EXHIBIT B
Filed  Case Census Form
Initial Census Questions

• Information
  • Claimant Name:
  • Claimant Email:
  • Original Case#:  
  • Original Case Filing Date:
  • MDL Case#:
  • MDL Case Filing Date:
  • Law Firm:
  • Gender:
  • Current State of Residence:
  • Number of years in current state of residence:
    
    
• Did the claimant serve in the military and/or armed forces?
  • Identify each of the claimant's duty stations between 2000 and the present.:
    

    Branch	Start Date	End Date	Is Present?

    
    
  • Identify each of the claimant's duty stations between 2000 and present:
    

    Duty Station/Military Occupational Specialty	Start Date	End Date	Is Present?	Used Combat Earplugs?
    Duty Station: Military Occupational Specialty:
    Duty Station: Military Occupational Specialty:
    Duty Station: Military Occupational Specialty:
    Duty Station: Military Occupational Specialty:
    Duty Station: Military Occupational Specialty:
    Duty Station: Military Occupational Specialty:
    Duty Station: Military Occupational Specialty:
    Duty Station: Military Occupational Specialty:
    Duty Station: Military Occupational Specialty:
    Duty Station: Military Occupational Specialty:

    
    
  • Identify each of the claimant's military occupational specialties between 2000 and present:
    

    Military Occupation Specialty	Start Date	End Date	Is Present?

    
    
• Is the claimant current on active military duty?
  
  
• Did the claimant use the Combat Arms Earplugs version 2 (“CAEv2”) when he or she served in the military and/or armed forces?
  • If yes, State whether the claimant used CAEv2 in training, combat or both:  
  • Identify the year(s), duty station(s), and military occupational specialties in which the claimant used the CAEv2 earplugs:
    

    Year(s)	Duty Station(s)	Military Occupation Specialty

    
    
• Did the claimant use CAEv2 earplugs, the Indoor-Outdoor Range earplugs, or the EAR Arc earplugs as a civilian at any time? 
  
  • If yes, select all that apply:  
  • Specify reason for use:  
• Identify the physical injuries claimant sustained as a result of using CAEv2 earplugs:
  • Identification:  
  • If Other - Specify:  
  • Percentage/grade of hearing loss in LEFT EAR, if known:  
  • Percentage/grade of hearing loss in RIGHT EAR, if known:
    
    
• Identify the approximate year on which the claimant first noticed:
  • that the CAEv2 was not providing adequate protection from loud noises;
  • the injury described above.
    

    Injury described above	Approx. year first noticed injury

    
    
• Has the hearing loss identified above been identified during an audiogram or other hearing test?
  • If yes, what was the approximate date of the first audiograms or other hearing tests that identified the injuries described above?
    

    Injury Identified	Approx. date of the first hearing tests

    
    
    
• Has the claimant received disability benefits as a result of hearing loss, tinnitus or other hearing injury?
  • If yes, identify the agency or entity that provided the claimant with disability benefits:  

I declare under penalty of perjury pursuant to 28 U.S.C. § 1746 that all the information provided in response to these Census Questions is true and correct to the best of my knowledge, information and belief formed after a reasonable inquiry. I understand that I am under an obligation to supplement these responses.

Today's Date:
Claimant Name:  
Claimant Email: