Mobile Phone
Alternate Contact Number
Date of Birth
Social Security Number
Driver's License Number
Employment Status


Location(s) where you were exposed to contamination (See above)
Time frame when you were exposed to contamination
Address(es) and circumstances surrounding your exposure to contaminated water at CL
Family members or relatives that you resided with who were exposed to toxic water. Please identify the person (name and contact information if known), if they are military personnel - identify name and rank), their relationship to you, the period of time they were with you when the exposure to toxic water occurred and what, if any, medical conditions they experienced that you believe may be related to their exposure. (Identify potential witnesses).


Conditions you believe were caused by and/or related to your exposure to toxic water at Camp Lejeune (CL). For each condition, please set forth when you first experienced the symptoms associated with the condition, the symptoms you experienced, what and when were you diagnosed with the condition and by whom (name/address) and if the diagnosing physician provided you with any information as to his/her belief as to the cause or a cause of the condition.
Identify any other health conditions for which you were diagnosed that are not related to your exposure to toxic water at CL. As to each, please state the diagnosis, when you were diagnosed and by whom.
With respect to each condition you identified herein above, please identify each health care provider (name and address if known) that diagnosed you with the condition and/or provided treatment for the condition. Further state the nature of the treatment, if any, and when and where the treatment took place.

Health Care Provider 1


Health Care Provider 2

Please identify every time, if any, that you were hospitalized (overnight stay) for a condition that is not related to your exposure to toxic water at CL. Please identify the condition, the treatment and the hospital/facility providing treatment.
As to the condition(s) which you have been diagnosed, is there any family history of this condition in your family. Please include parents, siblings, grandparents, aunts, uncles and first cousins. Please note in this response if anyone with the same condition, or similar conditions, lived, were housed or experienced any significant time within the Camp Lejeune Map included above, please note


Describe the damages (physical, mental, medical, economic, non-economic) caused by the condition(s) that you believe were caused by your exposure to toxic water.


Have you made any type of claim for the condition for which you believe was caused or caused in part by your exposure to toxic water at CL. Includes workers compensation, civil suit, medical malpractice suit, administrative claim with the Veterans Administration? If so, please state when you filed the claim/suit, with whom, the nature of the claim and if you were represented by counsel, and if so, whom.
Have you ever filed an insurance claim, civil suit, workers compensation claim or other civil suit for any matter unrelated to your exposure to toxic water at CL. If so, please state when, where, the nature of the suit, the damage(s) you claim you suffered, the result of the claim/suit, name of counsel - if represented by counsel and when the action commenced and when, if, it ended.
Have you ever filed for bankruptcy? If yes, please indicate when, the Court where it was filed, the attorney, if any, representing you, the current status of the suit and if closed, when was it closed.


Do you smoke? If so, how much a day. If you no longer smoke, set forth the time frame (commenced and ended) which you smoked and the estimated amount smoked on a daily basis.
Have you been diagnosed with any conditions that were caused by and/or related to smoking? If yes, please identify the condition(s), the date of diagnosis, the Doctor making the diagnosis and his contact information and the treatment, if any, you received or currently receiving.
Have you ever had an occupation or lived in an area where you were exposed to hazardous materials or chemicals on a “regular basis” ? For example, a farmer who sprayed pesticides/herbicides? Worked at a nuclear power plant? An occupation where you were exposes to radiation on a regular basis? Painter using lead paints? Insulators installing insulation ? Welder?
Have you ever been convicted of a crime? If yes, please state the charge, the approximate date of conviction, the city and state of the conviction and the sentence.