPLOYEE’S (d) state the names, ADDRESSES, and telephone
TERMINATION; numbers of all PERSONS who had responsibility for
(b) state the name, ADDRESS, and telephone number of evaluating the specific job performance of the
each PERSON who participated in the TERMINATION EMPLOYEE;
decision; (e) state the names, ADDRESSES, and telephone
(c) state the name, ADDRESS, and telephone number of (f) numbers of all PERSONS who have knowledge of the
each PERSON who provided any information relied EMPLOYEE'S specific job performance that played a
upon in the TERMINATION decision; and role in that ADVERSE EMPLOYMENT ACTION; and
(d) identify all DOCUMENTS relied upon in the (g) describe all warnings given with respect to the
TERMINATION decision. EMPLOYEE’S specific job performance.

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201.5 Was any PERSON hired to replace the EMPLOYEE (c) identify each characteristic (for example, gender, race,
after the EMPLOYEE’S TERMINATION or demotion? If so, age, etc.) on which you base your claim of harassment;
state the PERSON'S name, job title, qualifications,
ADDRESS and telephone number, and the date the (d) state all facts upon which you base your contention that
PERSON was hired. you were unlawfully harassed;

201.6 Has any PERSON performed any of the (e) state the name, ADDRESS, and telephone number of
EMPLOYEE’S former job duties after the EMPLOYEE’S each PERSON with knowledge of those facts; and
TERMINATION or demotion? If so:
(f) identify all DOCUMENTS evidencing those facts.
(a) state the PERSON’S name, job title, ADDRESS, and
204.0 Disability Discrimination
telephone number;
204.1 Name and describe each disability alleged in the
(b) identify the duties; and PLEADINGS .
(c) state the date on which the PERSON started to 204.2 Does the EMPLOYEE allege any injury or illness
perform the duties. that arose out of or in the course of EMPLOYMENT? If
so, state:
201.7 If the ADVERSE EMPLOYMENT ACTION involved
the failure or refusal to select the EMPLOYEE (for (a) the nature of such injury or illness;
example, for hire, promotion, transfer, or training), was any
other PERSON selected instead? If so, for each ADVERSE (b) how such injury or illness occurred;
EMPLOYMENT ACTION, state the name, ADDRESS, and
telephone number of each PERSON selected; the date the (c) the date on which such injury or illness occurred;
PERSON was selected; and the reason the PERSON was
(d) whether EMPLOYEE has filed a workers’
selected instead of the EMPLOYEE .
compensation claim. If so, state the date and outcome
of the claim; and
202.0 Discrimination—Interrogatories to Employee
(e) whether EMPLOYEE has filed or applied for disability
202.1 Do you contend that any ADVERSE benefits of any type. If so, state the date, identify the
EMPLOYMENT ACTIONS against you were nature of the benefits applied for, and the outcome of
discriminatory? If so: any such application.
(a) identify each ADVERSE EMPLOYMENT ACTION that 204.3 Were there any communications between the
involved unlawful discrimination; EMPLOYEE (or the EMPLOYEE’S HEALTH CARE
PROVIDER) and the EMPLOYER about the type or extent
(b) identify each characteristic (for example, gender, race,
of any disability of EMPLOYEE? If so:
age, etc.) on which you base your claim or claims of
discrimination; (a) state the name, ADDRESS, and telephone number of
each person who made or received the
(c) state all facts upon which you base each claim of
communications;
discrimination;
(b) state the name, ADDRESS, and telephone number of
(d) state the name, ADDRESS, and telephone number of
each PERSON who witnessed the communications;
each PERSON with knowledge of those facts; and
(c) describe the date and substance of the
(e) identify all DOCUMENTS evidencing those facts. communications; and
202.2 State all facts upon which you base your contention
(d) identify each DOCUMENT that refers to the
that you were qualified to perform any job which you
communications.
contend was denied to you on account of unlawful
discrimination. 204.4 Did the EMPLOYER have any information about the
type, existence, or extent of any disability of EMPLOYEE
203.0 Harassment—Interrogatories to Employee
other than from communications with the EMPLOYEE or the
203.1Do you contend that you were unlawfully harassed in EMPLOYEE’S HEALTH CARE PROVIDER? If so, state the
your employment? If so: sources and substance of that information and the name,
ADDRESS, and telephone number of each PERSON who
(a) state the name, ADDRESS, telephone number, and provided or received the information.
employment position of each PERSON whom you
contend harassed you; 204.5 Did the EMPLOYEE need any accommodation to
perform any function of the EMPLOYEE’S job position or
(b) for each PERSON whom you contend harassed you, need a transfer to another position as an accommodation? If
describe the harassment; so, describe the accommodations needed.

