MARY E. STANLEY, United States Magistrate Judge
Having considered the submissions of the parties, and the comments and proposals presented to the Court, it is hereby ORDERED that:
1. Plaintiffs Fact Sheet
The parties have agreed upon a Plaintiff's Fact Sheet (Exhibit A) ["PFS"], an Authorization for Release of Medical Records (Exhibit B), an Authorization for Release of Employment and Unemployment Records (Exhibit C), an Authorization for Release of Education Records (Exhibit D), and an Authorization For Release of Workers' Compensation, Social Security and other Disability Records (Exhibit E) [collectively the "Authorizations"]. The PFS and Authorizations will be completed by each plaintiff pursuant to the terms of this Order. Each plaintiffs responses in the PFS shall be verified under oath and treated as answers to interrogatories and requests for the production of documents, pursuant to Federal Rules of Civil Procedure 33 and 34. Each plaintiff shall supplement his/her responses in accordance with Federal Rule of Civil Procedure 26.
2. Initial Wave Due Date
Each plaintiff whose case was filed before August 12, 2002, shall have until March 7, 2003 to complete and serve a PFS, and the Authorizations and documents required therein, on Defendant's Liaison Counsel in accordance with the terms of this Order.
Each plaintiff whose case was filed after August 12, 2002, and before the date of this Order, shall have sixty (60) days from the date of this Order to complete and serve a PFS, and the Authorizations and documents required therein, on Defendant's Liaison Counsel in accordance with the terms of this Order.
3. Later Filed Cases Due Dates
Each plaintiff whose case was filed after the date of this Order shall have sixty (60) days from the date the PFS and Authorizations are served on his/her counsel (or such plaintiff, if unrepresented) to complete and serve the PFS, and the Authorizations and documents required therein, on Defendant's Liaison Counsel in accordance with the terms of this Order.
4. Service
With respect to those cases governed by Paragraph 3 of this Order, Defendant's Liaison Counsel shall serve the PFS and Authorizations, along with a copy of this Order, on counsel representing plaintiff(s) (or plaintiff, if unrepresented) within five (5) days of the docketing of a case in this MDL by mail or by delivery service. A copy of each cover letter serving a PFS and Authorizations shall also be forwarded to Plaintiffs' Liaison Counsel.
Each plaintiff shall serve his/her completed PFS, executed Authorizations, and documents required therein, in accordance with the terms of this Order, directly on Defendant's Liaison Counsel by mail or by delivery service:
If Mailed:
Michael B. Victorson, Esq. Jackson Kelly PLLC Post Office Box 553 Charleston, West Virginia 25322
If Delivery Service is Used:
Michael B. Victorson Jackson Kelly PLLC 1600 Laidley Tower Charleston, West Virginia 25301
Each plaintiff shall, likewise, serve a copy of his/her PFS, executed Authorizations, and documents required therein, upon Plaintiffs Liaison Counsel by mail or by delivery service:
Carl N. Frankovitch, Esq. Frankovitch, Anetakis, Colantonio Simon 337 Penco Road Weirton, West Virginia 26062-3828
5. Responsive Documents
If neither a particular plaintiff nor that plaintiffs counsel possesses documents responsive to the requests contained in Section IX of the PFS, at the time the completed PFS is served, that plaintiff's counsel (or that plaintiff, if unrepresented) must inform Defendant's liaison Counsel [Michael B. Victorson, Esq.] of such in writing by letter via mail, c-mail or facsimile, a copy of which shall be delivered to Plaintiffs' Liaison Counsel.
6. Record Copy Service
The defendant has retained [COMPANY NAME], a national medical record copy service, to collect and copy each plaintiffs medical, employment and other records. Although it is contemplated that [COMPANY NAME] will generally be responsible for collecting each plaintiffs records, there may be times when, due to concerns for expediency, the defendant will itself endeavor to collect certain records. In those instances: (A) the defendant will provide notice of the use of authorizations as required by paragraph 7 herein; and (B) any timely objection should be served via e-mail or facsimile on Plaintiffs' Liaison Counsel and Defendant's Liaison Counsel, as required by paragraph 8. Additionally, the defendant will stamp all records "Confidential, Subject to Protective Order," in accordance with paragraph 10. Each plaintiff shall be entitled to receive, upon request, a complete list, and to inspect and obtain copies, of all records collected directly by the defendant, at a reasonable cost.
7. Notice of Use of Authorizations [COMPANY NAME] shall provide each plaintiffs counsel (or each plaintiff, if unrepresented) ten (10) days advance notice of its intention to use an authorization to collect records from any health care provider, employer or other source beyond those identified in a plaintiffs PFS (including any subsequent supplements thereto) or by a plaintiff at his/her deposition. Such notice shall be via e-mail or facsimile with a copy to Defendant's Liaison Counsel, For those health care providers, employers and other sources of information identified in a plaintiff's PFS or by a plaintiff at his/her deposition, such plaintiff and his/her counsel waives any notice requirement, except as provided in paragraph 8(A).
8. Objections to Use of Authorizations
A. Should a plaintiff object to the collection of records from a health care provider, employer, or other source of information identified in his/her PFS (including any subsequent supplements thereof), or at his/her deposition, then such objection (in letter form) shall accompany that plaintiffs PFS upon service, or shall be preserved on the record at such plaintiff's deposition, or otherwise shall be waived. If made at the time of the service of the PFS, the objection, in two (2) pages or less, shall identify the legal basis for the objection and describe the nature of the documents to which the objection is asserted in a manner that, without revealing the information protected, will enable the defendant to assess the applicability of the protection. if preserved at a plaintiffs deposition, within five (5) business days of that deposition, that plaintiff shall, in a form similar to that used when the objection accompanies the PFS, identify the legal basis for the objection and describe the nature of the documents to which the objection is asserted in a manner that, without revealing the information protected, will enable the defendant to assess the applicability of the protection. Any such objection will then be resolved pursuant to the procedure set forth in paragraph 9.
B. When a plaintiff receives notice from [COMPANY NAME] of its intention to use an authorization to collect medical, employment or other records from sources beyond those identified in his/her PFS (including any subsequent supplements thereof) or at his/her deposition, that plaintiff shall have five (5) business days from the date or notice to submit an objection (in letter form) to the use or the authorization. The objection, in two (2) pages or less, shall identify the legal basis for the objection and describe the nature of the documents to which the objection is asserted in a manner that, without revealing the information protected, will enable the defendant to assess the applicability of the protection. Copies of the objection shall be served, via e-mail or facsimile, on:
[COMPANY NAME] [CONTACT NAME] [E-MAIL ADDRESS] [FAX NUMBER]
AND If Mailed:
Michael B. Victorson, Esq. Jackson Kelly PLLC Post Office Box 553 Charleston, West Virginia 25322
If a Delivery Service is Used:
Michael B. Victorson Jackson Kelly PLLC 1600 Laidley Tower Charleston, West Virginia 25301
Or, if by E-Mail or Facsimile,
E-Mail: mvictorson@jacksonkelly.com Fax: (304) 340-1050
AND Carl N. Frankovitch, Esq. Frankovitch, Anetakis, Colantonio Simon 337 Penco Road Weirton, West Virginia 26062-3828
E-Mail: carln@facslaw.com Facsimile: (304) 723-5892
If no such objection is received within five (5) business days of notice, the records shall be requested and produced to the defendant.
