Silica Exposure Questionnaire

This field is hidden when viewing the form

case id

First Name

Last Name

Who are you contacting us on behalf of?

If loved one, state loved one's name and your affiliation with loved one:

What type of injury or diagnosis are you calling about? [Death vs. serious injury]

How did you hear about our law firm?

Have you reached out to other law firms for representation?

If so, about how many other law firms?

Do you or your loved one currently smoke cigarettes (tobacco)?

Yes

If yes, How many packs a day?

For how long have you / your loved one smoked this much daily? (MM/YYYY – MM/YYYY)

Are you / your loved one a former smoker (tobacco)?

Yes

If yes, Provide approximate dates of smoking [MM/YYYY – MM/YYYY]

Approximately how many a packs a day would you / your loved one smoke?

Have you / your loved one ever been exposed to second-hand smoke at any job?

Yes

If yes, describe [dates; employer; method of exposure (e.g., worked in a diesel shop and co-worker smoked in the garage)]

Have you / your loved one ever lived with anyone, currently or formerly, that smoked cigarettes?

Yes

If yes, did the smoker smoke indoors within the household?

Approximate dates that you / your loved one lived with the smoker? [MM/YYYY – MM/YYYY]

Prior to working with engineered stone, were you / your loved one ever diagnosed with any of the following (select all that apply):

Please provide approximate date of diagnosis and nature of treatment for each of your selection(s) above:

Has anyone in your family / your loved one’s family ever been diagnosed with any of the following (select all that apply):

Please describe nature of diagnosis and familial relation for each of your selection(s) above:

Did you or your loved one work with Corian and/or engineered stone such as Quartz, Quartzite, QuartzStone, Cambria Quartz Surfaces, Caesarstone, Basalt, Granite, Travertine, Soapstone, Serpentine, Dolomite, Onyx, Porcelain, Sandstone, Terrazzo, Marble, Sensa, or Silestone?

Yes

If yes, state engineered stone product(s) worked with:

Dates which you / loved one worked with engineered stone [MM/YYYY – MM/YYYY]

8. Which of the following manufacturers manufactured the engineered stone products you worked with? [Select all that apply.]

If other, please provide the manufacturer(s):

List the name(s) of the companies you / your loved one worked for while working with engineered stone [Company Name – Address – Dates of Employment (MM/YYYY – MM/YYYY) – Position with Employer – Engineered Stone Materials Worked With]:

For each employer listed above, please describe the following:

What safety instructions were you / your loved one given regarding inhalation of silica dust?

Were you / your loved one instructed to wear a mask while working with engineered stone products?

Did you / your loved one wear a mask at all times while working with engineered stone products?

Yes

If "yes" to any of the above, please describe:

Were you or your loved one diagnosed with any of the following? [Select all that apply]

Date(s) of diagnoses [select all that apply]:

Name(s) and address(es) of diagnosing medical professional(s):

Describe your treatment for the above diagnoses [narrative answer]:

Date(s) of treatment(s):

Name(s) and address(es) of treating medical professional(s):

Select all of the following that apply with respect to the treatment(s) or procedure(s) you / your loved one have undergone due to your exposure to silica dust:

If other was chosen above, please provide the treatment(s) or procedure(s) you / your loved one have undergone due to your exposure to silica dust:

Have you / your loved one been recommended for a lung transplant by a medical professional because of your silica dust exposure?

Yes

If yes, please provide [Name of medical professional, Address of medical professional, and Telephone # of medical professional]: