3M Unfiled Case Census Form ESignature


EXHIBIT B
Unfiled Case Census Form
Initial Census Questions

  1. Information
    • Claimant Name:  
    • Claimant Email:
    • Law Firm:  
    • Gender:  
    • Current State of Residence:  
    • Number of years in current state of residence:

  2. Did the claimant serve in the military and/or armed forces?  
    • Identify each branch the claimant served in, and the dates of service in each branch:
      BranchStart DateEnd DateIs Present?

    • Identify each of the claimant's duty stations between 2000 and present:
      Duty StationStart DateEnd DateIs Present?

    • Identify each of the claimant's military occupational specialties between 2000 and present:
      Military Occupation SpecialtyStart DateEnd DateIs Present?

  3. Is the claimant current on active military duty?

  4. 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

  5. Did the claimant use CAEv2 earplugs as a civilian any time?

  6. Identify the physical injuries claimant sustained as a result of using CAEv2 earplugs:
    • Identication:  
    • If Other - Specify:  
    • Percentage/grade of hearing loss in LEFT EAR, if known:  
    • Percentage/grade of hearing loss in RIGHT EAR, if known:

  7. 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

  8. 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


  9. 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 Initial 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 Unfiled Case Census Form ESignature
lock iconUnique Document ID: bcc4dd3e44fc90e777694ef685c99e255b69a25f
TimestampAudit
November 11, 2019 5:33 pm CST3M Unfiled Case Census Form ESignature Uploaded by Ketra Francis - kfrancis@hollandtriallawyers.com IP 104.53.59.73
November 11, 2019 5:33 pm CST3M Unfiled Case Census Form ESignature Uploaded by Ketra Francis - kfrancis@hollandtriallawyers.com IP 104.53.59.73