3M AERO Unfiled Case Census Form

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*
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)*
- 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)
- 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)
- 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)
- 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)
- 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:
The YEAR that the the injury described above was noticed.
- Injury (1)*
- Approx. year first noticed injury (1)*
- Injury (2)
- Approx. year first noticed injury (2)
- Injury (3)
- Approx. year first noticed injury (3)
- Injury (4)
- Approx. year first noticed injury (4)
- Injury (5)
- 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)
- Approx. Date of the first hearing tests (1)
  MM slash DD slash YYYY
- Injury Identified (2)
- Approx. Date of the first hearing tests (2)
  MM slash DD slash YYYY
- Injury Identified (3)
- Approx. Date of the first hearing tests (3)
  MM slash DD slash YYYY
- Injury Identified (4)
- Approx. Date of the first hearing tests (4)
  MM slash DD slash YYYY
- Injury Identified (5)
- 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.

3M AERO Unfiled Case Census Form

Claimant Information

Military Service

Duty Station

Occupational Specialties

Combat Arms Earplugs version 2 (CAEv2) usage