Paraquat Plantiff Assessment Form - The Smith Law Firm

1Representative Capacity

2Personal Information

3Employment History

4Family Medical History

5Plaintiff's Medical History

6Insurance & Claim Information

7Farming History

8Workplace Paraquat Exposure

9Additional Medical Questions

10Lawsuit Details

11Document Uploads

12Authorization Documentation

13Verification

14Verification Cont.

(I.) Representative Capacity

Are you completing this Fact Sheet in a representative capacity of a Plaintiff/decedent on whose behalf this action was filed?

Yes

If you answered yes, please provide the representative’s:

First Name

Last Name

Relationship

Is the Related Representative Capacity document:

Confidential

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(II.) Personal Information

Plaintiff's Name(Required)

First Middle Last

Plaintiff's Birth Date(Required)

MM slash DD slash YYYY

Plaintiff's Social Security Number(Required)

Plaintiff's Medicare / Medicaid Numbers

(III.) Residential History

Identify every place you have lived for ten (10) years before the onset of the symptoms of the injury(ies) you are claiming in this lawsuit.(Required)

Address

City

State

Zip

From Year To Year

NOTE: Add any additional addresses by clicking on the (+) icon to the right.

(IV.) Military Service

Have you served in the military in any capacity?(Required)

Yes

If you answered yes, please identify:

Service Dates

Branch

Highest Rank Attained

(V.) Employment History

Were you employed in any job(s) during the ten (10) years prior to the onset of the symptoms of the injury(ies) you are claiming in this lawsuit?(Required)

Yes

Identify every job you have had for the ten (10) years prior to the onset of the symptoms of the injury(ies) you are claiming in this lawsuit.

Employer Name

Supervisor Name

Employer Address (City, State)

Job Description

From Year to Year

Paraquat Exposure

NOTE: Add any additional Job(s) by clicking on the (+) icon to the right.

(VI.) Union Membership

Have you ever been a member of any labor union?(Required)

Yes

If you answered yes, please provide:

Name of Union

City

State

NOTE: Add any additional union information by clicking on the (+) icon to the right.

(VII.) Family Medical History

Has a close blood relative of yours (parents, siblings, or children) been diagnosed with Parkinson’s disease or any other nervous system disorder or neurodegenerative disorder?(Required)

Yes

If you answered yes, please provide the following information. Create a separate entry for each blood relative diagnosed with these conditions.

Name

Diagnosed with?

Relationship with Plaintiff

NOTE: Add any additional family information by clicking on the (+) icon to the right.

(VIII.) Plaintiff's Medical History

(i) Identify the names of all primary care providers you have seen from ten (10) years prior to the onset of any symptoms of the injury(ies) you are claiming in this lawsuit; and Identify any neurologists who have treated you for a neurological disorder, including Parkinson’s Disease, since birth. Please use a separate entry for each primary care provider or neurologist you have seen during the referenced time periods.

Provider Name

Provider Type

Name Of Facility

Provider Address

Diagnosis

Year of Diagnosis

Other Diagnosis

NOTE: Add any additional provider information by clicking on the (+) icon to the right.

(ii) Has any medical provider ever determined that the injury(ies) you are claiming in this lawsuit was caused by and/or associated with your exposure to an agricultural, industrial, or other toxic chemical?(Required)

Yes

Do not recall

If you answered yes, please identify...

Type of testing

Results of Testing

NOTE: Add any additional testing information by clicking on the (+) icon to the right.

Have you seen other medical providers (that were not already listed in previous questions i and ii. above) since the onset of symptoms of the injury(ies) you are claiming in this lawsuit?(Required)

Yes

Do not recall

To the extent not already listed in previous questions (see questions i and ii. above), identify the names of any medical providers you have seen since the onset of symptoms of the injury(ies) you are claiming in this lawsuit. To the extent you received care at a hospital or other institution, provide the name of the hospital or other institution.

Provider Name

Name of Facility

Provider Address

NOTE: Add any additional provider information by clicking on the (+) icon to the right.

Has a medical provider ever ordered genetic testing related to your claimed injury(ies) in this lawsuit?(Required)

Yes

Do not recall

If you answered yes, please identify...

Type of Testing

Results of that testing

NOTE: Add any additional testing information by clicking on the (+) icon to the right.

(IX.) Insurance & Claim Information

Have you filed a disability claim relating to your injuries claimed in this lawsuit?(Required)

Yes

If you answered yes, please identify the name of the insurance company:(Required)

Was your application denied?(Required)

Yes

If you answered yes, please provide the year you filed.

Example: (1988)

If yes, what was the reason for denial and the month/year of denial?

