Fill and Sign the Comes Now Plaintiff by and through His Attorneys and Files This His Form

IN THE UNITED STATES DISTRICT COURT FOR THE _____________ DISTRICT OF ____________ _____________ DIVISION ______________________________ PLAINTIFF VS CIVIL ACTION NO. _____________ ______________________________ DEFENDANT COMPLAINT (Jury Trial Requested) COMES NOW _____________, Plaintiff, by and through his attorneys, and files this his Complaint against _________________________________________, and would show as follows: I. This action arises under the Federal Tort Claims Act, Sections _____ through _______ of Title ___ of the United States Code. This Court is vested with jurisdiction pursuant to Section _______(b) of Title ____of the United States Code. II. Plaintiff, _______________, is an adult resident citizen of _____________ County, ____________. III. On _________ ____, 20___, Plaintiff was an outpatient at the _____________________ in _____________, ____________ ( A____________ ), which is operated by the __________________, an agency of the Defendant United States of America, in order to receive a ___________. After this procedure, Plaintiff was moved to the recovery area. IV. From the recovery area, Plaintiff was taken by wheelchair to a dressing room. In spite of the fact that Plaintiff is ___ years old, and was still under the influence of anest hesia, he was left alone by a Nurse on staff at the __________________, in his wheelchair, to dress. There was no handrail or any other device to aid Plaintiff in standing and moving around while dressing. As a result, he fell and sustained a ____________ that required surgery. This injury could have been 2 prevented if a nurse, nurses aid, orderly or some other employee had stayed to help Plaintiff. A family member also could have been asked to help. They were in the waiting room on t he same floor. V. After sustaining this injury, Plaintiff and his family had to wait over two hours before receiving any medical attention. Plaintiff was in great pain during this time, which was worsened by the careless way a nurse swung his legs while getting him back in his wheelc hair. Despite the severe pain that Plaintiff was suffering, he did not receive any pain me dication for eight hours after his accident. Such a delay is grossly negligent, particularly since it was obvious to all around Plaintiff that he was in significant pain during this eight-hour period. VI. The negligence of Defendant's employees in failing to adequately supervise, care for, a nd otherwise prevent Plaintiff from falling was the proximate cause of Plaintiff's fall and of the resulting injuries sustained from such fall. VII. As a result of Plaintiff's fall, Plaintiff suffered serious and permanent personal injuries that have caused and will continue to cause great pain and will cause Plai ntiff to incur substantial medical and nursing care expenses. VIII. On _______ _____, 20____, a claim was filed with the __________________, on behalf of Plaintiff, and the _______________________has neither accepted nor rejected the claim and, pursuant to 28 U.S.C.A. __________(a), Plaintiff elects to consider the failure to act as a final denial of the claim. WHEREFORE, Plaintiff requests judgment against Defendant as follows: Because of the negligence of the hospital staff as described above, _____________ should be liberally compensated in the amount of $______________. WHEREFORE , Plaintiff requests judgment against ________________________as follows: 1. Damages in the amount of $______________; 3 2. Plaintiff's costs of suit; and 3. Such other and further relief as the Court may deem just and proper. THIS THE ____ DAY OF __________, 20____.Respectfully submitted, ___________________, Plaintiff By: ______________________________________ _________________ OF COUNSEL: _____________________ MSB# __________________________________________ Telephone ____________________ Facsimile _____________________