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CAMP LEJEUNE WATER CONTAMINATION LAWSUIT

INTAKE QUESTIONNAIRE FORM

NOTE: PLEASE answer every question as completely as possible. Failure to provide complete details will delay our ability to review and process your case. PLEASE either print clearly and neatly OR type form.

Case Number

INFORMATION RE: DECEASED (IF APPLICABLE)

If person on whose behalf you are bringing this claim is deceased, please provide:

Date of Death

Place of Death (City & State)

City

State

Cause of death (if known)

What is your relationship to the decedent?

Was the decedent married at the time of their death?

Yes No

If yes, what is the full name of the decedent’s spouse?*

First Name

Last Name

Decedent’s social security number

Decedent’s date of birth

Do you have a copy of the death certificate?

Yes No

If yes, please provide a copy of the death certificate when returning this document.

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Did the decedent have a Last Will?

Yes No

Has an Executor or Administrator been appointed?

Yes No

If yes, please provide a copy of Letters of Administration/Letters Testamentary when returning this document.

No File Chosen

File uploads may not work on some mobile devices.

TIME SPENT AT CAMP LEJEUNE BY INJURED/DECEASED PARTY

Dates Lived/Worked at Camp Lejeune From*

From

Dates Lived/Worked at Camp Lejeune To*

Did you or the decedent live or work at Camp Lejeune for more than 30 days between August 1, 1953 and December 31, 1987?

Yes No

If “Yes”, was the exposed party serving in the military?

Yes No

If the exposed party was serving in the military, what was their military occupation

If “No”, was the exposed party a relative of a service member?

Yes No

If “Yes”, please indicate the exposed party’s relationship to the service member

Self Spouse Child

Other:

What was the name/address of the community/where the exposed party resided?

Community*

Time frame of Residence

Additional Community if Applicable

Time frame of Residence

Was the exposed party a civilian worker at Camp Lejeune?

Yes No Not Applicable

Where did the exposed party work at Camp Lejeune?

When did the exposed party work at Camp Lejeune?

What was the exposed party’s occupation while working at Camp Lejeune?

If no, why was the exposed party present at Camp Lejeune for more than 30 days between

8/1/1953 and 12/31/1987?

Does the exposed party have a family history of any of the following?

Does the exposed party have a family history of any of the following?
	Yes	No
Leukemia	Does the exposed party have a family history of any of the following? : Leukemia (Yes)	Leukemia (No)
Liver Cancer	Liver Cancer (Yes)	Liver Cancer (No)
Bladder Cancer	Bladder Cancer (Yes)	Bladder Cancer (No)
Kidney Cancer	Kidney Cancer (Yes)	Kidney Cancer (No)
Parkinson’s Disease	Parkinson’s Disease (Yes)	Parkinson’s Disease (No)

Please check all that apply and list the family member that suffered from the condition

(i.e., mother, father, sibling, grandparent)

Has the exposed party ever smoked cigarettes?

Yes No

If Yes, when did the exposed party smoke?

If Yes, how many cigarettes/packs per day/week?

If applicable, does the exposed party currently smoke cigarettes?

Yes No

If no, when did the exposed party quit smoking?