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204.6 Were there any communications between the (d) state whether, at the time the statement was
EMPLOYEE (or the EMPLOYEE’S HEALTH CARE PUBLISHED, the PERSON who PUBLISHED the
PROVIDER) and the EMPLOYER about any possible statement believed it to be true; and
accommodation of EMPLOYEE? If so, for each
communication: (e) state all facts upon which the PERSON who published
the statement based the belief that it was true.
(a) state the name, ADDRESS, and telephone number of
each PERSON who made or received the
206.2 State the name and ADDRESS of each agent or
communication;
employee of the EMPLOYER who responded to any
(b) state the name, ADDRESS, and telephone number of inquiries regarding the EMPLOYEE after the EMPLOYEE’S
each PERSON who witnessed the communication; TERMINATION .
(c) describe the date and substance of the communication;
and 206.3 State the name and ADDRESS of the recipient and
the substance of each post-TERMINATION statement
(d) identify each DOCUMENT that refers to the PUBLISHED about EMPLOYEE by any agent or employee
communication. of EMPLOYER.
204.7 What did the EMPLOYER consider doing to
accommodate the EMPLOYEE? For each accommodation 207.0 Internal Complaints
considered:
207.1 Were there any internal written policies or regulations
(a) describe the accommodation considered; of the EMPLOYER that apply to the making of a complaint
(b) state whether the accommodation was offered to the of the type that is the subject matter of this lawsuit? If so:
EMPLOYEE;
(a) state the title and date of each DOCUMENT containing
(c) state the EMPLOYEE’S response; or
the policies or regulations and a general description of
(d) if the accommodation was not offered, state all the the DOCUMENT’S contents;
reasons why this decision was made;
(e) state the name, ADDRESS, and telephone number of (b) state the manner in which the DOCUMENT was
each PERSON who on behalf of EMPLOYER made communicated to EMPLOYEES;
any decision about what accommodations, if any, to
make for the EMPLOYEE; and (c) state the manner, if any, in which EMPLOYEES
acknowledged receipt of the DOCUMENT or knowledge
(f) state the name, ADDRESS, and telephone number of of its contents, or both;
each PERSON who on behalf of the EMPLOYER
made or received any communications about what (d) state, if you contend that the EMPLOYEE failed to use
accommodations, if any, to make for the EMPLOYEE . any available internal complaint procedures, all facts
205.0 Discharge in Violation of Public Policy that support that contention; and

205.1 Do you contend that the EMPLOYER took any

(e) state, if you contend that the EMPLOYEE’S failure to
ADVERSE EMPLOYMENT ACTION against you in
use internal complaint procedures was excused, all
violation of public policy? If so:
facts why the EMPLOYEE’S use of the procedures was
(a) identify the constitutional provision, statute, regulation, excused.
or other source of the public policy that you contend
was violated; and 207.2 Did the EMPLOYEE complain to the EMPLOYER
about any of the unlawful conduct alleged in the
(b) state all facts upon which you base your contention
PLEADINGS? If so, for each complaint:
that the EMPLOYER violated public policy.
206.0 Defamation (a) state the date of the complaint;
206.1 Did the EMPLOYER'S agents or employees
(b) state the nature of the complaint;
PUBLISH any of the allegedly defamatory statements
identified in the PLEADINGS? If so, for each statement:
(c) state the name and ADDRESS of each PERSON to
(a) identify the PUBLISHED statement; whom the complaint was made;
(b) state the name, ADDRESS, telephone number, and
(d) state the name, ADDRESS, telephone number, and job
job title of each person who PUBLISHED the
title of each PERSON who investigated the complaint;
statement;
(c) state the name, ADDRESS, and telephone number of (e) state the name, ADDRESS, telephone number, and job
each person to whom the statement was title of each PERSON who participated in making
PUBLISHED; decisions about how to conduct the investigation;