Who were you determined to be disabled by?

As you fill out this questionnaire, are you still disabled?(Required)

Yes

(X.) Farming History

Did you engage in farming?(Required)

Yes

Please create a separate entry for each location at which you engaged in farming. If you harvested multiple crops and applied the same chemicals at a single location, please use the Other Crops Planted field to delineate the additional crops. If you applied different chemicals to different crops, please use a separate entry for each crop you planted or harvested.

Row ID	Name of Business	Crops Planted or Harvested	Business City	Business State	From Month	From Year	To Month	To Year	Agricultural Chemicals You Applied:	How You Applied the Chemicals	Other Chemical Application Method:	Actions

There are no Entries.

Maximum number of entries reached.

NOTE: Add any additional farm/crop information by clicking on the add entry button.

(XI.) Training, Certification, Licensing

Have you ever received any formal training, certification, or licensing regarding agricultural chemicals of any kind, including, but not limited to paraquat? (“Formal” training includes instruction or tutorial provided by an employment supervisor.)(Required)

Yes

Please create a separate entry for each different type

Type of Training/Certification/Licensing*

Person or Entity Providing Training/Certification/Licensing

Month & Year of Completion

NOTE: Add any additional training, certification, and or licensing information by clicking on the (+) icon to the right.

(XII.) Workplace Paraquat Exposure

Were you exposed to Paraquat in your place of work?(Required)

Yes

For each time you were exposed to Paraquat (ie: handled, mixed, applied, assisted in application, sprayed or otherwise came in contact with) while working, provide the following information. If you use Paraquat on multiple crops at a single location, please use the Other Crops Used On field to delineate the additional crops.

Row ID	Specific Job Title During Exposure	From Year/Month (of Exposure)	To Year/Month (of Exposure)	Method of Use/Exposure (How Was it Used/Applied)?	Used on Approximately How Many Acres?	Approximately How Many Gallons Used?	How Many Days Per Year on Average Was It Applied?	Individual/Entity Who Sold or Supplied You with Paraquat?	Name of Product	Specific Location's Use, City	Specific Location's Use, State	Strength or Concentration of Product	What Other Product (If Any) Was Product Mixed With?	Do you possess records of purchase of product?	Name of Person/Entity Holding Applicator License	License Number (If Known)	Was a label affixed to any of the containers of the paraquat	Did you review and follow any instructions or recommendations included on the label and/or within the safety-related information?	Reviewed Date (Month & Year)	Did you wear any personal protective equipment when exposed to paraquat?	If YES to the previous question, what protective gear did you wear?	Actions

There are no Entries.

Maximum number of entries reached.

(XIII.) Other Paraquat Exposure

Do you claim that you were exposed to paraquat and/or a paraquat-based product in a location other than your workplace?(Required)

Yes

Please create a separate entry for each location outside of your workplace at which you were exposed to paraquat and/or a paraquat-based product and provide the requested information.

Row ID	Your Location at time of paraquat exposure	Other Exposure Locations:	Where did your paraquat exposure originate?	Your proximity from where the paraquat originated.	Description of paraquat exposure.	City	State	From Month	To Month	From year	To Year	Actions

There are no Entries.

Maximum number of entries reached.

NOTE: Add any additional location of exposure information by clicking on the add entry button.

(XIV.) Use of Other Industrial/Agricultural Chemicals

Have you ever been exposed to a "restricted use" agricultural chemical (other than paraquat)? NOTE: ROUNDUP is *not* considered “restricted use”.(Required)

Yes

If yes, please create a separate entry for each "restricted use" agricultural chemical (other than paraquat) that you handled, mixed, applied, assisted in application, sprayed or otherwise came in contact and identify the following.

Name of Product

Length of exposure

NOTE: Add any additional 'restricted use' information by clicking on the (+) icon to the right.

(XV.) Substance History

Have you ever used methamphetamines?(Required)

Yes

If yes, please create a separate entry for each time frame that you consistently or periodically used methamphetamines:

From Date (Use of methamphetamines)

To Date (Use of methamphetamines)

NOTE: Add any additional use of methamphetamines information by clicking on the (+) icon to the right.

(XVI.) Occupational Welding History

Have you ever been employed as a welder or welded for more than 50% of your workday?(Required)

Yes

If yes, please create a separate entry for each time frame that you were employed as a welder or welded for more than 50% of your workday.

Row ID	Employer Name	Employer Address	From Year	To Year	Frequency	City	State	Did your welding take place in confined space?	Types of Welding	Type of Metal Involved	Type of Equipment Used:	Actions

There are no Entries.

Maximum number of entries reached.

