Roundup Plaintiff Information Sheet

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Case Number

First Name*

Last Name*

SSN*

State*

DOB*

DOD – Date of deceased (leave blank if NA)

Occupation*

Do you have prior personal history of cancer?*

Yes
No
N/A

Date of cancer diagnosis? (example 05/2020)*

What type of cancer?

Were you employed as (select all that apply)*

Did you serve in the military?*

Yes
No

If yes, years of military service?*

Health history / conditions (select all that apply)*

If you selected autoimmune above, please list disorders*

If you selected immunosuppressive medications above, please list medications*

If you selected smoking above, how much and how long?*

Family Cancer History

Does your family have a history of cancer?*

Yes
No
N/A

Family cancer 1 full name*

Family cancer 1 relationship to you*

Family cancer 1 type of cancer*

Family cancer 2 full name*

Family cancer 2 relationship to you*

Family cancer 2 type of cancer*

Family cancer 3 full name*

Family cancer 3 relationship*

Family cancer 3 relationship to you*

NHL Diagnosis, Treatment

Were you diagnosed with NHL?*

Yes
No
N/A

Date of NHL diagnosis (Example 01/01/2020)*

What type and stage of NHL?*

What type of NHL treatment?*

NHL treatment dates (start, end) or treatment rounds*

Years of NHL remission?*

Have you had a recurrence(s)?*

Yes
No
N/A

Product Use

Type of Exposure (select all that apply)*

First month / year of use (Example: 01/2001)*

Last month / year of use (Example: 01/2001)*

Do you have proof of exposure? (receipts, pictures, medical records)*

Yes
No
N/A

Did plaintiff use PPE? Personal Protetive Equiment (such as goggles, eyewear, overalls)*

Yes
No

What type of PPE?*

Roundup Product Usage

Product Used 1, Please provide the amount of time the Plaintiff used a Roundup Product (Example: 9 months OR 5 years)*

Product Used 1, Product Used*

Product Used 1, Frequency of Exposure (Example 2 times a week)*

Product Used 1, Location*

Product Used 1, Approximate Acreage (residential only)*

Product Used 2, Please provide the amount of time the Plaintiff used a Roundup Product (Example: 9 months OR 5 years)*

Product Used 2, Product Used*

Product Used 2, Frequency of Exposure (Example 2 times a week)*

Product Used 2, Location*

Product Used 2, Approximate Acreage (residential only)*

Product Used 3, Please provide the amount of time the Plaintiff used a Roundup Product (Example: 9 months OR 5 years)*

Product Used 3, Frequency of Exposure (Example 2 times a week)*

Product Used 3, Location*

Product Used 3, Approximate Acreage (residential only)*

Name

This field is for validation purposes and should be left unchanged.