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(f) state the name, ADDRESS, telephone number, and (d) state the name, ADDRESS, telephone number, and
job title of each PERSON who was interviewed or who job title of each PERSON who was interviewed or who
provided an oral or written statement as part of the provided an oral or written statement as part of the
investigation of the complaint; investigation.
(g) state the nature and date of any action taken in
response to the complaint; 209.0 Other Employment Claims by Employee or Against
Employer
(h) state whether the EMPLOYEE who made the
complaint was made aware of the actions taken by the
209.1 Except for this action, in the past 10 years has the
EMPLOYER in response to the complaint, and, if so,
EMPLOYEE filed a civil action against any employer
state how and when;
regarding the EMPLOYEE’S employment? If so, for each
(i) identify all DOCUMENTS relating to the complaint, the civil action:
investigation, and any action taken in response to the
complaint; and (a) state the name, ADDRESS, and telephone number of
(j) state the name, ADDRESS, and telephone number of each employer against whom the action was filed;
each PERSON who has knowledge of the
EMPLOYEE’S complaint or the EMPLOYER'S (b) state the court, names of the parties, and case number
response to the complaint. of the civil action;

208.0 Governmental Complaints (c) state the name, ADDRESS, and telephone number of
208.1 Did the EMPLOYEE file a claim, complaint, or charge any attorney representing the EMPLOYEE; and
with any governmental agency that involved any of the
material allegations made in the PLEADINGS? If so, for (d) state whether the action has been resolved or is
each claim, complaint, or charge: pending.
(a) state the date on which it was filed;
209.2 Except for this action, in the past 10 years has any
(b) state the name and ADDRESS of the agency with employee filed a civil action against the EMPLOYER
which it was filed; regarding his or her employment? If so, for each civil action:
(c) state the number assigned to the claim, complaint, or
charge by the agency; (a) state the name, ADDRESS, and telephone number of
each employee who filed the action;
(d) state the nature of each claim, complaint, or charge
made;
(b) state the court, names of the parties, and case number
(e) state the date on which the EMPLOYER was notified of the civil action;
of the claim, complaint, or charge;
(f) state the name, ADDRESS, and telephone number of (c) state the name, ADDRESS, and telephone number of
all PERSONS within the governmental agency with any attorney representing the EMPLOYER; and
whom the EMPLOYER has had any contact or
communication regarding the claim, complaint, or (d) state whether the action has been resolved or is
charge; pending.
(g) state whether a right to sue notice was issued and, if
210.0 Loss of Income—Interrogatories to Employee
so, when; and
(h) state whether any findings or conclusions regarding 210.1 Do you attribute any loss of income, benefits, or
the complaint or charge have been made, and, if so, earning capacity to any ADVERSE EMPLOYMENT
the date and description of the agency’s findings or ACTION? (If your answer is “no,” do not answer
conclusions. Interrogatories 210.2 through 210.6.)
208.2 Did the EMPLOYER respond to any claim,
complaint, or charge identified in Interrogatory 208.1? If so, 210.2 State the total amount of income, benefits, or earning
for each claim, complaint, or charge: capacity you have lost to date and how the amount was
calculated.
(a) state the nature and date of any investigation done or
any other action taken by the EMPLOYER in response
210.3 Will you lose income, benefits, or earning capacity in
to the claim, complaint, or charge:
the future as a result of any ADVERSE EMPLOYMENT
(b) state the name, ADDRESS, telephone number, and ACTION? If so, state the total amount of income, benefits,
job title of each person who investigated the claim, or earning capacity you expect to lose, and how the amount
complaint, or charge; was calculated.
(c) state the name, ADDRESS, telephone number, and
job title of each PERSON who participated in making 210.4 Have you attempted to minimize the amount of your
decisions about how to conduct the investigation; and lost income? If so, describe how; if not, explain why not.

