Aqueous Film-Forming Foam Exposure Questionnaire

Background Information

Please enter the information of the affected person:

Client's Name

Place of Birth

Birthdate

Social Security Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email

Spouse's Name

Spouse's Date of Birth

Spouse's Social Security Number

Are you a member of the International Association of Firefighters Union?

Member of International Association of Firefighters Union?

Yes
No

Are you a member of any other unions?

Member of Other Union?

Yes
No

Please List Any Additional Unions of which You Are a Member:

Are you a member of a local union?

Member of Local Union?

Yes
No

Please List Your Local Union's Name and Address:

Are you a professional or volunteer firefighter?

Professional or Volunteer Firefighter?

Professional
Volunteer

Are you a paramedic or first responder?

Paramedic or First Responder?

Paramedic
First Responder

Have you retained any other attorney in about your exposure to PFAS (including firefighting foam)?

Retained other Attorney re PFAS?

Yes
No

Please Identify that Attorney and/or Firm

Nature of Injury

Have you been diagnosed with kidney cancer?

Kidney Cancer Diagnosis?

Yes
No

Clinic's Address and Phone Number:

Are You Currently Being Treated for Your Condition?

Yes
No

Describe the Treatments You Have Had To Date:

Have you been diagnosed with testicular cancer?

Testicular Cancer Diagnosis?

Yes
No

Clinic's Address and Phone Number:

Are You Currently Being Treated for Your Condition?

Yes
No

Describe the Treatments You Have Had To Date:

Have you been diagnosed with another type of cancer?

Other Cancer Diagnosis?

Yes
No

Which Type of Cancer?

Please describe the non-cancer injury you believe may be related to PFAS exposure:

Non-cancer Injury

Have you ever been tested for PFAS in your bloodstream?

Had PFAS Blood Test?

Yes
No

What was the Result?

Work and Exposure History

How long have you been a firefighter?

Duration of Service as Firefighter?

Please describe your work history as a firefighter (dates, employers, job sites, and addresses):

Firefighter Work History

Have you ever worked as a firefighter primarily at an airport or military base?

Firefighter at Airport of Military Base?

Yes
No

Please Identify Where:

To the best of your ability, please list the names of the manufacturers of the turnout gear you have worn, and the dates you wore it:

Turnout Gear Types, Manufacturers, Dates?

Does your gear get washed or otherwise cleaned?

Was Gear Washed/Cleaned?

Yes
No

By Whom, Where, and How Frequently?

Do you bring your gear home or leave it at the firehouse?

Bring Gear Home or Leave at Firehouse?

Bring it Home
Leave at Firehouse

Do you wear your gear for non-firefighting duties as part of your job as firefighter or first responder?

Non-firefighting Gear Worn?

Yes
No

Were you ever exposed to aqueous firefighting foam?

Exposed to Aqueous Firefighting Foam?

Yes
No

Please Describe the Nature of the Exposure:

Have you filed a line of duty or worker’s compensation claim in connection with PFAS or occupational cancers?

Filed Claim re PFAS or Occupational Cancers?

Yes
No

Who Handled It?

What was the Result?

Do you have a copy of the paperwork?

Yes
No

Medical History

Please list the name and address of your current primary care physician:

Doctor’s name:

Date You Became their Patient:

Name and Location of Primary Care Physician's Practice:

Please list additional relevant diagnoses, other doctors seen, and appointment dates:

Diagnoses, Doctors Seen, Appointment Dates:

Prior Lawsuits

Have you ever been involved in a lawsuit?

Ever Involved in a Lawsuit?

Yes
No

Please Name Your Attorney:

Please Describe the Lawsuit:

Amount of Damages Awarded:

Have you ever been involved in a worker’s compensation claim?

Ever Involved in a Worker's Comp Claim?

Yes
No

Please Name Your Attorney:

Please Describe the Claim:

Amount of Damages Awarded:

Requested Documents

Please collect the following documents, to the extent that you have them in your possession and it is not an inconvenience for you to locate and send, and we will request them once we have reviewed your questionnaire.

Please provide a summary of the medical bills paid by you or on behalf of you (such as by an insurance company) since the date of your diagnosis. For example, some insurance companies list on their explanation of benefits the total amount paid for an insured in a policy period. Please do not contact your insurance company to obtain this information if you do not have documents at home.
Please provide a summary-type medical record (often found in a discharge summary) confirming your diagnosis / diagnoses.
Please provide any medical or scientific articles documenting a causal link between your diagnosis and your occupational exposure.