By Ronald G. Bankston and John A. Tarantino

When properly used, a client interview questionnaire or intake form will help you obtain the information necessary to evaluate the client’s case from both a liability and damage perspective. It will also help you understand and appreciate the client and how he or she will likely be perceived by the fact finder. It can be useful to utilize different versions of the questionnaire depending upon the type of case.

Client Interview Questionnaire: The Slip and Fall Accident

1. Date of the accident: _______________________________________________________

Day of the week: ____________________________________________________________

Time of day: ________________________________________________________________

Weather conditions: __________________________________________________________

2. Describe in detail the location of the accident. ____________________________________

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3. Describe in detail how the accident occurred. _____________________________________

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4. Did you see any warnings, instructions, or signs giving notice of any dangerous conditions? If so, what did the warning or instructions say, or what did the sign depict? __________________

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5. Give the name and address of the defendant(s) (include both owner and tenant of the property. if known). _____________________________________________________________

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6. Give the name and address of defendant’s insurance carrier, and describe how you acquired this information. ________________________________________________________________

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7. Give the name and address of defendant’s insurance adjuster, and describe how you acquired this information. ________________________________________________________

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8. List the names and addresses of all witnesses to the accident. ________________________

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9. Was an ambulance called? _____ If so, who called the ambulance, and when did it arrive?

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Did anyone accompany you to the hospital? ________ If so, give his or her name. ___________

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10. Were you hospitalized? __________ If so, list the name and address of the hospital and the charges you incurred. __________________________________________________________

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11. List the names and addresses of all doctors, nurses and medical technicians who treated you, and their corresponding charges. ______________________________________________

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12. Did you give any statements to any insurance company or to any other person about the accident? __________ If so, when, where and to whom did you give the statement? _________

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13. Do you have a copy of the statement(s)? _________________________________________

14. Has the defendant’s insurance carrier made any settlement offer to you? __________ If so, when was the offer made, by whom and in what amount? _____________________________

15. Did the accident take place while you were working? ______________________________

16. Did the accident take place at your workplace? ___________________________________

17. Were any co-workers involved? __________ If so, list the names and addresses of co-workers involved and what their specific involvement was. _____________________________

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18. Do you know whether any photographs, pictures, or films were taken of the scene of the accident? ____ If so, when was the offer made, by whom and in what amount? _____________

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19. Do you have copies of any photographs, pictures, or films of the accident? ______________

20. Were any photographs, pictures or films taken of you either at the scene of the accident or in the hospital? __________ If so, when were they taken, and by whom? __________________

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Do you have copies? ___________________________________________________________

21. Are you aware of any actions taken to correct the condition which caused the accident/incident? ___________ If so, describe such actions and indicate who was responsible for such actions. _______________________________________________________________

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Client Interview Questionnaire: Automobile Accident Cases

1. Date of the accident: _________________________________________________________

Day of the week: ______________________________________________________________

Time of day: ___________________________________________________________________

Weather conditions: ____________________________________________________________

2. Describe in detail the location of the accident (include in your answer proximity to driveways, intersections, traffic signs, homes, businesses or other fixed objects). ____________________

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3. Describe (a) where you were going at the time of the accident, (b) where you were coming from, (c) if you were the driver of the vehicle, and (d) how many times you have driven along the route which you were traveling at the time of the accident. ______________________________

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4. Describe in detail how the accident happened. Include in your answer (a) distances, (b) speeds, (c) road or weather conditions, (d) any defects in the vehicles or road, (e) whether the highway was marked or divided, (f) any visual obstructions, (g) the presence of any skid marks, (h) a notation of any unusual sounds or noises heard, and (i) whether you used directional signals. ______________________________________________________________________

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5. Did you have a conversation with the driver of the other vehicle? If so, were any statements made as to who was at fault? What statements? _____________________________________

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6. Did you have any other conversations at that time or subsequent to the accident with the driver, his passenger, or any other party? If so, specify the name of the person, his address and the substance of the conversation. _________________________________________________

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7. Did the police investigate the accident? If so, did you give a statement to the police? If so, state in detail exactly what you told the police. Also, state in detail any other statements you overheard being given to the police. ________________________________________________

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8. Who called the police? ________________________________________________________

9. Was anyone else injured in the accident? If so, who was injured and what was the extent of his injuries? ___________________________________________________________________

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10. Did an ambulance arrive at the scene of the accident? If so, who called the ambulance, and when did it arrive? Did anyone accompany you to the hospital? If so, give his name and address. _____________________________________________________________________

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10. Did an ambulance arrive at the scene of the accident? If so, who called the ambulance, and when did it arrive? Did anyone accompany you to the hospital? If so, give his name and address. _____________________________________________________________________

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11. Identify all witnesses known to you, giving names, addresses and any relationship to you. ______________________________________________________________________________

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12. Did you have any discussions with any of the witnesses at the scene of the accident? If so, with whom did you speak and what was said? ________________________________________

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13. Give the address of the defendant(s). Include both the owner and the operator of the other vehicle, if known. _______________________________________________________________

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14. Give the name and address of the defendant’s insurance carrier and specify how you acquired this information. _______________________________________________________

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15. Give the name and address of the defendant’s insurance adjuster and specify how you acquired this information. ________________________________________________________

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16. Have any statements, either oral or written, been given by you or anyone on your behalf to the defendant’s insurance carrier or anyone else representing the defendant? If so, give the substance of the statement, when you gave it, where you gave it and to whom you gave it. _____________________________________________________________________________

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17. Do you have a copy of the statement(s)? ________________________________________

18. Were any photographs taken of the scene of the accident, the vehicles involved, or the persons injured? If so, identify the subject of each photograph and indicate when it was taken, where and by whom. ___________________________________________________________

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19. Identify all persons currently having possession of any such photographs. ______________________________________________________________________________

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20. Was the vehicle you were riding in damaged? If so, describe what portions of the vehicle were damaged and the estimate of any cost of repair of which you are aware. ______________

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21. Has the vehicle in which you were riding been repaired? If so, indicate who performed the repairs, who paid for them, the cost of the repairs and whether you have a copy of the invoice of the repair costs. _______________________________________________________________

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22. Who were the actual owners of the vehicles involved in the accident?

Other vehicle: _________________________________________________________________

Your vehicle: __________________________________________________________________

Describe the make, model, year, and license number of each vehicle.

Other vehicle: _________________________________________________________________

Your vehicle: __________________________________________________________________

When was the vehicle in which you were riding purchased, from whom and at what price? ____

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23. Were there any defects in or problems with your vehicle or the vehicle you were riding in? If so, describe. __________________________________________________________________

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24. Did the vehicle you were riding in have a current inspection sticker at the time of the accident? If so, state the date and by whom the sticker was issued. _____________________ _____________________________________________________________________________

25. Give the name and address of the insurance company insuring the vehicle you were in. _____________________________________________________________________________

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26. Do you have a copy of the policy? ______________________________________________

27. Are you a named insured under any automobile insurance policy? If so, identify the insurance company and the policy number. __________________________________________

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Provide a copy of the policy if available and if not available, provide the name of your agent so that we may obtain a copy of it. ___________________________________________________

28. If you were hospitalized, give the names and addresses of all hospitals and the amount of total charges incurred. _________________________________________________________

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29. List the names and addresses of all doctors, nurses, and technicians who have treated you, the dates of the treatment received, and the charges incurred. __________________________

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30. Did the accident occur in the course of your employment? __________________________

31. Were you driving the vehicle or were you a passenger in it? _________________________

32. Have you applied for any medical or insurance benefits (including workers’ compensation) as a result of the accident? If so, when and to whom did you apply, and what response to your application did you receive? _____________________________________________________

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33. Have you received any medical or insurance benefits (including workers’ compensation) as a result of the accident? If so, who made the payments, when and in what amount were they made? ______________________________________________________________________ _____________________________________________________________________________

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34. Did you or the driver of your vehicle consume any alcohol prior to the accident? If so, identify what each of you was drinking, where each drink was consumed, with whom each of you was drinking, the amount that each of you had to drink, and how long prior to the accident each of you had your last drink. __________________________________________________________ ______________________________________________________________________________

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35. Did you or the driver of your vehicle take any medication or drugs before the accident? If so, identify the type of drug each of you took, who prescribed the medication, the dosage and how long before the accident each of you took the last dose. _______________________________

