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3M AERO Unfiled Case Census Form
3M AERO Unfiled Case Census Form
Golamac Support
2019-11-12T16:10:53-06:00
Claimant Information
Claimant Name
*
Claimant Email
*
Enter Email
Confirm Email
Law Firm
*
Gender
*
Male
Female
Date of Birth
*
MM slash DD slash YYYY
Current State of Residence
*
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Number of years in current state of residence
*
Military Service
Did the claimant serve in the military and/or armed forces?
*
Yes
No
Is the claimant currently on active military duty?
*
Yes
No
If Yes to the above, Identify each branch of service the claimant served in, and the dates of service in each branch.
Branch of Service (1)
*
Army
Air Force
Marine Corps
Navy
Coast Guard
Reserves
National Guard
Branch Start Date (1)
*
MM slash DD slash YYYY
Branch End Date (1)
*
MM slash DD slash YYYY
Presently Serving (1)
*
Yes
No
Branch of Service (2)
Army
Air Force
Marine Corps
Navy
Coast Guard
Reserves
National Guard
Branch Start Date (2)
MM slash DD slash YYYY
Branch End Date (2)
MM slash DD slash YYYY
Presently Serving (2)
Yes
No
Branch of Service (3)
Army
Air Force
Marine Corps
Navy
Coast Guard
Reserves
National Guard
Branch Start Date (3)
MM slash DD slash YYYY
Branch End Date (3)
MM slash DD slash YYYY
Presently Serving (3)
Yes
No
Branch of Service (4)
Army
Air Force
Marine Corps
Navy
Coast Guard
Reserves
National Guard
Branch Start Date (4)
MM slash DD slash YYYY
Branch End Date (4)
MM slash DD slash YYYY
Presently Serving (4)
Yes
No
Branch of Service (5)
Army
Air Force
Marine Corps
Navy
Coast Guard
Reserves
National Guard
Branch Start Date (5)
MM slash DD slash YYYY
Branch End Date (5)
MM slash DD slash YYYY
Presently Serving (5)
Yes
No
Duty Station
Identiry each of the claimant's duty stations between 2000 and the present.
Duty Station (1)
*
Duty Station Start Date (1)
*
MM slash DD slash YYYY
Duty Station End Date (1)
*
MM slash DD slash YYYY
Present Duty Station (1)
*
Yes
No
Duty Station (2)
Duty Station Start Date (2)
MM slash DD slash YYYY
Duty Station End Date (2)
MM slash DD slash YYYY
Present Duty Station (2)
Yes
No
Duty Station (3)
Duty Station Start Date (3)
MM slash DD slash YYYY
Duty Station End Date (3)
MM slash DD slash YYYY
Present Duty Station (3)
Yes
No
Duty Station (4)
Duty Station Start Date (4)
MM slash DD slash YYYY
Duty Station End Date (4)
MM slash DD slash YYYY
Present Duty Station (4)
Yes
No
Duty Station (5)
Duty Station Start Date (5)
MM slash DD slash YYYY
Duty Station End Date (5)
MM slash DD slash YYYY
Present Duty Station (5)
Yes
No
Duty Station (6)
Duty Station Start Date (6)
MM slash DD slash YYYY
Duty Station End Date (6)
MM slash DD slash YYYY
Present Duty Station (6)
Yes
No
Duty Station (7)
Duty Station Start Date (7)
MM slash DD slash YYYY
Duty Station End Date (7)
MM slash DD slash YYYY
Present Duty Station (7)
Yes
No
Duty Station (8)
Duty Station Start Date (8)
MM slash DD slash YYYY
Duty Station End Date (8)
MM slash DD slash YYYY
Present Duty Station (8)
Yes
No
Duty Station (9)
Duty Station Start Date (9)
MM slash DD slash YYYY
Duty Station End Date (9)
MM slash DD slash YYYY
Present Duty Station (9)
Yes
No
Duty Station (10)
Duty Station Start Date (10)
MM slash DD slash YYYY
Duty Station End Date (10)
MM slash DD slash YYYY
Present Duty Station (10)
Yes
No
Occupational Specialties
Identify the claimant's military occupational specialties between 2000 and present.
Military Occupation Specialty (1)
*
Specialty Start Date (1)
*
MM slash DD slash YYYY
Specialty End Date (1)
*
MM slash DD slash YYYY
Present Specialty (1)
*
Yes
No
Military Occupation Specialty (2)
Specialty Start Date (2)
MM slash DD slash YYYY
Specialty End Date (2)
MM slash DD slash YYYY
Present Specialty (2)
Yes
No
Military Occupation Specialty (3)
Specialty Start Date (3)
MM slash DD slash YYYY
Specialty End Date (3)
MM slash DD slash YYYY
Present Specialty (3)
Yes
No
Military Occupation Specialty (4)
Specialty Start Date (4)
MM slash DD slash YYYY
Specialty End Date (4)
MM slash DD slash YYYY
Present Specialty (4)
Yes
No
Military Occupation Specialty (5)
Specialty Start Date (5)
MM slash DD slash YYYY
Specialty End Date (5)
MM slash DD slash YYYY
Present Specialty (5)
Yes
No
Military Occupation Specialty (6)
Specialty Start Date (6)
MM slash DD slash YYYY
Specialty End Date (6)
MM slash DD slash YYYY
Present Specialty (6)
Yes
No
Military Occupation Specialty (7)
Specialty Start Date (7)
MM slash DD slash YYYY
Specialty End Date (7)
MM slash DD slash YYYY
Present Specialty (7)
Yes
No
Military Occupation Specialty (8)
Specialty Start Date (8)
MM slash DD slash YYYY
Specialty End Date (8)
MM slash DD slash YYYY
Present Specialty (8)
Yes
No
Military Occupation Specialty (9)
Specialty Start Date (9)
MM slash DD slash YYYY
Specialty End Date (9)
MM slash DD slash YYYY
Present Specialty (9)
Yes
No
Military Occupation Specialty (10)
Specialty Start Date (10)
MM slash DD slash YYYY
Specialty End Date (10)
MM slash DD slash YYYY
Present Specialty (10)
Yes
No
Combat Arms Earplugs version 2 (CAEv2) usage
Did the claimant use the Combat Arms Earplugs version 2 (“CAEv2”) when he or she served in the military and/or armed forces?
*
Yes
No
If yes to the above, State whether the claimant used CAEv2 in training, combat, or both:
Training
Combat
Both
Identify the year(s), duty station(s), and military occupational specialties in which the claimant used the CAEv2 earplugs:
Year(s) of Use (1)
*
Duty Station(s) (1)
*
Military Occupational Specialty (1)
*
Year(s) of Use (2)
Duty Station(s) (2)
Military Occupational Specialty (2)
Year(s) of Use (3)
Duty Station(s) (3)
Military Occupational Specialty (3)
Year(s) of Use (4)
Duty Station(s) (4)
Military Occupational Specialty (4)
Year(s) of Use (5)
Duty Station(s) (5)
Military Occupational Specialty (5)
Did the claimant use CAEv2 earplugs as a civilian any time?
*
Yes
No
Identify the physical injuries claimant sustained as a result of using CAEv2 earplugs:
*
Total Hearing Loss, Left Ear
Total Hearing Loss, Right Ear
Partial Hearing Loss, Left Ear
Partial Hearing Loss, Right Ear
Tinnitus, Left Ear
Tinnitus, Right Ear
Tinnitus - Extent Unknown
Other
Other Injury, Please 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 the following:
The YEAR that the CAEv2 was not providing adequate protection from loud noises:
Unknown
Don’t remember
Not applicable
Never
I didn’t notice
Other
The YEAR that the the injury described above was noticed.