9. Procedure for Resolution of Objections to Use of Authorizations
Upon receipt of a plaintiffs objection, no further effort will be made by the defendant (or its representative) to collect the records at issue until the objection is resolved. The parties shall have five (5) business days, from the date of a plaintiffs objection, to meet and confer to resolve the objection. Should the parties be unable to resolve the objection, then such plaintiffs objection and a response by the defendant (in letter form) of two (2) pages or less, shall be submitted to the Magistrate Judge for resolution. The Magistrate Judge will rule on the objection. Any party wishing to appeal the ruling must follow the provisions of Federal Rule of Civil Procedure 72.
10. Confidentiality
Pursuant to Pretrial Order No. 2, all records regarding any plaintiff collected by [COMPANY NAME] through the use of the Authorizations ["Collected Records"] are hereby designated "CONFIDENTIAL." All Collected Records shall be stamped or otherwise marked by [COMPANY NAME] with the legend:
CONFIDENTIAL SUBJECT TO PROTECTIVE ORDER
Disclosure of Collected Records shall be governed by the provisions of Pretrial Order No. 2.
11. Copies of Collected Records
Each plaintiff shall be entitled to receive, upon request, a complete list, and to inspect and obtain copies, of all Collected Records pertaining to such plaintiff, directly from [COMPANY NAME], at a reasonable cost.
12. Extension of Discovery Deadlines
Nothing in this order shall be interpreted as a restriction upon the ability of: (a) the parties to stipulate to a reasonable extension of discovery deadlines in a particular case; or (b) a plaintiff or the defendant to move for an extension of discovery deadlines in a particular case based on a showing of good cause.
The Clerk is directed to send a copy of this Discovery Order #5 to Plaintiffs' Liaison Counsel and to Defendant's Liaison Counsel.
EXHIBIT A IN RE SERZONE PRODUCTS LIABILITY LITIGATION MDL-1477 PLAINTIFF'S FACT SHEET
Each plaintiff in MDL-1477 who has taken the antidepressant Serzone® must complete this Plaintiff's Fact Sheet, including all of the questions asked, the List of Medical Providers and Other Sources of Information, the request for the production of documents and the request for authorizations. In completing this Fact Sheet, you are under oath and must provide information that is true and correct to the best of your knowledge.
INSTRUCTIONS
In completing this Fact Sheet it is expected that you will fully respond to each question and will provide all the information available to you that is sought by each question. The questions should be read broadly. If you do not know the answer to any question, please state that you do not know the answer. If any question is not applicable to you and your case, please state that it is not applicable. To the extent you cannot completely answer any question, please provide whatever information is available to you and, as to any information sought by the question which you do not know, please identify what part of the question you cannot answer. You may consult with your attorney if you have any questions regarding the completion of these forms.
If you are completing these forms for someone who took the antidepressant Serzone® who has died or cannot complete them him/herself please answer as completely as you can for that person.
You may attach as many sheets of paper as necessary to answer these questions.
DEFINITIONS
In answering the questions set forth in this Fact Sheet, with the exception of the terms and phrases defined below, each term and phrase should be given their usual meaning.
The term " injury" shall mean any physical, emotional or psychological condition which it is alleged was caused or may be caused in the future by your use of Serzone®.
The phrase " liver condition" shall mean any failure, dysfunction, disease or abnormality of the liver, including, but not limited to, cirrhosis, hepatitis, necrosis, fibrosis, encephalopathy, inflammation or scarring of the liver.
The phrase " liver function testing" shall mean any examination, test, or procedure in which blood is drawn and analyzed to determine the level of liver enzymes or to evaluate the manner in which the liver is functioning. I. CASE INFORMATION [If you are completing this questionnaire in a representative capacity, please respond to the remaining questions with respect to the person who took Serzone®. Those questions using the term "You" refer to the person who took Serzone®. If the individual is deceased, please respond as of the time immediately prior to his or her death unless a different time period is specified.] II. PERSONAL INFORMATION III. FAMILY INFORMATION IV. CONDITION FOR WHICH SERZONE® WAS PRESCRIBED V. DEPRESSION Date First Date Last Medication Yes No I Don't Know Taken/Dosage Taken/Dosage Selective Serotonin Reuptake Inhibitors (SSRIs): Tricyclic Anti- depressants (TCAs): Heterocyclic Anti- depressants: Monoamine Oxidase Inhibitors e.g. MAOIs): Other Anti- depressants: Other Prescription Medications to Control Depression: Date First Date Last Medication Yes No I Don't Know Taken/Dosage Taken/Dosage VI. MEDICAL BACKGROUND Date First Date Last Medication Yes No I Don't Know Taken/Dosage Taken/Dosage Dates of Use, Ingestion or Yes No I Don't Know Exposure Insecticides Floor wax Cleaning supplies Dry cleaning chemicals Asbestos Hazardous waste material Vinyl chloride Carbon tetrachloride Benzene Chlorinated hydrocarbons Arsenic Aflotoxin Amanita mushroom poisoning If yes, healthcare provider I perform- If yes, If yes, don't ing pro- date(s) of results of Tests/Studies Yes No know cedure procedure procedure Radiographic studies Sonographic studies Biopsy Liver transplant Liver function testing and/or monitoring Blood studies Hepatitis testing Other If yes, name, address and I don't telephone number If yes, date of Condition Yes No know of individual diagnosis making the diagnosis VII. INJURIES CLAIMED AS A RESULT OF SERZONE® USE Employer Type of Salary or, if address business/ self-employed) Name of employer and position held Dates of income telephone employment number Person's name, Nature of knowledge or address and Relation to you, if any information telephone number VIII. LIST OF MEDICAL PROVIDERS AND OTHER SOURCES OF INFORMATION Your current family physician: healthcare provider hospital inpatient hospital or healthcare facility outpatient pharmacy drugstore for social security disability benefits workers compensation private health insurance? IX. DOCUMENTS X. AUTHORIZATIONS
DECLARATION
28 U.S.C. § 1746AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS — EXHIBIT B ACKNOWLEDGMENT 28 U.S.C. § 1746 In re. Serzone Products Liability Litigation, AUTHORIZATION FOR RELEASE OF EMPLOYMENT AND UNEMPLOYMENT RECORDS — EXHIBIT C ACKNOWLEDGMENT 28 U.S.C. § 1746 In re. Serzone Products Liability Litigation, AUTHORIZATION FOR RELEASE OF EDUCATION RECORDS — EXHIBIT D ACKNOWLEDGMENT 28 U.S.C. § 1746 In re. Serzone Products Liability Litigation, ACKNOWLEDGMENT 28 U.S.C. § 1746 In re. Serzone Products Liability Litigation, A. Please provide the following information for the civil action which you filed: 1. Case Caption: _____________________________________________________________ 2. MDL Civil Action No.: _____________________________________________________ 3. Court in which action originally brought (transferor district): ___________________________________________________________________________ 4. Original Civil Action number in the transferor court, if applicable. Civil Action No.: ________________________________________________________ 5. Please state name, address, telephone number, fax number and e-mail address of the principal attorney representing you. __________________________________________________________________________ Name __________________________________________________________________________ Firm __________________________________________________________________________ City, State and Zip Code __________________________________________________________________________ Telephone number Fax number __________________________________________________________________________ E-mail address B. If you are completing this questionnaire in a representative capacity (e.g., on behalf of the estate of a deceased person or a minor), please complete the following: 1. ____________________________________________________________________________ Your Name 2. ____________________________________________________________________________ Street Address 3. ____________________________________________________________________________ City, State and Zip Code 4. In what capacity are you representing the individual: ___________________________________________________________________________ 5. If you were appointed by a court, state the: ___________________________________________________________________________ Court Date of Appointment 6. Your relationship to deceased or represented person: ___________________________________________________________________________ 7. If you represent a decedent's estate, state the date of death of the decedent. ___________________________________________________________________________ C. Claim Information 1. Do you claim that you have suffered a physical injury as the result of Serzone® use? Yes __________ No __________ 2. If the answer to the foregoing question is "yes", state the nature of the physical injury or injuries which you claim. ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 3. Do you claim that you have suffered a psychological or emotional injury as the result of Serzone® use? Yes __________ No __________ 4. If the answer w the foregoing question is "yes", state the nature of the psychological or emotional injury or injuries which you claim. ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 5. If you do not claim to have suffered a physical, psychological or emotional injury as the result of Serzone® use, state how you have been injured or damaged. ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ A. Last Name: ____________________________________________________________________ First Name: ___________________________________________________________________ Middle Name or Initial: _______________________________________________________ B. Maiden or other names used or by which you have been known, including the dates you used each name: _______________________________________________________________________________ _______________________________________________________________________________ C. Address Information 1. Present Street Address: ___________________________________________________________________________ Street Address City State Zip Code 2. List all other addresses where you have lived for the last fifteen (15) years: ___________________________________________________________________________ Street Address City State Zip Code ___________________________________________________________________________ Street Address City State Zip Code ___________________________________________________________________________ Street Address City State Zip Code ___________________________________________________________________________ Street Address City State Zip Code [ATTACH ADDITIONAL SHEETS IF NECESSARY] D. Employment 1. ___________________________________________________________________________ Name of Current or Last Employer ___________________________________________________________________________ Name of Current or Last Supervisor or Superior ___________________________________________________________________________ Current or Last Employer Address ___________________________________________________________________________ Current or Last Employer Telephone Number ___________________________________________________________________________ Dates of Current or Last Employment ___________________________________________________________________________ Current or Last Occupation 2. Have you been unemployed for health reasons for 30 consecutive days or more within the last fifteen (15) years? Yes __________ No __________ If so, please state the following for each period: a. First and last date of period of unemployment: ________________________ b. Reason for unemployment: ______________________________________________ c. With respect to any period of unemployment indentified above, identify all unemployment benefits claimed and received for that period of unemployment: _______________________________________________________________________ [ATTACH ADDITIONAL SHEETS IF NECESSARY] E. Social Security, Visa or Green Card Number: ___________________________________ F. Date of Birth: ________________________________________________________________ G. Place of Birth: _______________________________________________________________ H. Are you a citizen of the United States? _______________________________________ Yes __________ No __________ I. Sex: Male _____ Female _____ J. Have you ever served in any branch of the U.S. Military? Yes __________ No __________ If so, please state: 1. What branch and the dates of service. _____________________________________ 2. Were you discharged for any reason relating to your health, physical or mental condition? Yes __________ No __________ If yes, state what that condition was. _________________________________________________________________________ K. Have you ever been rejected from military service for any reason relating to your health, physical or mental condition? Yes__________ No ___________ If so, state what that condition was. _________________________________________ I. Have you filed a worker's compensation claim within the past 15 years? Yes __________ No __________ If so, please state the following for each claim filed: 1. Year claim was filed: _____________________________________________________ 2. Where claim was filed: ____________________________________________________ 3. Claim/docket number, if applicable: _______________________________________ 4. Nature of disability: _____________________________________________________ 5. Period of disability: _____________________________________________________ 6. Attorney, if any, who represented you (name, address and telephone number): ___________________________________________________________________________ ___________________________________________________________________________ [ATTACH ADDITIONAL SHEETS IF NECESSARY] M. Have you filed a social security disability claim within the past 15 years? Yes __________ No __________ If so, please state the following for each claim filed: 1. Year claim was filed: _____________________________________________________ 2. Where claim was filed: ____________________________________________________ 3. Claim/docket number, if applicable: _______________________________________ 4. Nature of disability: _____________________________________________________ 5. Period of disability: _____________________________________________________ 6. Attorney, if any, who represented you (name, address and telephone number): ___________________________________________________________________________ ___________________________________________________________________________ [ATTACH ADDITIONAL SHEETS IF NECESSARY] N. Have you ever filed a lawsuit or made a claim, other than in the present suit, relating to any physical, psychological or emotional injury? Yes __________ No __________ If so, please state the following for each claim filed: 1. Year claim was filed: _____________________________________________________ 2. Where claim was filed: ____________________________________________________ 3. Claim/docket number, if applicable: _______________________________________ 4. Nature of claim: __________________________________________________________ 5. Attorney who represented you (name, address and telephone number): ___________________________________________________________________________ ___________________________________________________________________________ [ATTACH ADDITIONAL SHEETS IF NECESSARY] O. Have you been convicted of or pled guilty to any crime? Yes __________ No __________ If so: 1. What was the offense? _____________________________________________________ 2. What was the case number? _________________________________________________ 3. What was the date of conviction? __________________________________________ 4. In what court was the conviction entered? _________________________________ [ATTACH ADDITIONAL SHEETS If NECESSARY] P. Education Beginning with high school, complete the following information regarding educational institutions you have attended: Name and Address of Degrees/Certifications Educational Institution Dates Attended Received [ATTACH ADDITIONAL SHEETS IF NECESSARY] A. Are you currently married? Yes __________ No __________ B. Date of marriage: _____________________________________________________________ C. Has your spouse filed a loss of consortium claim in connection with this action? Yes __________ No __________ D. 1. Spouse's name: ____________________________________________________________ 2. Spouse's date of birth: ___________________________________________________ 3. Spouse's occupation: ______________________________________________________ 4. Spouse's current address: _________________________________________________ E. Have you had any prior marriages? Yes __________ No __________ If so, for each marriage, state the following: Prior Spouse's Name: __________________________________________________________ Prior Spouse's Last Known Address and Telephone Number: _______________________ _______________________________________________________________________________ Prior Spouse's Current Age: ___________________________________________________ [ATTACH ADDITIONAL SHEETS IF NECESSARY] F. Complete the following regarding your mother: Mother's Name, Address and Telephone number: _______________________________________________________________________________ _______________________________________________________________________________ Mother's Maiden Name: _________________________________________________________ Mother's Age (or Age at Death): _______________________________________________ If Applicable, Cause of Death: ________________________________________________ G. Complete the following regarding your father: Father's Name, Address and Telephone Number: _______________________________________________________________________________ _______________________________________________________________________________ Father's Age (or Age at Death): _______________________________________________ If Applicable, Cause of Death: ________________________________________________ H. Complete the following regarding your siblings, if any: 1. Sibling's Name, Address and Telephone Number: _______________________________________________________________________________ _______________________________________________________________________________ Sibling's Age (or Age at Death): ______________________________________________ If Applicable. Cause of Death: ________________________________________________ 2. Sibling's Name, Address and Telephone Number: _______________________________________________________________________________ _______________________________________________________________________________ Sibling's Age (or Age at Death): ______________________________________________ If Applicable, Cause of Death: ________________________________________________ 3. Sibling's Name, Address and Telephone Number: _______________________________________________________________________________ _______________________________________________________________________________ Sibling's Age (or Age at Death): ______________________________________________ If Applicable, Cause of Death: ________________________________________________ 4. Sibling's Name, Address and Telephone Number: _______________________________________________________________________________ _______________________________________________________________________________ Sibling's Age (or Age at Death): ______________________________________________ If Applicable, Cause of Death: ________________________________________________ [ATTACH ADDITIONAL SHEETS IF NECESSARY] I. Do you have any children (whether by a current or prior marriage or relationship)? Yes __________ No __________ If yes, state the number of children: _________________________________________ If so, for each child, state the following: 1. Child's Name, Address and Telephone Number: _______________________________________________________________________________ _______________________________________________________________________________ Child's Age (or Age at Death):__________________________________________________ Does this child currently reside with you? Yes __________ No __________ 2. Child's Name, Address and Telephone Number: _______________________________________________________________________________ _______________________________________________________________________________ Child's Age (or Age at Death):_________________________________________________ Does this child currently reside with you? Yes __________ No __________ 3. Child's Name, Address and Telephone Number: _______________________________________________________________________________ _______________________________________________________________________________ Child's Age (or Age at Death): ________________________________________________ Does this child currently reside with you? Yes __________ No __________ [ATTACH ADDITIONAL SHEETS [F NECESSARY] J. Has any parent, grandparent, sibling or child been diagnosed with any liver conditions? Yes __________ No__________ I don't know __________ If yes, identify each such person below and provide the information requested. 