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210.5 Have you purchased any benefits to replace any 212.0 Physical, Mental, or Emotional Injuries—
benefits to which you would have been entitled if the Interrogatories to Employee
ADVERSE EMPLOYMENT ACTION had not occurred? If
so, state the cost for each benefit purchased. 212.1 Do you attribute any physical, mental, or emotional
injuries to the ADVERSE EMPLOYMENT ACTION? (If your
210.6 Have you obtained other employment since any answer is “no,” do not answer Interrogatories 212.2 through
ADVERSE EMPLOYMENT ACTION? If so, for each new 212.7.)
employment:
212.2 Identify each physical, mental, or emotional injury that
you attribute to the ADVERSE EMPLOYMENT ACTION
(a) state when the new employment commenced;
and the area of your body affected.
(b) state the hourly rate or monthly salary for the new 212.3 Do you still have any complaints of physical, mental,
employment; and or emotional injuries that you attribute to the ADVERSE
EMPLOYMENT ACTION? If so, for each complaint state:
(c) state the benefits available from the new employment.
(a) a description of the injury;
211.0 Loss of Income—Interrogatories to Employer (b) whether the complaint is subsiding, remaining the
[See instruction 2(d).] same, or becoming worse; and

211.1 Identify each type of BENEFIT to which the (c) the frequency and duration.
EMPLOYEE would have been entitled, from the date of the 212.4 Did you receive any consultation or examination
ADVERSE EMPLOYMENT ACTION to the present, if the (except from expert witnesses covered by Code of Civil
ADVERSE EMPLOYMENT ACTION had not happened and Procedure section 2034) or treatment from a HEALTH
the EMPLOYEE had remained in the same job position. For CARE PROVIDER for any injury you attribute to the
each type of benefit, state the amount the EMPLOYER ADVERSE EMPLOYMENT ACTION? If so, for each
would have paid to provide the benefit for the EMPLOYEE HEALTH CARE PROVIDER state:
during this time period and the value of the BENEFIT to the
EMPLOYEE. (a) the name, ADDRESS, and telephone number;
(b) the type of consultation, examination, or
211.2 Do you contend that the EMPLOYEE has not made
treatment provided;
reasonable efforts to minimize the amount of the
EMPLOYEE’S lost income? If so: (c) the dates you received consultation, examination, or
treatment; and
(a) describe what more EMPLOYEE should have done;
(d) the charges to date.
(b) state the names, ADDRESSES, and telephone 212.5 Have you taken any medication, prescribed or not, as
numbers of all PERSONS who have knowledge of the a result of injuries that you attribute to the ADVERSE
facts that support your contention; and EMPLOYMENT ACTION? If so, for each medication state:

(c) identify all DOCUMENTS that support your contention (a) the name of the medication;
and state the name, ADDRESS, and telephone (b) the name, ADDRESS and telephone number of the
number of the PERSON who has each DOCUMENT. PERSON who prescribed or furnished it;
211.3 Do you contend that any of the lost income claimed (c) the date prescribed or furnished;
by the EMPLOYEE, as disclosed in discovery thus far in this
case, is unreasonable or was not caused by the ADVERSE (d) the dates you began and stopped taking it; and
EMPLOYMENT ACTION? If so: (e) the cost to date.

(a) state the amount of claimed lost income that you 212.6 Are there any other medical services not previously
dispute; listed in response to interrogatory 212.4 (for example,
ambulance, nursing, prosthetics) that you received for
(b) state all facts upon which you base your contention; injuries attributed to the ADVERSE EMPLOYMENT
ACTION? If so, for each service state:
(c) state the names, ADDRESSES, and telephone (a) the nature;
numbers of all PERSONS who have knowledge of the
facts; and (b) the date;
(c) the cost; and
(d) identify all DOCUMENTS that support your contention
and state the name, ADDRESS, and telephone (d) the name, ADDRESS, and telephone number of
number of the PERSON who has each DOCUMENT. each HEALTH CARE PROVIDER .

