Additional Information: Please upload supporting case documents...

[VLN-Roundup] Saddle Rock Intake Questionnaire

Legal Information

*Please be advised that this call is recorded for training and information purposes and that your responses will be recorded exactly as you state them and reviewed by our staff and counsel. The informa... *

INBOUND ONLY: Please be advised that this call may be recorded for quality and training purposes. If you agree to receive automated text notifications and phone calls by or on behalf of Saddle Rock to the number you are calling from regarding your potential case, please clearly say “Yes.” Your consent is not a condition of purchase. (If outbound, leave blank)

*Are you willing to affirm, under penalty, that you have not sought legal representation or advice from any other law firm or attorney for this specific matter? *

*Prior to contacting Young & Partners, LLP to discuss your potential claim, have you contacted or spoken with any other law firm regarding this matter or previously settled a Round up claim with an... *

If Yes, Name and Address of law firm

If Yes, did you sign an employment contract

*We understand the importance of keeping you updated on the progress of your case. Our goal is to provide regular updates, usually every 90 days. We offer flexible communication options including phone calls, texts, emails, or other means. Please let us know your preferred method of communication or if you have any specific platforms or channels you prefer for receiving updates: *

*What is the best way to reach this lead/intake/client? During the day, after 5 pm on weekdays, etc *

Caller Information

*First Name *

*Last Name *

*Street Address Line 1 *

Street Address Line 2

*City *

County name

*State *

*Zip *

*Phone *

Home Phone

*Email *

Secondary Email Address

Injured Party Information

*Are you calling on behalf of yourself or someone else? *

*Injured Party's full name *

*Date of birth *

Social Security Number

*Is the injured party deceased? *

If yes, when did they pass away and what was listed as the cause of death on the death certificate?

*Is the Injured Party a Minor? *

*Is the Injured Party Married? *

Round Up

*How did you first learn of a connection between Roundup and your injuries/cancer? *

*Date of first exposure/usage (at least the approx year) *

*Date of last exposure/use (Total date range must have used for at least 10 hours or 10 total times of use over a minimum of 2 years. If less, disqualify) *

*What is the total number of years you used Roundup? *

*In what state(s) did you use Roundup in? (please list all) *

*Did you use Roundup at home, work, or both? [ Match case to the possible value set given] *

*Please list the home address(es) where you used it. (Please list all) *

*Please list the work address(es) were you used it. (Please list all) *

*Where did you apply it and how big of an area was it applied? (Was it a residential, commerical, farm, a fence line, yard, acres, etc.) *

*How was it applied? (Hand sprayer, backpack, tractor with hoses, etc.) *

*What type of Roundup was used Concentrate, Pre-Mix or both? [ Match case to the possible value set given] *

*Was it applied seasonly yearly or monthly? *

*How often was it applied? (# of uses est. per year) *

*Were you exposed indirectly or directly? *

*How were you first exposed to Roundup? *

*Why did you stop using Roundup? *

*When and where was the Roundup purchased? *

*Describe what purchase information you may have or can obtain (proof of purchase(s), pictures, or credit card receipts) *

*Do you live near a water well? *

If yes, has it been tested and do you have the results? (Please describe)

Medical

*Have you been diagnosed with Non-Hodgkin's Lymphoma? *

*What Subtype Of Non-Hodgkin's Or Blood Cancer Do You Have? (Please Reference The Approved List) Unkown Is Ok, But If It Is Not Specifically Listed DQ [ Match Case To The Possible Value Set Given] *

*How old were you at the time of diagnosis? (If under 18 or over 80 at time of dx, disqualify) *

*When were you diagnosed? (Must be after 2000 if alive or after 2014 if a death case) *

*What treatment have you received? (Please list treatments for Chemo, Radiation & Surgery and the dates of each) *

*Please list the names of the treating physician(s) and facility/hosipital information of your treatments (Doctor's Name, Hospital name, and full address. List all) *

*Do you have a medical record that indicates the cancer dx and type? *

*Have there been any recurrences? (Did the cancer return after being in remission?) *

If so, what is the date(s) of reccurrence? (Please list all)

Prior to your current Cancer dx, did you have a history of any of the following? [ Send multiple values seperated by a comma]

If you marked yes to any of these, please list all relevant information

*Are you a smoker? *

2-3 Sentence of Case Summary

*Case Description/Synopsis of the Case *

Emergency Contact

*Emergency Contact Name *

*Emergency Contact Relationship *

*Emergency Phone *