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Full Name*

Phone Number*

Email*

Location*

I am a victim of:

Complete incident-based questionnaires to check your qualification for the Mass Tort case.

Questions

Yes No

Do I Qualify?

Yes No

Are you filling this out for yourself or on behalf of someone else?

Yes

Did you or anyone on your property suffer from physical injuries during the Dixie fire?

Yes

Were you hospitalized and/or treated by a physician for those injuries?

Yes

Was your home or property, owned or rented by you, burned (either partially or completely) by the Dixie fire?

Yes

Address

City

State

Zip

If smoke damage only, was the total in uninsured contents loss $50,000.00 or more?

Yes

Address

City

State

Zip

Was your place of business, either owned or rented by you, or goods related to your business (including any merchantable timber, pre-merchantable timber, or other forest products) or equipment, owned by you, burned (either partially or completely) by the Dixie fire?

Yes

Address

State

City

Zip

Was your place of employment burned completely or partially by the Dixie fire?

Yes

If asserting a claim for lost personal income only, was or will the dollar amount lost over $25,000.00?

Address

State

City

Zip

Were any of the above places only damaged by smoke and ash?

Yes

Did you or anyone on your property suffer from physical injuries during the Hermits Peak fire?

Yes

Were you hospitalized and/or treated by a physician for those injuries?

Yes

Was your home or property, owned or rented by you, burned (either partially or completely) by the Hermits Peak fire?

Yes

If smoke damage only, was the total in uninsured contents loss $50,000.00 or more?

Yes

Address

State

City

Zip

Address

State

City

Zip

Yes

Address

State

City

Zip

Was your place of employment burned completely or partially by the Hermits Peak fire?

Yes

If asserting a claim for lost personal income only, was or will the dollar amount lost over $25,000.00?

Address

State

City

Zip

Were any of the above places only damaged by smoke and ash?

Yes

Did you or anyone on your property suffer from physical injuries during the McBride fire?

Yes

Were you hospitalized and/or treated by a physician for those injuries?

Yes

Was your home or property, owned or rented by you, burned (either partially or completely) by the McBride fire?

Yes

Address

State

City

Zip

If smoke damage only, was the total in uninsured contents loss $50,000.00 or more?

Yes

Address

State

City

Zip

Yes

Address

State

City

Zip

Was your place of employment burned completely or partially by the McBride fire?

Yes

If asserting a claim for lost personal income only, was or will the dollar amount lost over $25,000.00?

Address

State

City

Zip

Were any of the above places only damaged by smoke and ash?

Yes

Was the child born before or during 37 weeks of gestation?

Yes

After the hospital began feeding the child formula, did the child suffer NEC?

Yes

Did the child’s NEC cause the child to pass or, instead, to require extensive, additional medical care, e.g.,weeks of additional hospitalization, surgery, etc?

Yes

Did the mother use tobacco during the pregnancy?

Yes

How long/much?

Did the mother use cocaine during the pregnancy?

Yes

Did the mother use methamphetamine during the pregnancy?

Yes

Did the mother use phencyclidine / phenylcyclohexyl piperidineopiods (PCP) during pregnancy?

Yes

The applicable limitations and repose periods have not expired and will not expire for at least 6 months?

Yes

Has anyone ever hired a lawyer to represent the child or the mother in connection with the child’s NEC?

Yes

Are you already represented by counsel in this litigation?

Yes

Are the client already represented by counsel in this litigation?

Yes

Are you over 80 years of age currently?

Yes

Are the client over 80 years of age currently?

Yes

Were the client diagnosed with mesothelioma in or after 2000?

Yes

Were you diagnosed with mesothelioma in or after 2000?

Yes

Were the client diagnosed with ovarian cancer or fallopian tube cancer in or after 2000?

Yes

Were you diagnosed with ovarian cancer or fallopian tube cancer in or after 2000?

Yes

If ovarian cancer, was it epithelial cell ovarian cancer? (serous, endometrioid, undifferentiated, clear cell, borderline or mucinous?)

Yes

Are you sure that it was indeed ovarian or fallopian tube cancer and NOT solely uterine or cervical or another type of cancer affecting the female anatomy other than ovarian or fallopian tube cancer?

Yes

Are the client sure that it was indeed ovarian or fallopian tube cancer and NOT solely uterine or cervical or another type of cancer affecting the female anatomy other than ovarian or fallopian tube cancer?

Yes

If the client was diagnosed with ovarian cancer or fallopian tube cancer did you / she regularly or routinely apply body powder containing Johnson’s® Baby Powder or Shower to Shower® to her genital area for a minimum of four years BEFORE DIAGNOSIS? (does not have to be continuous)

Yes

Did you use it during or after puberty?