1. Name, Address and Telephone Number: ___________________________________________________________________________ ___________________________________________________________________________ Current Age (or Age at Death) _____________________________________________ Diagnosis: ________________________________________________________________ If Applicable, Cause of Death______________________________________________ 2. Name, Address and Telephone Number: ___________________________________________________________________________ ___________________________________________________________________________ Current Age (or Age at Death): ____________________________________________ Diagnosis: ________________________________________________________________ If Applicable, Cause of Death: ____________________________________________ 3. Name, Address and Telephone Number: ___________________________________________________________________________ ___________________________________________________________________________ Current Age (or Age at Death): ____________________________________________ Diagnosis: ________________________________________________________________ If Applicable, Cause of Death: ____________________________________________ A. For what condition were you prescribed Serzone®? _______________________________________________________________________________ B. Identify the healthcare provider(s) that prescribed Serzone® for you: _______________________________________________________________________________ Name _______________________________________________________________________________ Address _______________________________________________________________________________ Telephone Number C. Did your receive relief from the symptoms for which Serzone® was first prescribed? Yes __________ No __________ I don't know __________ If yes, please identify the benefits received and for how long you continued to take the medication: _______________________________________________________________ _______________________________________________________________________________ If no, please state whether you continued to take the medication and, if so, why and for how long you continued to take the medication: ________________________ _______________________________________________________________________________ If you have been diagnosed with depression or any condition that led to your use of an antidepressant, answer the following: A. How old were you when you were first diagnosed with depression or any condition that led to your use of an antidepressant? ______________________ B. State the exact diagnosis: ________________________________________________ C. By whom first diagnosed? ___________________________________________________________________________ Name ___________________________________________________________________________ Address ___________________________________________________________________________ Telephone Number D. Which of the following medications (or generic equivalents) have you used to treat your depression or any other condition that led to your use of an antidepressant? (If you do not know or do not recall, please indicate) Fluoxctine hydrochloride (e.g. Prozac®) Sertaline hydrochloride (e.g. Zoloft®) Paroxetine hydrochloride (e.g. Paxil®) Amitriptyline hydrochloride (e.g. Amitril®, Elavil®, Endep®, Emitrip®, Enovil® Clomipramine (e.g. Anafranil® Desipramine hydrochloride (e.g. Norpramin®, Pertofranc® Doxepin hydrochloride (e.g. Adapin®, Sinequan®) Imipramine hydrochloride (e.g. Janimine®, SK-Pramine, Tipramine®, Tofranil®, Tofranil-PM® Nortriptyline (e.g. Aventyl®, Pamelor® Protriptyline hydrochloride (e.g. Vivactil® Trimipramine maleate (e.g. Surmontil® Amoxapine (e.g. Asendin®) Trazodone hydrochloride (e.g. Desyrel®) Maprotiline hydrochloride (e.g. Ludiomil® Isocarboxazide (e.g. Marplan®) Phenelzine sulfate (e.g. Nardil® Tranylcypromi ne sulfate (e.g. Parnate® Bupropion Hydrochloride (e.g. Wellsbutrin® Venlafaxine (e.g. Effexor® Mirtazapine (e.g. Remeron®, Remeron®, SolTab® Type: [ATTACH ADDITIONAL SHEETS if NECESSARY] E. Have you taken any herbal treatments to control your depression or any other condition that led to your use of an antidepressant? Yes __________ No__________ I don't know __________ If yes, state: Type:__________________________________________________________ Date First Taken: ______ Dosage: ______ mg ______times per day Date Last Taken: _______ Dosage: ______ mg_______times per day F. Have you taken any other treatments, not previously listed, to control your depression or any other condition that led to your use of an antidepressant? Yes __________ No __________ I don't know __________ If yes, state: Type: _________________________________________________________ Date First Taken: ______ Dosage: ______ mg _____ times per day Date Last Taken: _______ Dosage: ______ mg _____ times per day [ATTACH ADDITIONAL SHEETS if NECESSARY] G. Have you taken Serzone®? Yes __________ No __________ If yes, state: Date First Taken: ______ Dosage: ______ mg ______ times per day Date Last Taken: _______ Dosage: ______ mg.______ times per day H. If there was a change in dosage, what was your understanding of the reason for the change? ________________________________________________________________________________ I. Were there any gaps in your Serzone® use? Yes __________ No __________ I don't know __________ If yes, please explain: _______________________________________________________ _______________________________________________________________________________ J. When you were taking Serzone®, were you also taking any other medication(s)? Yes ___________ No __________ I don't know __________ If yes, please state: Name of Medication ________________Dosage:_________ mg ______ times per day Name of Medication _______________Dosage:_________ mg ______ times per day Name of Medication ______________Dosage:________ mg _____ times per day [ATTACH ADDITIONAL SHEETS IF NECESSARY] K. What medications, if any, were you taking to control the medical condition for which Serzone® was prescribed, prior to beginning Serzone®? (If you do not know or do not recall, please indicate.) [ATTACH ADDITIONAL SHEETS IF NECESSARY] A. Height: ___________________________________________________________________ B. Current Weight: ___________________________________________________________ C. Lowest Adult Weight: ______________________________________________________ From _______________________ to_________________________ D. Highest Adult Weight: ____________________________________________________ From _______________________ to ________________________ E. Average Adult Weight: ___________________________________________________ F. To the best of your knowledge, have you ever taken any of the following medications or their generic equivalent? (If you do not know or do not recall, please indicate.) Aceta- minophen (e.g. Tylenol®) Paracetamol Nyquil® Dielofenae (e.g. Voltaren®) Sulindae (e.g. Clinoril®) Aspirin Ibuprofen (e.g. Advil®, Motrin®) Penicillin Carbenicillin Oxacillin Amoxicillin Erthyromycin Tetracyclines Sulfonamides Antifungal agents Ketoconazolle Fluconazole Anti-TB drugs Rifampin Isoniazid (INH) Zidovudine Didanosine Fialuridine Interferon alpha Oral Contraceptives Type: Estrogens Type: Anabolic steriods Type: Androgenic steriods Type: Flutar Hormones Type: Niacin HMG COA reductase Halothane (anesthetic) Chloropro- mazine (e.g. Thorazine®) Carba- mazepine (e.g. Tegretol®) Phenytoin (e.g. Dilantin®) Valproic acid (e.g. DepaKene®) Antipsychotics Type: Amiodarone Alpha- methyldopa (e.g. Aldomet®) Ace inhibitors Type: Calcium channel blockers Type: Methotrexate Fluorouracil (5-FU) Azathiprine Cyclosporine Chemothera- peutic agents Type: Immunosup- pressive agents Type: Vicodin® Duract® Tagamet® Entex® Vibramycin® Darvocet® Rezulin® Vancenase® Cipro® Relafen® Daypro® Ultram® Biazin® Paxil® Allergy medications Type: Herbal preparations Type: G. List any other prescription medications taken by you from fifteen (15) years before the onset of the condition for which Serzone® was prescribed until today: ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ H. For any of the medications you indicated you have taken in subpart F and G of this section, did you experience any adverse reaction associated with that medication? Yes ________ No ________ If so, for each adverse reaction, please: Describe the reaction: ___________________________________________________________________ Provide approximate date and duration of the reaction: ___________________________________________________________________ Did you discontinue use of this medication?: ___________________________________________________________________ Did you seek medical attention for the adverse reaction? __________ If yes, please provide the name, address and telephone number of the person or entity that provided the medical attention, the dates of treatment, and a description of the treatment rendered: _____________________________________________________________________________________ _____________________________________________________________________________________ I. To the best of your knowledge, have you used, ingested or been exposed to any of the following during the course of your employment: Name/type of insecticide (if known): Type of floor wax (if known: Name/type of cleaning supplies (if known: Name/type of dry cleaning chemicals (if known: Type of hazardous waste material: (fire extinguishers, solvents, fumigants) (dyes, paint, petro- leum, ceramic, semi- conductors) (nuts, corn, wheat, barley, soybeans) J. To the best of your knowledge, state which of the following tests/studies you have undergone within the past fifteen (15) years. (e.g. x- ray) (e.g. liver sonogram) (e.g., liver enzymes) Type: [ATTACH ADDITIONAL SHEETS IF NECESSARY] K. Smoking history [Check 1, 2 or 3 and answer the appropriate subsection.] 