(XVII.) History of Head Injuries

Have you ever suffered from any head injuries that required medical treatment and/or concussions diagnosed by a medical professional?(Required)

Yes

If yes, please create a separate entry for each head injury and/or concussion and indicate the following:

Type of Injury/Concussion

From Date

To Date

(XVIII.) Knowledge Regarding Lawsuit

Do you have in your possession any documents or information (other than anything obtained through or from your attorneys) that the onset of the symptoms of the injury(ies) you are claiming in this lawsuit are connected in any way to your exposure to paraquat?(Required)

Yes

If yes, please identify such documents or information:

NOTE: Add any additional document identification information by clicking on the (+) icon to the right.

(XIX.) Wage Loss

Do you claim that you have been unable to work or had to transfer to a lesser paying employment role because of your claimed injury(ies) in this lawsuit?(Required)

Yes

If yes, please create a separate entry for each time period in which you were either unable to work or had to transfer to a lesser paying employment role because of your claimed injury(ies) and indicate the following.

Name of Employer

Employer Address (City, State)

From Date (of Wage Loss) Month/Year

To Date (of Wage Loss) Month/Year

(XX.) Relevant Persons/Witnesses

Is there any person(s) whom you believe has firsthand personal knowledge about your exposure and/or claimed injury(ies)?

Yes

Identify any person whom you believe has firsthand personal knowledge about your exposure and/or claimed injury(ies):

Name

Relationship

NOTE: Add any additional individuals information by clicking on the (+) icon to the right.

(XXI.) Communications Regarding Defendants

Have you, or anyone acting on your behalf, directly communicated with, interviewed, or obtained statements from (1) any of the Defendants (i.e. Syngenta Crop Protection LLC, Syngenta AG, Chevron USA Inc., or any other defendant named in your specific lawsuit) regarding the allegations in the lawsuit or (2) from any person or entity specifically about Defendants’ business with respect to paraquat, the health effects of paraquat, and/or the usage of and practices associated with paraquat in the United States, since the filing of this lawsuit? This question excludes privileged communications exclusively with your counsel, exclusively between you and your counsel, and between your counsel and experts retained in this litigation.

Yes

If you answered yes, identify any person whom you believe has firsthand personal knowledge about your exposure and/or cliamed injury(ies):

First Name

Last Name

Relationship

NOTE: Add any additional individuals information by clicking on the (+) icon to the right.

(XXII.) Bankruptcy

Since you were first exposed to Paraquat, have you filed for bankruptcy?(Required)

Yes

If yes, please create a separate entry for each time you filed for bankruptcy and provide the following information.

Name of Trustee.	Month You Filed for Bankruptcy:	Year You Filed for Bankruptcy:	Month Bankruptcy was Closed/Finalized:	Year Bankruptcy was Closed/Finalized:	Court Where Bankruptcy was Filed.	Name of Your Bankruptcy Attorney, if any:	Case Number	Actions

There are no Entries.

Maximum number of entries reached.

NOTE: Add any additional bankruptcy filings by clicking on the add entry button.

(XXIII.) Documentation

Section A. Any and all Documents showing any type of medical care, services, and/or consultation you have received from (1) all primary care providers you have seen from ten (10) years before you began experiencing symptoms for the injury(ies) you claim in this lawsuit through the present; (2) any neurologists who have treated you for a neurological disorder since birth; (3) any providers you have treated you in relation to any brain or head injury identified above; and (4) all providers you have seen since the onset of Parkinson’s Disease symptoms.(Required)

I do not have this document.

Yes I have this document.

Do you have an electronic copy(ies) of the "Section A." document(s) that you can upload now, and/or will you mail them to our firm via the return envelope in the PAQ mailer you received? Please select all that apply.

Electronic file upload

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Section B. Documents in your possession that show proof of your employment history, including Documents indicating the names of and your formal affiliations with any limited liability corporations, partnerships, or other business entities.(Required)

I do not have this document.

Yes I have this document.

Do you have an electronic copy(ies) of the "Section B." document(s) that you can upload now, and/or will you mail them to our firm via the return envelope in the PAQ mailer you received? Please select all that apply.

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Section C. All Documents related to any training, certification, or licensing that any person or entity, including you or any of your employers or supervisors, have received related to Restricted Use Chemicals, including but not limited to paraquat.(Required)

I do not have this document.

Yes I have this document.

Do you have an electronic copy(ies) of the "Section C." document(s) that you can upload now, and/or will you mail them to our firm via the return envelope in the PAQ mailer you received? Please select all that apply.