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212.7 Has any HEALTH CARE PROVIDER advised that 215.0 Investigation
you may require future or additional treatment for any
injuries that you attribute to the ADVERSE EMPLOYMENT 215.1 Have YOU OR ANYONE ACTING ON YOUR
ACTION? If so, for each injury state: BEHALF interviewed any individual concerning the
ADVERSE EMPLOYMENT ACTION? If so, for each
(a) the name and ADDRESS of each HEALTH CARE individual state:
PROVIDER;
(a) the name, ADDRESS, and telephone number of the
(b) the complaints for which the treatment was advised; individual interviewed;
and
(b) the date of the interview; and
(c) the nature, duration, and estimated cost of the
treatment. (c) the name, ADDRESS, and telephone number of the
PERSON who conducted the interview.
213.0 Other Damages—Interrogatories to Employee
215.2 Have YOU OR ANYONE ACTING ON YOUR
213.1 Are there any other damages that you attribute to the BEHALF obtained a written or recorded statement from any
ADVERSE EMPLOYMENT ACTION? If so, for each item of individual concerning the ADVERSE EMPLOYMENT
damage state: ACTION? If so, for each statement state:

(a) the nature; (a) the name, ADDRESS, and telephone number of the
individual from whom the statement was obtained;
(b) the date it occurred;
(b) the name, ADDRESS, and telephone number of the
(c) the amount; and individual who obtained the statement;
(d) the name, ADDRESS, and telephone number of each (c) the date the statement was obtained; and
PERSON who has knowledge of the nature or amount
of the damage. (d) the name, ADDRESS, and telephone number of each
PERSON who has the original statement or a copy.
213.2 Do any DOCUMENTS support the existence or
amount of any item of damages claimed in Interrogatory 216.0 Denials and Special or Affirmative Defenses
213.1? If so, identify the DOCUMENTS and state the name, 216.1 Identify each denial of a material allegation and each
ADDRESS, and telephone number of the PERSON who has special or affirmative defense in your PLEADINGS and for
each DOCUMENT . each:
214.0 Insurance (a) state all facts upon which you base the denial or special
or affirmative defense;
214.1 At the time of the ADVERSE EMPLOYMENT
ACTION, was there in effect any policy of insurance (b) state the names, ADDRESSES, and telephone
through which you were or might be insured in any manner numbers of all PERSONS who have knowledge of
for the damages, claims, or actions that have arisen out of those facts; and
the ADVERSE EMPLOYMENT ACTION? If so, for each
policy state: (c) identify all DOCUMENTS and all other tangible things,
that support your denial or special or affirmative
(a) the kind of coverage; defense, and state the name, ADDRESS, and
telephone number of the PERSON who has each
(b) the name and ADDRESS of the insurance company; DOCUMENT .
(c) the name, ADDRESS, and telephone number of each 217.0 Response to Request for Admissions
named insured;
217.1 Is your response to each request for admission
(d) the policy number; served with these interrogatories an unqualified admission?
If not, for each response that is not an unqualified
(e) the limits of coverage for each type of coverage
admission:
contained in the policy;
(a) state the number of the request;
(f) whether any reservation of rights or controversy or
coverage dispute exists between you and the (b) state all facts upon which you base your response;
insurance company; and
(c) state the names, ADDRESSES, and telephone
(g) the name, ADDRESS, and telephone number of the numbers of all PERSONS who have knowledge of
custodian of the policy. those facts; and
214.2 Are you self-insured under any statute for the (d) identify all DOCUMENTS and other tangible things that
damages, claims, or actions that have arisen out of the support your response and state the name,
ADVERSE EMPLOYMENT ACTION? If so, specify the ADDRESS, and telephone number of the PERSON
statute. who has each DOCUMENT or thing.

DISC-002 [Rev. January 1, 2009] Page 8 of 8

FORM INTERROGATORIES–EMPLOYMENT LAW
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