3M Aero Filed Case Census Form


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.:
      BranchStart DateEnd DateIs Present?

    • Identify each of the claimant's duty stations between 2000 and present:
      Duty Station/Military Occupational Specialty Start DateEnd DateIs 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 SpecialtyStart DateEnd DateIs 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 aboveApprox. 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 IdentifiedApprox. 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:  
 

Declaration

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.


Claimant Name:  
Claimant Email:

Leave this empty:

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Signature Certificate
Document name: 3M Aero Filed Case Census Form
lock iconUnique Document ID: d1caaf75864eaab059c6833fa842d830421cbc1b
TimestampAudit
August 27, 2020 3:48 pm CST3M Aero Filed Case Census Form Uploaded by Ketra Francis - kfrancis@hollandtriallawyers.com IP 104.53.59.73