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Section D. All Documents (including, without limitation, receipts, invoices, labeling, instructions, warnings, precautions, and marketing materials) relating to your purchase, use, handling, and/or disposal of agricultural chemicals, including but not limited to paraquat, and/or the purchase, use, handling, and/or disposal of Restricted Use Chemicals at farms at which you worked.(Required)

I do not have this document.

Yes I have this document.

Do you have an electronic copy(ies) of the "Section D." document(s) that you can upload now, and/or will you mail them to our firm via the return envelope in the PAQ mailer you received? Please select all that apply.

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Section E. All Documents, including all publications or studies, from which you, your family members, or your personal acquaintances have relied upon to learn about the relationship between Parkinson’s disease and paraquat.(Required)

I do not have this document.

Yes I have this document.

Do you have an electronic copy(ies) of the "Section E." document(s) that you can upload now, and/or will you mail them to our firm via the return envelope in the PAQ mailer you received? Please select all that apply.

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Section F. All Documents, including public records, identifying, referring, or relating to surveillance, investigation, or other information gathering performed by or on behalf of Plaintiff relating to any of the Defendants in this action, Defendants’ employees (current or former), and Defendants’ disclosed witnesses in this case. This Request includes Documents obtained from any source.(Required)

I do not have this document.

Yes I have this document.

Do you have an electronic copy(ies) of the "Section F." document(s) that you can upload now, and/or will you mail them to our firm via the return envelope in the PAQ mailer you received? Please select all that apply.

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Section G. All Documents in your possession that refer or relate to Defendants in this action or Defendants’ employees (current or former). This Request includes but is not limited to surveys, questionnaires, promotional materials, or other Documents or materials exchanged between you and Defendants.(Required)

I do not have this document.

Yes I have this document.

Do you have an electronic copy(ies) of the "Section G." document(s) that you can upload now, and/or will you mail them to our firm via the return envelope in the PAQ mailer you received? Please select all that apply.

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Section H. Documents reflecting, depicting, or describing any piece of farm equipment or implement you used to apply paraquat at any time, including without limitation the tractor, tank, and sprayer (including nozzles). For row crops, this request includes the farm equipment or implement(s) used to prepare, or to plant any crop planted on, acreage treated with paraquat, including without limitation the planter, drill, any type of cultivator or harrow, and fertilizer application equipment. This request encompasses documents such as, without limitation, photographs, videos, equipment manuals or instructions, proof of purchase, warranties, and/or maintenance or repair records.(Required)

I do not have this document.

Yes I have this document.

Do you have an electronic copy(ies) of the "Section H." document(s) that you can upload now, and/or will you mail them to our firm via the return envelope in the PAQ mailer you received? Please select all that apply.

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Section I. Inspection of any equipment or implement responsive to Request H (directly above) that remains in your possession.(Required)

I do not have this document.

Yes I have this document.

Do you have an electronic copy(ies) of the "Section I." document(s) that you can upload now, and/or will you mail them to our firm via the return envelope in the PAQ mailer you received? Please select all that apply.

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Section J. All Documents identified in your answers to any interrogatories directed to you in this case and all Documents on which you relied in responding to any questions directed to you in this case.(Required)

I do not have this document.

Yes I have this document.

Do you have an electronic copy(ies) of the "Section J." document(s) that you can upload now, and/or will you mail them to our firm via the return envelope in the PAQ mailer you received? Please select all that apply.

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(XXIV.) Authorization Documents

(1) Authorization for release of Health Information (Attachment A). For this authorization, include an authorization for release of records for all health Care Providers listed in this Fact Sheet, including those listed in sections VIII and XVII. Please upload the relevant document:

Is A Confidential Document

(1) Upload (Attachment A) Document Here:

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(2) Authorization to Disclose Employment Information (Attachment B). For this authorzation, include an authorzation for release of records for all employers listed in Section IV. Please upload the relevant document:

Is A Confidential Document

(2) Upload (Attachment B) Document Here:

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(3) Request Pertaining to Military Records (Attachment C). Please upload the relevant document below:

Is A Confidential Document

(3) Upload (Attachment C) Document Here:

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(XXV.) Verification

Pursuant to 28 U.S.C. § 1746, I declare that all information provided in connection with this Plaintiff Assessment Questionnaire is true and correct to the best of my knowledge, information, and belief. I further declare that I have engaged in the best efforts to identify, locate, and supply all of the information and documentation requested in this Plaintiff Assessment Questionnaire. I acknowledge that I may supplement the above responses if necessary.

I was exposed to the chemical paraquat. I declare and affirm this based on the information and evidence included in this form including the dates, location, and exposure information that I have supplied above.

I declare under penalty of perjury that the foregoing is true and correct.

Please upload the relevant document below(Required)

Is Confidential Document

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