Yes

Did the client use it during or after puberty?

Yes

If client was diagnosed with ovarian cancer or fallopian tube cancer have you or she ever tested positive for BRCA 1 or BRCA 2?

Yes

If you were diagnosed with ovarian cancer or fallopian tube cancer have you or she ever tested positive for BRCA 1 or BRCA 2?

Yes

If client was diagnosed with ovarian cancer or fallopian tube cancer were you / was she previously diagnosed with ovarian cancer before using talc?

Yes

If you were diagnosed with ovarian cancer or fallopian tube cancer were you / was she previously diagnosed with ovarian cancer before using talc?

Yes

If client was diagnosed with ovarian cancer or fallopian tube cancer, do you / does she have a history of endometriosis?

Yes

If you were diagnosed with ovarian cancer or fallopian tube cancer, do you / does she have a history of endometriosis?

Yes

If client was diagnosed with ovarian cancer or fallopian tube cancer, do you / does she have a parent, sibling, or child who has or had ovarian cancer, fallopian tube cancer, or breast cancer?

Yes

If you were diagnosed with ovarian cancer or fallopian tube cancer, do you / does she have a parent, sibling, or child who has or had ovarian cancer, fallopian tube cancer, or breast cancer?

Yes

Describe more information on what you had.

If you were diagnosed with ovarian cancer or fallopian tube cancer, did at least ten (10) years elapse between the date of first exposure to Johnson’s® Baby Powder or Shower to Shower® and the diagnosis?

Yes

If client was diagnosed with ovarian cancer or fallopian tube cancer, did at least ten (10) years elapse between the date of first exposure to Johnson’s® Baby Powder or Shower to Shower® and the diagnosis?

Yes

If client was diagnosed with Mesothelioma, did you, he or she regularly or routinely use a personal care/cosmetic/hygiene product containing Johnson’s® Baby Powder or Shower to Shower® for a minimum of four years BEFORE DIAGNOSIS OR have personal occupational exposure (whether direct or bystander) to Cyprus and/or Imerys Industrial Talc not incorporated in a product for a minimum of one year BEFORE DIAGNOSIS?

Yes

If you were diagnosed with Mesothelioma, did you, he or she regularly or routinely use a personal care/cosmetic/hygiene product containing Johnson’s® Baby Powder or Shower to Shower® for a minimum of four years BEFORE DIAGNOSIS OR have personal occupational exposure (whether direct or bystander) to Cyprus and/or Imerys Industrial Talc not incorporated in a product for a minimum of one year BEFORE DIAGNOSIS?

Yes

If client was diagnosed with Mesothelioma did at least ten (10) years elapse between the date of first exposure to Johnson’s® Baby Powder or Shower to Shower® or Cyprus and/or Imerys Industrial Talc and the diagnosis?

Yes

If you were diagnosed with Mesothelioma did at least ten (10) years elapse between the date of first exposure to Johnson’s® Baby Powder or Shower to Shower® or Cyprus and/or Imerys Industrial Talc and the diagnosis?

Yes

If client was diagnosed with Mesothelioma, did you / he or she have any other significant exposure to asbestos?

Yes

If you were diagnosed with Mesothelioma, did you / he or she have any other significant exposure to asbestos?

Yes

If client qualifies, get names and city/states of doctors and of hospitals, medical facilities where the client was diagnosed with and treated for the qualifying injury

If you qualifies, get names and city/states of doctors and of hospitals, medical facilities where you was diagnosed with and treated for the qualifying injury

One or more of the following apply:

What state were you prescribed Topamax?

What year were you prescribed/did you take Topamax?

When was the affected child born?

Were you prescribed or given samples of Topamax by your doctor?

Yes

Do any of the following apply?

Do any of the child’s siblings have Autism, an IEP for Autism, or an Intellectual Disability?

Yes

For siblings who have Autism, an IEP for Autism, or an Intellectual Disability, did the mother take Topamax?

Yes

Did the mother take more than 10 doses of acetaminophen (Tylenol) while pregnant with the other affected child?

Yes

Has the mother/guardian hired an attorney to investigate whether either Topamax or Acetaminophen caused affected children’s Autism or Intellectual Disability?

Yes

Describe your situation

Did you or anyone on your property suffer from physical injuries during the Maui fire?

Yes

Identify injury and were you hospitalized and/or treated by a physician for those injuries?

Was your home or property, owned or rented by you, burned (identify either partially or Completely destroyed) by the Maui fire?