Injury (1)
*
Total Hearing Loss, Left Ear
Total Hearing Loss, Right Ear
Partial Hearing Loss, Left Ear
Partial Hearing Loss, Right Ear
Tinnitus, Left Ear
Tinnitus, Right Ear
Tinnitus - Extent Unknown
Other
Approx. year first noticed injury (1)
*
Injury (2)
Total Hearing Loss, Left Ear
Total Hearing Loss, Right Ear
Partial Hearing Loss, Left Ear
Partial Hearing Loss, Right Ear
Tinnitus, Left Ear
Tinnitus, Right Ear
Tinnitus - Extent Unknown
Other
Approx. year first noticed injury (2)
Injury (3)
Total Hearing Loss, Left Ear
Total Hearing Loss, Right Ear
Partial Hearing Loss, Left Ear
Partial Hearing Loss, Right Ear
Tinnitus, Left Ear
Tinnitus, Right Ear
Tinnitus - Extent Unknown
Other
Approx. year first noticed injury (3)
Injury (4)
Total Hearing Loss, Left Ear
Total Hearing Loss, Right Ear
Partial Hearing Loss, Left Ear
Partial Hearing Loss, Right Ear
Tinnitus, Left Ear
Tinnitus, Right Ear
Tinnitus - Extent Unknown
Other
Approx. year first noticed injury (4)
Injury (5)
Total Hearing Loss, Left Ear
Total Hearing Loss, Right Ear
Partial Hearing Loss, Left Ear
Partial Hearing Loss, Right Ear
Tinnitus, Left Ear
Tinnitus, Right Ear
Tinnitus - Extent Unknown
Other
Approx. year first noticed injury (5)
Has the hearing loss identified above been identified during an audiogram or other hearing test?
*
Yes
No
If yes, what was the approximate date of the first audiograms or other hearing tests that identified the injuries described above?
Injury Identified (1)
Total Hearing Loss, Left Ear
Total Hearing Loss, Right Ear
Partial Hearing Loss, Left Ear
Partial Hearing Loss, Right Ear
Tinnitus, Left Ear
Tinnitus, Right Ear
Tinnitus - Extent Unknown
Other
Approx. Date of the first hearing tests (1)
MM slash DD slash YYYY
Injury Identified (2)
Total Hearing Loss, Left Ear
Total Hearing Loss, Right Ear
Partial Hearing Loss, Left Ear
Partial Hearing Loss, Right Ear
Tinnitus, Left Ear
Tinnitus, Right Ear
Tinnitus - Extent Unknown
Other
Approx. Date of the first hearing tests (2)
MM slash DD slash YYYY
Injury Identified (3)
Total Hearing Loss, Left Ear
Total Hearing Loss, Right Ear
Partial Hearing Loss, Left Ear
Partial Hearing Loss, Right Ear
Tinnitus, Left Ear
Tinnitus, Right Ear
Tinnitus - Extent Unknown
Other
Approx. Date of the first hearing tests (3)
MM slash DD slash YYYY
Injury Identified (4)
Total Hearing Loss, Left Ear
Total Hearing Loss, Right Ear
Partial Hearing Loss, Left Ear
Partial Hearing Loss, Right Ear
Tinnitus, Left Ear
Tinnitus, Right Ear
Tinnitus - Extent Unknown
Other
Approx. Date of the first hearing tests (4)
MM slash DD slash YYYY
Injury Identified (5)
Total Hearing Loss, Left Ear
Total Hearing Loss, Right Ear
Partial Hearing Loss, Left Ear
Partial Hearing Loss, Right Ear
Tinnitus, Left Ear
Tinnitus, Right Ear
Tinnitus - Extent Unknown
Other
Approx. Date of the first hearing tests (5)
MM slash DD slash YYYY
Has the claimant received disability benefits as a result of hearing loss, tinnitus or other hearing injury?
*
Yes
No
If yes, identify the agency or entity that provided the claimant with disability benefits:
Thank you for filling out the information in the census form. Please click below to be forwarded to REQUIRED E-SIGNATURE functionality.
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