1. never smoked cigarettes ___________________________________________________ 2. past smoker of cigarettes _________________________________________________ date on which smoking ceased_______________________________________________ amount smoked: _______ packs per day for ______ years 3. current smoker of cigarettes _______________________________________________ amount smoked: _______ packs per day for _______ years I. Alcohol consumption history 1. Do you now or have you in the past consumed alcohol (beer, wine, whiskey, etc.)? Yes ________ No ________ 2. If yes, check the box which represents your greatest alcohol consumption during any period of time. Number of Drinks Yes Your Age at Over what period of time? the Time? 1-5 drinks per week 6-10 drinks per week More than 15 drinks per week M. To the best of your knowledge, have you ever been told by any doctor or healthcare provider that you have, may have, or had any of the following: Hyper- glycemia (elevated blood sugar Hyperinsulin emia Nephropathy (kidney disease Retinopathy Glaucoma Vascular disease Autoimmune disease Systemic lupus crythe- matosus (SLE) Scleroderma (systemic sclerosis Rheumatoid arthritis Cancer Leukemia Lymphoma/ Hodgkin's disease Liver disease Dark urine Jaundice Liver enzyme [abnormalities Hypo- thyroidism Hyper- throidism Wilson's disease Hema- chromatosis Bacterial infections Spirochetal infections Parasitic disease Fungal liver disease Liver abscesses, cysts or tumors Tuberculosis Sarcoidosis Crohn's disease HIV and associated viral infections Amyloidosis Cardiac/heart disease Nephrogenic liver dysfunction Collagen vascular diseases Hematologic disease Nyman-Pick disorder Wolman's disease Tangier disease Metabolic disorders Antitrypsin deficiency Tyrosinemia Galactosemia Reyes syndrome Ischemic hepatic injury associated with heart disease Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E Alcoholic, toxic or drug-related hepatitis Nonalcoholic steato- hepatitis (NASH) or fatty liver Hepatic vein occlusion (Budd Chiari Syndrome) Autoimmune hepatitis Acute fatty liver of pregnancy (if female Substance abuse Alcohol abuse Cirrhosis of the liver Gallbladder disease Obesity Shortness of breath Hypertension Angina (chest pain) Athero- sclerosis Aterio- sclerosis (hardening of the arteries Myocardial infarction (heart attack) Congestive heart failure (CHF) Pulmonary/lu ng disorders Emphysema Asthma Measles, mumps ruebella N. If you are completing this Fact Sheet as the representative of a deceased person, what was the date of death? ________________________________ Was an autopsy performed? Yes _____________ No _____________ If yes, at which facility? ___________________________________________________________________ Name of Facility ___________________________________________________________________ Address A. 1. Have you had discussions with any healthcare provider about whether your condition is related to Serzone®? Yes ________ No ________ I don't know _______ 2. If yes, check one of the following: a. I was told my condition is related to Serzone®. ______ b. I was told my condition is not related to Serzone®. ______ c. I was told my condition may be related to Serzone® ______ d. I was told by the healthcare provider that he does not know whether my condition is related to Serzone®. ______ e. I don't recall what I was told. _______ 3. Identify the healthcare provider(s) (name, address and telephone number) with whom you have had these discussions: ___________________________________________________________________________ Name ___________________________________________________________________________ Address and telephone number 4. If discussed with more than one healthcare provider, please copy and complete Parts 2 and 3 for each healthcare provider. B. Were you told by any healthcare provider that you have a dormant medical condition or have an increased risk of future disease or injury caused by your Serzone® use? Yes ________ No ________ I don't know _______ If yes, please identify the following: the healthcare provider (name, address and telephone number) with whom you have had these discussions; the nature of the dormant medical condition or risk of future disease or injury; and the recommended course of action to address that risk. ____________________________________________________________________________________ Name ____________________________________________________________________________________ Address and Telephone Number ____________________________________________________________________________________ ____________________________________________________________________________________ Nature of dormant medical condition or risk of future disease or illness Recommended course of action C. List any other causes or contributing factors identified by your healthcare provider regarding the injury, dormant medical condition or increased risk of future disease or injury identified above: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ D. Were you given any written instructions or warnings regarding Serzone® at the time of your initial prescription or at any time during which you were using the drug? Yes _______ No __________ I don't know _______ If yes, please provide the following: the approximate date the written instructions or warnings were given; the name address and telephone number of each person or entity from whom you received the warnings or instructions; the substance of the warnings or instructions; the current location and/or custodian of the written warnings or instructions; and attach a copy of the written warnings or instructions to your completed Fact Sheet. Approximate date given: ____________________________________________________________ ____________________________________________________________________________________ Name, address and telephone number of person or entity providing the instructions or warnings ____________________________________________________________________________________ ____________________________________________________________________________________ The substance of the instructions or warnings ____________________________________________________________________________________ The current location and/or custodian of the written instructions or warnings E. Were you given any oral instructions or warnings regarding Serzone® at the time of your initial prescription or at any time during which you were using the drug? Yes _______ No _______ I don't know _______ If yes, please provide the following: when the oral instructions or warnings were given; the name address and telephone number of the person or entity from whom you received the warnings or instructions; and the substance of those warnings or instructions. Approximate date: __________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Name, Address and Telephone Number of person or entity ____________________________________________________________________________________ ____________________________________________________________________________________ The substance of those warnings or instructions. F. If you claim that any promises, assurances or representations made to you regarding Serzone® were broken, please provide the following: the substance of any such promises, assurances or representations; when, how and to whom they were made; the name, address and telephone number of any person with knowledge of the promise, assurance or representation; and attach any documents reflecting the promise, assurance or representation or its breach. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ G. If you claim that any of your doctor(s) or hcaltheare provider(s) relied on any promises, assurances or representations regarding Serzone®, please provide the following: the name, address and telephone number of the person(s) making such promise, assurance or representation; the substance of any such promise, assurance or representation; the date it was made; and the name address and telephone number of the person to whom it was made: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ H. Complete the following information with respect to your employment for the past fifteen (15) years [ATTACH ADDITIONAL SHEETS If NECESSARY] 1. State the total amount of time which you have lost from work as a result of any condition which you claim or believe was caused by your use of Serzone® and your personal understanding of the amount of income which you lost. ____________________________________________________________________________________ 2. State your earned income for each of the last five years. Year Income _____ $_________ _____ $_________ _____ $_________ _____ $_________ _____ $_________ I. Have you paid or incurred any medical expenses, including amounts billed or paid by insurers and other third party payors, which are related to any condition which you claim or believe was caused by your use of Serzone® and for which you seek recovery in the action which you have filed? Yes ______ No ______ I don't know ______ If yes, state the total amount of such expenses at this time. $ _____________ [PLEASE ITEMIZE THIS TOTAL USING AN ATTACHED SHEET] J. If any person (not identified elsewhere in this questionnaire) has knowledge or information concerning your use of Serzone® and/or the injuries you claim as a result of your use, please provide the information requested below: [ATTACH ADDITIONAL SHEETS IF NECESSARY] K. Clinical Studies Have you ever participated in a Serzone® clinical study trial? Yes _____ No _________ If yes, what was the name of the study? __________________________________________________________________________ __________________________________________________________________________ What was the date you enrolled in the study? ______________________________ To which health care facility did you report? _____________________________ ___________________________________________________________________________ Facility ___________________________________________________________________________ Address ___________________________________________________________________________ City, State Zip Code To whom did you report? ___________________________________________________________________________ Name of health care professional. ___________________________________________________________________________ Address ___________________________________________________________________________ City, State Zip Code L. Other Clinical Studies Have you ever participated in other clinical study trials? Yes ____ No ________ If yes, what was the name of the study? _____________________________________________________________________ _____________________________________________________________________ What was the date you enrolled in the study? ________________________ To which health care facility did you report? _____________________________________________________________________ Facility _____________________________________________________________________ Address _____________________________________________________________________ City, State Zip Code To whom did you report? _____________________________________________________________________ Name of health care provider. _____________________________________________________________________ Address _____________________________________________________________________ City, State Zip Code List the name and address of each of the following: A. Name: _____________________________________________________ Street Address: ___________________________________________ City, State, Zip Code: ____________________________________ Telephone Number: _________________________________________ Since when: _______________________________________________ B. Each who has seen or treated you in the past fifteen (15) years. 1. _________________________________________________________________________________ Name _________________________________________________________________________________ Specialty _________________________________________________________________________________ Street Address _________________________________________________________________________________ City, State, Zip Code _________________________________________________________________________________ Telephone Number 2. _________________________________________________________________________________ Name _________________________________________________________________________________ Specialty _________________________________________________________________________________ Street Address _________________________________________________________________________________ City, State, Zip Code _________________________________________________________________________________ Telephone Number 3. _________________________________________________________________________________ Name _________________________________________________________________________________ Specialty _________________________________________________________________________________ Street Address _________________________________________________________________________________ City, State, Zip Code _________________________________________________________________________________ Telephone Number 4. ________________________________________________________________________________ Name _________________________________________________________________________________ Specialty _________________________________________________________________________________ Street Address _________________________________________________________________________________ City, State, Zip Code _________________________________________________________________________________ Telephone Number [ATTACH ADDITIONAL SHEETS IF NECESSARY] C. Each where you have received treatment during the past fifteen (15) years: 1. ____________________________________________________________________________ Name ____________________________________________________________________________ Specialty ____________________________________________________________________________ Street Address ____________________________________________________________________________ City, State, Zip Code ____________________________________________________________________________ Telephone Number 2. ____________________________________________________________________________ Name ____________________________________________________________________________ Specialty ____________________________________________________________________________ Street Address ____________________________________________________________________________ City, State, Zip Code ____________________________________________________________________________ Telephone Number 3. ____________________________________________________________________________ Name ____________________________________________________________________________ Specialty ____________________________________________________________________________ Street Address ____________________________________________________________________________ City, State, Zip Code ____________________________________________________________________________ Telephone Number [ATTACH ADDITIONAL SHEETS IF NECESSARY] D. Each where you have received treatment (including treatment in an emergency room) during the past fifteen (15) years: 1. ____________________________________________________________________________ Name ____________________________________________________________________________ Specialty ____________________________________________________________________________ Street Address ____________________________________________________________________________ City, State, Zip Code ____________________________________________________________________________ Telephone Number ____________________________________________________________________________ 2. ____________________________________________________________________________ Name ____________________________________________________________________________ Specialty ____________________________________________________________________________ Street Address ____________________________________________________________________________ City, State, Zip Code ____________________________________________________________________________ Telephone Number 3. ____________________________________________________________________________ Name ____________________________________________________________________________ Specialty ____________________________________________________________________________ Street Address ____________________________________________________________________________ City, State, Zip Code ____________________________________________________________________________ Telephone Number 4. ____________________________________________________________________________ Name ____________________________________________________________________________ Specialty ____________________________________________________________________________ Street Address ____________________________________________________________________________ City, State, Zip Code ____________________________________________________________________________ Telephone Number 5. ____________________________________________________________________________ Name ____________________________________________________________________________ Specialty ____________________________________________________________________________ Street Address ____________________________________________________________________________ City, State, Zip Code ____________________________________________________________________________ Telephone Number [ATTACH ADDITIONAL SHEETS IF NECESSARY] E. Each or where you have had prescriptions filled during the past fifteen (15) years: 1. ____________________________________________________________________________ Name ____________________________________________________________________________ Street Address ____________________________________________________________________________ City, State, Zip Code ____________________________________________________________________________ Telephone Number 2. ____________________________________________________________________________ Name ____________________________________________________________________________ Street Address ____________________________________________________________________________ City, State, Zip Code ____________________________________________________________________________ Telephone Number 3. ____________________________________________________________________________ Name ____________________________________________________________________________ Street Address ____________________________________________________________________________ City, State, Zip Code ____________________________________________________________________________ Telephone Number 4. ____________________________________________________________________________ Name ____________________________________________________________________________ Street Address ____________________________________________________________________________ City, State, Zip Code ____________________________________________________________________________ Telephone Number 5. ____________________________________________________________________________ Name ____________________________________________________________________________ Street Address ____________________________________________________________________________ City, State, Zip Code ____________________________________________________________________________ Telephone Number [ATTACH ADDITIONAL SHEETS IF NECESSARY] F. If you have submitted a claim within the past fifteen (15) years, state the name and address of the office which is most likely to have records concerning each claim filed. 