Yes

Address

State

City

Zip

If partially or completely destroyed by fire, address of damaged property including city, state and zip

Yes

Address

State

City

Zip

Was your place of business, either owned or rented by you, or goods related to your business (including any merchantable timber, pr e-merchantable timber, or other forest products) or equipment, owned by you, burned (identify either partially or Completely destroyed) by the Maui fire?

Yes

Address

State

City

Zip

Was your place of employment burned completely or partially by the Maui fire?

Yes

Address

City

State

Zip

Are you asserting a claim for lost personal income only?

Yes

Was the dollar amount lost over $25,000?

Yes

Is it smoke damage only?

Yes

While pregnant, did the mother use Tylenol or another acetaminophen product (APAP) sold by one or more of the companies itemized below?

Yes

Select one or more of the following (Click and drag or CTRL + Click to select multiple)

Is the child diagnosed with autism and/or child participating today or participated in the past in an individualized education program for autism. or child is participating today or participated in the past in an early intervention program for autism?

Yes

Did the mother suffer one or more of the following complications during pregnancy: gestational diabetes; gestational hypertension; or, an infection and related fever that required mother’s hospitalization?

Yes

Was the child born before the 26th week of pregnancy; or is the child diagnosed with one or more of Down syndrome, Fragile X syndrome, Tourette syndrome, and/or tuberous sclerosis?

Yes

Did the mother use one or more SSRI drugs while pregnant?

Yes

Was the father over 45 years of age when child was born?

Yes

Did the mother use alcohol while pregnant; or did the mother use one or more illegal drugs while pregnant?

Yes

Did the mother use tobacco while pregnant?

Yes

Is one of the child’s parents diagnosed with autism; or is one or more of child’s siblings diagnosed with autism?

Yes

Has the mother hired an attorney to investigate whether acetaminophen caused child’s autism?

Yes

Was the child born after March 26, 2020?

Yes

Is the child 18 years or over?

Yes

Did the mother's pregnancy or child’s birth occurr in either Michigan or Texas?

Yes

Are you filling out this form regarding a potential claim for injuries at Camp Lejeune?

Yes

Does the claim pertain to you or another person?

Self

Someone Else

Are you completing this form from our Jacksonville, North Carolina office?

Yes

What injury were you/they diagnosed with?

Please describe here:

Please separate injuries using ';' if more than one

Were you/they exposed to contaminated water at Camp Lejeune for at least 30 days between August 1, 1953 to December 31, 1987?

Yes

What is the approximate date you believe you/they were first exposed to contamination at Camp Lejeune?

What is the approximate date you believe you/they were last exposed to contamination at Camp Lejeune?

If you spent less than a year (365 days) at Camp Lejeune: What was the reason for you living at Camp Lejeune for less than a year?

Before we proceed, are you represented by another lawyer in connection with Camp Lejeune?

Do you have an email or letter terminating that representation?

Yes

Did you or anyone on your property suffer from physical injuries during the McKinney fire?

Yes

Were you hospitalized and/or treated by a physician for those injuries?

Yes

Was your home or property, owned or rented by you, burned (either partially or completely) by the McKinney fire?

Yes

Address

City

State

Zip

Was the total in uninsured contents loss $50,000.00 or more?

Yes

Address

City

State

Zip

Was your place of business, either owned or rented by you, or goods related to your business (including any merchantable timber, pre - merchantable timber, or other forest products) or equipment, owned by you, burned (either partially or com pletely) by the McKinney fire?

Yes

Address

City

State

Zip

Was your place of employment burned completely or partially by the McKinney fire?

Yes

If asserting a claim for lost personal income only, was or will the dollar amount lost over $25,000.00?

Address

City

State

Zip

Have you / they been diagnosed with Uterine, Endometrial or Ovarian cancer?

Yes

Was there use of any hair relaxer product 2 or more years before the Uterine, Endometrial or Ovarian cancer diagnosis?

Yes

Was there use of any hair relaxer product 2 or more years before Death from Uterine, Endometrial or Ovarian cancer?

Yes

Was there use of the hair relaxer in or after the year 2005 ?

Yes

Address

Phone Number

Was the person affected present for at least 8 hours or within 30 miles of the Ohio train derailment site for at least 8 hours between February 3rd, 2023, and February 8th, 2023?

Yes

Did the person affected own a property within 10 miles of the Ohio train derailment site?

Yes

Did the person affected lose commercial livestock with an uninsured value of at least $10,000?

Yes

Address

Phone Number

Date of Birth

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