Has the exposed party been diagnosed with the following conditions

Has the exposed party been diagnosed with the following conditions
	Yes	No
Adult Fibrosarcoma	Has the exposed party been diagnosed with the following conditions: Adult Fibrosarcoma (Yes)	Adult Fibrosarcoma (No)
Adult leukemia	Adult leukemia (Yes)	Adult leukemia (No)
Aplastic anemia	Aplastic anemia (Yes)	Aplastic anemia (No)
Bladder cancer	Bladder cancer (Yes)	Bladder cancer (No)
Breast cancer	Breast cancer (Yes)	Breast cancer (No)
Cancer of the Bronchus	Cancer of the Bronchus (Yes)	Cancer of the Bronchus (No)
Cancer of the Larynx	Cancer of the Larynx (Yes)	Cancer of the Larynx (No)
Cancer of the Trachea	Cancer of the Trachea (Yes)	Cancer of the Trachea (No)
Central Nervous System Damage	Central Nervous System Damage (Yes)	Central Nervous System Damage (No)
Chronic Lymphocycic Leukemia	Chronic Lymphocycic Leukemia (Yes)	Chronic Lymphocycic Leukemia (No)
Epstein-Barr Virus	Epstein-Barr Virus (Yes)	Epstein-Barr Virus (No)
Esophageal cancer	Esophageal cancer (Yes)	Esophageal cancer (No)
Female infertility	Female infertility (Yes)	Female infertility (No)
Hepatic steatosis	Hepatic steatosis (Yes)	Hepatic steatosis (No)
Hodgkin Disease	Hodgkin Disease (Yes)	Hodgkin Disease (No)
Immune Disorders	Immune Disorders (Yes)	Immune Disorders (No)
Kidney cancer	Kidney cancer (Yes)	Kidney cancer (No)
Kidney Damage	Kidney Damage (Yes)	Kidney Damage (No)
Leukemia	Leukemia (Yes)	Leukemia (No)
Liver cancer	Liver cancer (Yes)	Liver cancer (No)
Liver Damage	Liver Damage (Yes)	Liver Damage (No)
Lung cancer	Lung cancer (Yes)	Lung cancer (No)
Lymphoma	Lymphoma (Yes)	Lymphoma (No)
Miscarriage	Miscarriage (Yes)	Miscarriage (No)
Multiple myeloma	Multiple myeloma (Yes)	Multiple myeloma (No)
Myelodyplastic Syndrome	Myelodyplastic Syndrome (Yes)	Myelodyplastic Syndrome (No)
Refractory anemia with blasts	Refractory anemia with blasts (Yes)	Refractory anemia with blasts (No)
Refractory anemia with ringed sideroblasts	Refractory anemia with ringed sideroblasts (Yes)	Refractory anemia with ringed sideroblasts (No)
Refractory anemia	Refractory anemia (Yes)	Refractory anemia (No)
Refractory cytopenia with multilineage	Refractory cytopenia with multilineage (Yes)	Refractory cytopenia with multilineage (No)
Dysplasia and ringed sideroblasts	Dysplasia and ringed sideroblasts (Yes)	Dysplasia and ringed sideroblasts (No)
Refractory cytopenia with multilineage dysplasia	Refractory cytopenia with multilineage dysplasia (Yes)	Refractory cytopenia with multilineage dysplasia (No)
Neurobehavioral effects	Neurobehavioral effects (Yes)	Neurobehavioral effects (No)
Non-Hodgkin’s lymphoma	Non-Hodgkin’s lymphoma (Yes)	Non-Hodgkin’s lymphoma (No)
Parkinson’s disease	Parkinson’s disease (Yes)	Parkinson’s disease (No)
Prostate Cancer	Prostate Cancer (Yes)	Prostate Cancer (No)
Renal toxicity	Renal toxicity (Yes)	Renal toxicity (No)
Scleroderma	Scleroderma (Yes)	Scleroderma (No)
Soft-Tissue Sarcoma	Soft-Tissue Sarcoma (Yes)	Soft-Tissue Sarcoma (No)

Please check all that apply and list the date of diagnosis

Diagnosis Date

Additional Diagnosis Date - If applicable

Additional Diagnosis Date 2 - If applicable

Additional Diagnosis Date 3 - If applicable

Describe

MEDICAL PROVIDER(S) INFORMATION

Please list the following for the facility and/or doctor that diagnosed the above-listed condition(s):

Name of Medical Facility/Clinic/Practice

Names of Physician(s)

First Name

Last Name

Medical Facility Address

Address Line 1

Address Line 2

City

State

ZIP Code

Phone

Dates(s) of treatment

What treatment was rendered?

Was there an additional Medical Facility/Clinic/Practice?

Yes No

Additional Name of Medical Facility/Clinic/Practice

Additional Names of Physician(s)

First Name

Last Name

Additional Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Additional Medical Phone Facility Number

Dates(s) of treatment

What treatment was rendered?

Has any physician told you that this condition(s) may be related to residing at Camp Lejeune?

Yes No

Name of Medical Facility/Clinic/Practice

Names of Physician(s)

First Name

Last Name

Medical Practice Address

Medical Practice Phone Number

What exactly did the doctor say?

When (month/year) did you become aware that this condition could be related to the contaminated water?

Name of Medical Facility/Clinic/Practice

Medical Facility Names of Physician(s)

First Name

Last Name

Medical Facility Address

Medical Facility Phone

Dates(s) of treatment

What treatment was rendered?

Name of Medical Facility/Clinic/Practice

Names of Physician(s)

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Phone

Dates(s) of treatment

What treatment was rendered?

Has any physician told you that this condition(s) may be related to residing at Camp Lejeune?

Yes No

Name of Medical Facility/Clinic/Practice

Names of Physician(s)

First Name

Last Name

Medical Facility Phone Number

Address

Address Line 1

Address Line 2

City

State

ZIP Code

What exactly did the doctor say?

Did anyone else associate the exposed party’s condition(s) to Camp Lejeune

Yes No

If yes, who and what did they say

What treatment was rendered

When (month/year) did you become aware that this condition could be related to the contaminated water?

OTHER INFORMATION

Please advise us of any other information you may feel is relevant and/or important to us in evaluating this potential case

Attach additional paper as necessary

Please complete this questionnaire in its entirety.
Failure to provide complete responses will only delay our ability to review and process your case.
Please use additional paper, if necessary.

Signature

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Signature Date

CAMP LEJEUNE WATER CONTAMINATION LAWSUIT

NOTE: PLEASE answer every question as completely as possible. Failure to provide complete details will delay our ability to review and process your case. PLEASE either print clearly and neatly OR type form.

YOUR CONTACT INFORMATION (person completing this form)

INFORMATION RE: DECEASED (IF APPLICABLE)

TIME SPENT AT CAMP LEJEUNE BY INJURED/DECEASED PARTY

What was the name/address of the community/where the exposed party resided?

MEDICAL PROVIDER(S) INFORMATION

OTHER INFORMATION