1. ____________________________________________________________________________ Name ____________________________________________________________________________ Street Address ____________________________________________________________________________ City, State, Zip Code ____________________________________________________________________________ Telephone Number 2. ____________________________________________________________________________ Name ____________________________________________________________________________ Street Address ____________________________________________________________________________ City, State, Zip Code ____________________________________________________________________________ Telephone Number [ATTACH ADDITIONAL SHEETS IF NECESSARY] G. If you have submitted a claim for within the past fifteen (15) years, state the name and address of' the office which is most likely to have records concerning each claim. ______________________________________________________________________________ Name ______________________________________________________________________________ Street Address ______________________________________________________________________________ City, State, Zip Code If you were represented by counsel please provide: ______________________________________________________________________________ Attorney's Name ______________________________________________________________________________ Street Address ______________________________________________________________________________ City, State, Zip Code _______________________________________________________________________________ Telephone Number [ATTACH ADDITIONAL SHEETS IF NECESSARY] H. Do you currently have Yes _________ No ____________ If so, provide the following: Name of Health Insurance Company: ____________________________________________ ______________________________________________________________________________ Street Address ______________________________________________________________________________ City, State, Zip Code I. Identify all other health, life and/or disability insurance you have or have had during the past fifteen (15) years (either on an individual basis or as a member of an insured family, Including group coverage and coverage under policies of insurance issued to or on behalf of parents and/or spouses). 1. Name of Insurance Company: _______________________________________________ __________________________________________________________________________ Street Address __________________________________________________________________________ City, State, Zip Code __________________________________________________________________________ Dates of Coverage 2. Name of Insurance Company: ___________________________________________ __________________________________________________________________________ Street Address __________________________________________________________________________ City, State, Zip Code __________________________________________________________________________ Dates of Coverage [ATTACH ADDITIONAL SHEETS IF NECESSARY] J. Have you ever been denied insurance coverage? Yes _________ No _________ If so, identify the following: Name and address of company which denied coverage: ____________________________ _______________________________________________________________________________ Reason(s) coverage was denied: ________________________________________________ Date(s) on which coverage denied: _____________________________________________ [ATTACH ADDITIONAL SHEETS IF NECESSARY] Please provide a true and correct copy of all documents and things (e.g., written documents, photographs, drawings, sketches, videotapes, audiotapes and anything that may be on any computer or that you may have seen on the Internet) which fall into the categories listed below. This includes documents and things in your personal possession, as well as items being held for you by another person, including your lawyer, friends or any relatives. 1. All medical records, reports, billing statements and/or invoices, including psychiatric or psychological records, from any physician, hospital, clinic, healthcare provider or pharmacy that treated you, or filled your prescriptions, during the last fifteen (15) years. 2. All prescriptions, receipts, physician or office records, drug containers, packaging and other records which refer or relate to any medication referred to in Sections V or VI of this Fact Sheet. 3. All documents (e.g., applications, forms, statements, hearing transcripts, medical records, medical reports, orders or directives) that refer or relate to any claim for disability benefits made by you or filed on your behalf (e.g., claims for: medical insurance benefits; insurance benefits; worker's compensation benefits; or any sickness, accident or disability benefits) during the last fifteen (15) years. 4. All documents (e.g., correspondence, pleadings, interrogatories and their responses, statements, deposition transcripts, medical records or reports, expert records or reports) that refer or relate to any law-suit filed by you or on your behalf wherein you sought compensation for any physical, psychological or emotional injuries. 5. Except to the extent that such documents have been prepared by consulting experts, all photographs, x-rays, motion pictures, videotapes, drawings, or other visual reproduction of any type depicting the injuries and/or damages described in your Complaint or sought by you in this lawsuit. 6. If you claim or expect to claim that you lost earnings or earning capacity as a result of any condition which you believe was caused by your use of Serzone®, all documents that refer or relate to your employment or self-employment during the past fifteen (15) years, including but not limited to the following: A. All federal and state tax returns, including all schedules and attachments thereto, and all W-2 and 1099 forms; B. All documents that refer or relate to any termination of employment; C. All documents that refer or relate to any job reviews or evaluations and/or performance appraisals; D. All health questionnaires and documents that refer or relate to the results of any medical examination or treatment associated with any such employment or self-employment; and E. All written applications for employment that you have made. 7. If you claim to have suffered any injury or damages as a result of taking Serzone®, all documents that refer or relate to that injury and/or damages you claim to have sustained as a result of your ingestion of Serzone® (e.g., medical records, reports, charts, diaries, notes, photographs, videos, recordings, statements, billing statements and/or invoices). 8. All packaging (including the bottle, box and label), instructions, product warnings, package inserts, advertising materials, pamphlets, magazine or newspaper articles, internet information, promotional materials, any documents or materials from defendants, or pharmacy handouts regarding Serzone®. 9. If you participated in any clinical studies, tests or trials regarding Serzone®, all documents relating to such clinical studies, tests or trials. 10. All diaries, chronicles or journals that you have kept during the period from the date you began taking Serzone® to the present that record events related to the medical condition that led to your use Serzone®, your use of medications to treat or control the medical condition that led to your use Serzone®, and/or any injury or damages claimed in this action. 11. Decedent's death certificate, if applicable, and letters testamentary or letters of administration relating to your status as plaintiff, if applicable. Complete and sign the attached Authorizations for the Release of Medical Records, Employment Records and Educational Records. If you have filed a Workers' Compensation claim, a Social Security disability claim or any other disability claim, please complete and sign the attached Authorization for Release of documents associated with such disability claims, I declare under penalty of perjury subject to that all of the information provided in this Fact Sheet is true and correct to the best of my knowledge, information and belief; that all of the information provided in response to the List of Medical Providers and Other Sources of information is true and correct to the best of my knowledge, information and belief; that I have supplied true and accurate copies of all the documents requested in part IX of this declaration, to the extent that such documents are in my possession or control or in the possession of my lawyers; and that I have supplied the authorizations attached to this declaration. Signature __________________________________ Date _____________________ IN THE UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF WEST VIRGINIA IN RE SERZONE : PRODUCTS LIABILITY LITIGATION : MDL Docket No. 1477 To: _____________________________ Name _____________________________ Address _____________________________ City, State and Zip Code This will authorize you to furnish copies of all medical records, reports, radiographic or other films and images, prescription records, written statements, disability records, medical bills, and other documents in your possession including records of treatment for psychological, psychiatric or emotional problems, concerning: ______________________________________________ Name of Patient whose date of birth is _____________________________ and whose social security number is ________________________. You are authorized to release the above records to the following representatives of defendant in the above-entitled matter who has agreed to pay reasonable charges made by you to supply copies of such records. _____________________________________________________________________________________ Name of Representative _____________________________________________________________________________________ Representative Capacity (e.g. attorney, records requestor, agent, etc.) _____________________________________________________________________________________ Street Address _____________________________________________________________________________________ City, State and Zip Code This authorization does not authorize you to disclose anything other than documents and records to anyone. This authorization is not valid unless the record requestor named above has executed the acknowledgment at the bottom of this authorization. Date: _______________________________ _____________________________________ Patient or Guardian Signature Date: _______________________________ ______________________________________________ Witness Signature STATE OF_____________________________; COUNTY OF____________________________; Taken, subscribed and sworn to before me this _______ day of________________ 2002. My commission expires: _____________________________________________________ ______________________________ NOTARY PUBLIC The undersigned, as the record requestor named in the above authorization, hereby declares under penalty of perjury, pursuant to , that the attorney for the person (or the person, if not represented) named in the foregoing authorization has been given notice that the authorization will be used to request records from the person or entity to whom it is addressed and has been afforded an opportunity to object to the request and to order copies of the records requested from the undersized requestor at a reasonable cost pursuant to the terms of Discovery Order #5, entered by the Honorable Mary E. Stanley, U.S. Magistrate Judge, in the matter of: MDL 1477. __________________________________________ IN THE UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF WEST VIRGINIA IN RE SERZONE PRODUCTS LIABILITY LITIGATION : MDL Docket No. 1477 To: ______________________________ Name ______________________________ Address ______________________________ City, State and Zip Code This will authorize you to furnish copies of all written applications for employment, all employment records, wage records, W-2 and 1099 forms, all documents that refer or relate to any job reviews or evaluations and/or performance appraisals, all documents that refer or relate to any termination of employment, disability records, each health questionnaire and each document that refers or relates to the results of any medical examinations or treatments for any such employments medical bills, written statements and other documents in your possession concerning: ___________________________________________ Name of Employee whose date of birth is _____________________________ and whose social security number is _________________________. You are authorized to release the above records to the following representatives of defendant in the above-entitled matter who has agreed to pay reasonable charges made by you to supply copies of such records. ____________________________________________________________________________________________ Name of Representative ____________________________________________________________________________________________ Representative Capacity (e.g. attorney, records requestor, agent, etc.) ____________________________________________________________________________________________ Street Address ____________________________________________________________________________________________ City, State and Zip Code This authorization does not authorize you to disclose anything other than documents and records to anyone. This authorization is not valid unless the record requestor named above has executed the acknowledgment at the bottom of this authorization. Date: _____________________________ ____________________________________ Employee or Guardian Signature Date: _____________________________ ____________________________________ Witness Signature STATE OF __________________________; COUNTY OF _________________________; Taken, subscribed and sworn to before me this ________ day of ___________2002. My commission expires: ______________________________________________________ ______________________________________ NOTARY PUBLIC The undersigned, as the record requestor named in the above authorization, hereby declares under penalty of perjury, pursuant to , that the attorney for the person (or the person, if' not represented) named in the foregoing authorization has been given notice that the authorization will be used to request records from the person or entity to whom it is addressed and has been afforded an opportunity to object to the request and to order copies of the records requested from the undersigned requestor at a reasonable cost pursuant to the terms of Discovery Order #5, entered by the Honorable Mary E. Stanley, U.S. Magistrate Judge, in the matter of: MDL 1477. ____________________________________________ IN UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF WEST VIRGINIA IN RE SERZONE PRODUCTS LIABILITY LITIGATION : MDL Docket No. 1477 To: ______________________________ Name ______________________________ Address ______________________________ City, State and Zip Code This will authorize you to furnish copies of all educational records, including, but not limited to, copies of grades, standardized test scores, psychological testing, guidance counselor records, records of visits with mental health professionals, medical records, records of notes regarding academic achievements and extra-curricular activities, and copies of any notes including any and all information reflecting disciplinary actions or behavioral outbursts, concerning: __________________________ Name of Individual whose date of birth is _______ and whose social security number is __________________. You are authorized to release the above records to the following representatives of defendant in the above-entitled matter who has agreed to pay reasonable charges made by you to supply copies of such records. ____________________________________________________________________________________________ Name of Representative ____________________________________________________________________________________________ Representative Capacity (e.g. attorney, records requestor, agent, etc.) ____________________________________________________________________________________________ Street Address ____________________________________________________________________________________________ City, State and Zip Code This authorization does not authorize you to disclose anything other than documents and records to anyone. This authorization is not valid unless the record requestor named above has executed the acknowledgment at the bottom of this authorization. Date: ___________________________ ______________________________________ Individual or Guardian Signature Date: ___________________________ ______________________________________ Witness Signature STATE OF ________________________; COUNTY OF _______________________; Taken, subscribed and sworn to before me this ______ day of _____________ 2002. My commission expires: ________________________________________________________ ___________________________________________ NOTARY PUBLIC The undersigned, as the record requestor named in the above authorization, hereby declares under penalty of perjury, pursuant to , that the attorney for the person (or the person, if not represented) named in the foregoing authorization has been given notice that the authorization will be used to request records from the person or entity to whom it is addressed and has been afforded an opportunity to object to the request and to order copies of the records requested from the undersigned requestor at a reasonable cost pursuant to the terms of Discovery Order #5, entered by the Honorable Mary E. Stanley, U.S. Magistrate Judge, in the matter of: MDL 1477. __________________________________________ IN THE UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF WEST VIRGINIA IN RE SERZONE : PRODUCTS LIABILITY LITIGATION : MDL Docket No. 1477 AUTHORIZATION FOR RELEASE OF WORKERS' COMPENSATION, SOCIAL SECURITY, AND OTHER DISABILITY RECORDS — EXHIBIT E To: ____________________________________ Name ____________________________________ Address ____________________________________ City, State and Zip Code This will authorize you to furnish copies of all documents in your possession, including but not limited to, applications, evaluations, examinations, determinations, correspondence, or any other documents, related in any way to state workers' compensation, Social Security Administration and/or state employment security, or any other disability filings or applications in your possession concerning: ____________________________________ Name of Employee whose date of birth is __________________________________ and whose social security number is ________________________. You are authorized to release the above records to the following representatives of defendant in the above-entitled matter who has agreed to pay reasonable charges made by you to supply copies of such records. _______________________________________________________________________________ Name of Representative _______________________________________________________________________________ Representative Capacity (e.g. attorney, records requestor, agent, etc.) _______________________________________________________________________________ Street Address _______________________________________________________________________________ City, State and Zip Code This authorization does not authorize you to disclose anything other than documents and records to anyone. This authorization is not valid unless the record requestor named above has executed the acknowledgment at the bottom of this authorization. Date: ________________________________ _____________________________________ Employee or Guardian Signature Date: _________________________________ _____________________________________ Witness Signature STATE OF ______________________________; COUNTY OF _______________ Taken, subscribed and sworn to before me this ________ day of_________________ 2002. My commission expires: ________________________________________________________ _______________________________ NOTARY PUBLIC The undersigned, as the record requestor named in the above authorization, hereby declares under penalty of perjury, pursuant to . that the attorney for the person (or the person, if not represented) named in the foregoing authorization has been given notice that the authorization will be used to request records from the person or entity to whom it is addressed and has been afforded an opportunity to object to the request and to order copies of the records requested from the undersigned requestor at a reasonable cost pursuant to the terms of Discovery Order #5, entered by the Honorable Mary E. Stanley, U.S. Magistrate Judge, in the matter of: MDL 1477. __________________________________