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Hilliard Law
RoundUp Case Update
Case Number
*
First Name
Last Name
Hidden
Last 4 of SSN
Name of person completing the form:
Name of person who was injured by RoundUp:
Is the person who used Roundup a US citizen or legal resident?
Was the person who used Roundup a US citizen or legal resident at the time of exposure to RoundUp?
Yes
No
Diagnosis of the person who used Roundup:
Date of diagnosis:
MM slash DD slash YYYY
Age of the person who used Roundup at the time of diagnosis:
Please enter a number from
10
to
100
.
Height of the person who used Roundup at the time of diagnosis (in inches):
Please enter a number greater than or equal to
1
.
Weight of the person who used Roundup at the time of diagnosis (in pounds):
Name, city and state of the doctor(s) who diagnosed the injury:
Did the person who used Roundup die as a result of Roundup exposure?
Yes
No
Is the person who used Roundup in remission?
Yes
No
How long has the person who used Roundup been in remission?
Did the person who used Roundup have recurrence of the injury?
Yes
No
Date when the person who used Roundup started using RoundUp:
Total amount of time the person who used Roundup used Roundup for residential use of less than three acres of property:
Total amount of time the person who used Roundup used Roundup for residential use of more than three but less than five acres:
Total amount of time the person who used Roundup used Roundup for residential use of more than five acres of property:
Total amount of time the person who used Roundup used Roundup for industrial use:
Total amount of time the person who used Roundup used Roundup for turf usage:
Total amount of time the person who used Roundup used Roundup for agricultural use:
Total amount of time the person who used Roundup used Roundup for horticulture use:
Total amount of time the person who used Roundup used Roundup for landscaping:
Total amount of time the person who used Roundup used Roundup for ornamental use:
Does the person who used Roundup have a first degree relative (mother, father, sister, brother, son, or daughter) who has been diagnosed with any of the following (select all that apply):
Lymphoma
Leukemia
Non-Hodgkin’s Lymphoma
Other cancer Follicular Cancer Thyroid
None
No response
Has the person who used Roundup had any of the following (select all that apply):
Organ or stem cell transplant
Autoimmune disorder
Epstein-Barr virus
Immunosuppressive Medications
HIV/AIDS
Chemotherapy prior to the time of RoundUp exposure
Chlamydia psittaci
H. Pylori
Hepatitis B
Hepatitis C
Radiation Exposure as treatment for a prior cancer
Cancer before RoundUp exposure
Diabetes
Breast implants
None
No response
Has the person who used Roundup had any of the following occupations (select all that apply):
Car mechanic
Cleaning service worker
Electrician
Hairdresser
A job that requires handling of fission products/jet propellant/solvents
Metal worker
Painter
Pest Exterminator
Petroleum refinery worker
Rubber factory worker
Textile worker
Woodworker
A job that involves frequent exposure to x- or gamma radiation
None
No response
Comments
This field is for validation purposes and should be left unchanged.
