Questionnaire Form

Product Liability Questionnaire

Your full name: Street address:

City: State: Zip: County:

Birth date: Social Security Number:

Home phone: Work phone: ext. Cell/pager: E-mail:

THE ACCIDENT

Location of the incident:

Date of the accident: Day of the week: Time of day:

Weather conditions:

Describe in detail how the incident occurred:

What type the product (include any details such as manufacturer and brand/model) caused your injury?

How do you think the accident happened?

What could have been done to avoid the accident?

What could have been done to make the accident less severe?

THE PRODUCT

What is your previous knowledge of or experience with the product before you were injured?

Do you know of any modifications or changes that were made to the product? Yes No
If yes, describe:

Who purchased the product which injured you?

Who owned the product which injured you?

Where was it purchased? Price: Reason for purchase:

Did you receive any warnings or instructions on the use of the product which injured you? Yes No

If yes, who gave the instructions or warnings?

If yes, what were the instructions or warnings?

If yes, were the instructions or warnings oral or written? Oral Written

Were you using the product under the supervision of anyone? Yes No
If yes, under whom?

Was the product prescribed by a health-care provider, or recommended by some other professional? Yes No
If yes, by whom?

THIRD PARTIES

Were you injured while working for an employer? Yes No
If yes, explain:

Employer’s name: Employer’s address: Employer’s phone number:

Were you injured at the workplace or an outside work site? Yes No
If yes, explain:

Did your employer own the product that injured you? Yes No

Did your employer manufacture, distribute, design or produce the product which injured you? Yes No

Were any co-workers involved? Yes No

Name: Address: How person was involved:

Name: Address: How person was involved:

Name: Address: How person was involved:

Name: Address: How person was involved:

Were there any witnesses? Yes No

Name: Address: Phone Number:

Name: Address: Phone Number:

Name: Address: Phone Number:

Name: Address: Phone Number:

Who do you think is responsible for the accident?
Name: Address: Phone Number:

Any information you have about this person’s insurance carrier:

RESPONSE TO ACCIDENT

Did you make any oral or written statements at the scene of the accident? Yes No
If yes, please describe statement and to whom:

Did you read and sign the statement? Yes No
Do you have a copy of the statement? Yes No

Did you make any oral or written statements after the accident, such as to an insurance adjuster? Yes No
If yes, please describe statement and to whom:

Did you read and sign the statement? Yes No
Do you have a copy of the statement? Yes No

Did the police come to the scene of the accident? Yes No
Do you have a copy of the police report? Yes No
Were any citations issued or arrests made? Yes No
Did anyone take pictures of the accident scene? Yes No
Did anyone take pictures of your injuries? Yes No

Do you believe alcohol/drugs/medication was a factor in causing the accident? Yes No
If yes, why?

INJURIES

Were you injured in the accident? Yes No

Were you taken to the hospital? Yes No
If yes, name of hospital: If yes, name of doctor:

If by ambulance, did the ambulance attendants place you in a neck brace neck brace back brace other

Did you get any medication or medical supplies? Yes No
If yes, describe:

Did you have x-rays taken at the hospital? Yes No

What medical treatment have you received?

How often did you see the doctor? How long did you see the doctor?

Next visit scheduled: Diagnosis:

Have you had any similar problems before? Yes No
If yes, explain:

Have you ever been rejected for military service because of physical, mental, or other reasons? Yes No
If yes, explain:

Do you wear glasses, contact lenses, or any prosthetic devices? Yes No
If yes, explain:

Is there any limitation on your driver’s license to operate? Yes No
If yes, what is the limitation?

Have you ever been treated for alcohol or drug use? Yes No
If yes, explain:

Have you ever been denied health or life insurance because of your health? Yes No
If yes, by which company, and why?

List here every claim you have ever made for personal injury or property damage:

Are you diabetic? Yes No

Do you have high blood pressure? Yes No

Do you have low blood pressure? Yes No

Do you have arthritis or degenerative joint disease? Yes No

Are you currently under medical care for injuries due to the accident? Yes No

Have you lost any days of work from this injury? Yes No
If yes, give dates:

Have you lost any overtime from work from this injury? Yes No
If yes, give dates and times:

Was time off authorized by a doctor? Yes No

Are your work activities limited due to this accident? Yes No

Have you received any increases or decreases in your pay since the accident? Yes No
If yes, describe:

Are other activities limited due to this accident? Yes No
If yes, describe:

Have you received Social Security benefits, worker’s compensation, or Medicare benefits as a result of this accident? Yes No

Since this injury are your symptoms improving worsening same?

Do you have a criminal record? Yes No
If yes, please describe:

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