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First Name:
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Last Name:
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Address 1:
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Address 2:
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City:
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State:
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Zip:
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Daytime Phone:
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Evening Phone:
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Email:
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1. Have you ever been employed by CVS, SAV-ON, or ALBERTSON's ("C/S/A") as a Pharmacy Clerk or Technician?
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2(a). Date you BEGAN work as a Pharmacy TECHNICIAN for C/S/A:
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2(b). LAST date you worked as a Pharmacy TECHNICIAN for C/S/A (if still employed use today's date):
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2(c). Date you BEGAN work as a Pharmacy CLERK for C/S/A:
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2(d). LAST date you worked as a Pharmacy CLERK for C/S/A (if still employed use today's date):
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3(a). Please list all California C/S/A Pharmacy locations in which you worked:
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3(b). Please indicate the number of hours per shift you worked at each of the California C/S/A Pharmacy stores listed above.
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4. Were you authorized to leave the pharmacy department for MEAL BREAKS?
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5. Did you always clock in and out for MEAL BREAKS?
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6. Were you able to take a 30-minute, DUTY-FREE MEAL BREAK WITHOUT INTERRUPTION for each 5-hour shift you worked? NOTE: "DUTY-FREE" means that you were not on duty or required to be present. "DUTY-FREE" means that you were completely free to spend that time as you saw fit (leave the pharmacy, run a personal errand, take a nap, eat, etc.) -- WITHOUT INTERRUPTIONS.)
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7. What PERCENTAGE of the time were you able to take a 30-minute, DUTY-FREE MEAL BREAK, WITHOUT INTERRUPTIONS?
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8. In a few words, if you were unable to take a 30-minute DUTY-FREE MEAL BREAK, please state why:
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9. Were you authorized to leave the pharmacy department for REST BREAKS?
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10. Were you able to take a 10-minute DUTY-FREE REST BREAK WITHOUT INTERRUPTION for each 4-hours that you worked?
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11. What PERCENTAGE of the time were you able to take a 10-minute, DUTY-FREE REST BREAK?
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12. In a few words, if you were unable to take a 10-minute DUTY-FREE REST BREAK, please state why:
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13(a). While at C/S/A, did you ever work over 8 hours per day or over 40 hours per week (OVERTIME)?
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13(b). If you worked OVERTIME, were you ALWAYS paid time and a half for OVERTIME hours worked?
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13(c). If your answer to 13(b) was NO, please provide details.
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14(a). At C/S/A, if you did not take your earned VACATION time, were you paid for it instead?
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14(b). If your answer to 14(a) was NO, please provide details.
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15. Would you like to speak with an attorney at no charge about the CVS lawsuits?
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16(a). Would you be willing to sign a FORMAL declaration regarding your experiences at C/S/A?
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16(b). If you are willing to sign a formal declaration or speak with us further, please provide your preferred telephone number and the best time(s) to call (if not, enter NONE):
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17. Would you like your email address added to the LISTSERV so you can receive updates about this case?
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18. Are there any other COMMENTS you would like to make?
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