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36. If either you or the driver of your vehicle took any medication or drugs within the 24-hour period before the accident, state whether any physician had prescribed any medication or drugs for either of you which should have been taken at the time of the accident and, if so, identify the physician who prescribed the medication, the nature of the medication, the reasons it was prescribed and the reasons it was not taken. ________________________________________

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37. Did the driver of your vehicle have any restrictions on his driver’s license? If so, state what they are. _____________________________________________________________________

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38. Were any persons charged with motor vehicle violations or criminal charges as a result of the accident? If so, who was and what were the charges? _____________________________

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39. Has there been a resolution to the charges? If so, how were they resolved? ____________

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40. Were you employed at the time of the accident? If so, identify your employer, the specific nature of your employment (including job duties) and your average weekly earnings at the time of the accident. _______________________________________________________________

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41. Were you prevented from working as a result of any injuries you suffered in the accident? If so, how long were you out of work and on whose advice? ___________________________

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42. If you did not actually lose any time from work as the result of your injuries, did any physician tell you not to work for any period of time? If so, identify the physician, the reason that you were told not to work and the reason that you worked despite these instructions. _______________

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43. Describe all activities you typically engaged in which you were prevented from doing as a result of the accident. __________________________________________________________

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44. Provide the name of your spouse and the names and birth dates of your children. ________

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45. Describe any household tasks you typically performed which others had to perform because of any injuries you suffered in the accident. _________________________________________

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46. Provide the name of your health insurance carrier and list all medical bills it has paid. ____

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47. Identify any other source of payments for medical bills you have incurred. ______________

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48. List all other expenses you have incurred as a result of the accident and which have not yet been reimbursed. _____________________________________________________________

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Client Interview Questionnaire: Product Liability

1. Date of the accident: ________________________________________________________

Day of the week: _____________________________________________________________

Time of day: __________________________________________________________________

Weather conditions: ___________________________________________________________

2. Describe the location of the incident. ___________________________________________

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3. Describe in detail how the incident occurred. _____________________________________

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4. Describe in detail the product, machine, or substance which caused your injury. _________

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5. Explain what you believe was the cause of the accident. ___________________________

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6. Explain what you believe could have been done to avoid the accident. __________________

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7. Had you ever worked with, seen, or been exposed to the product, machine, or substance before you were injured? If so, explain. _____________________________________________

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8. Did you purchase the product, machine, or substance which injured you? If so, when did you purchase it, from whom, for what purpose, and at what price? _________________________

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9. Did you receive any warnings or instructions on the use of the product, machine, or substance which injured you? If so, what were the warnings or instructions, by whom were they given, when were they given, and were they written or oral? ____________________________

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10. Were you injured during the course of your employment? If so, explain. ________________

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11. Were you injured at the workplace? If so, explain. _________________________________

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12. Did your employer own the product, machine, or substance that injured you? __________

13. Did your employer manufacture, distribute, design or produce the product, machine, or substance which injured you? ___________________________________________________

14. Were any co-workers involved? If so, give their names and addresses, and explain how they were involved. ________________________________________________________________

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15. List the names and addresses of all witnesses to the accident. _______________________

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16. List the name and address of the defendant. _____________________________________

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17. List the name and address of the defendant’s insurance carrier, and explain how you acquired this information. _______________________________________________________

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18. List the name and address of the defendant’s insurance adjuster, and explain how you acquired this information. ______________________________________________________

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19. Was an ambulance called? If so, who called the ambulance and when did it arrive? ______

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20. Did anyone accompany you to the hospital? If so, give his name and address. __________

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21. If you were taken to a hospital, list the name(s) of the hospital(s) involved, and specify the total charges you incurred. ______________________________________________________

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22. Was any statement given by you, or anyone acting on your behalf, to the defendant’s insurance carrier? If so, was it written or oral, and when was it given? ____________________

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23. Do you have a copy of the statement? __________________________________________

24. Did you read and sign the statement? __________________________________________

25. Have you given a statement about the accident to any other person? If so, to whom did you give the statement; and when, where, and for what purpose did you give it? _______________

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26. Do you know whether any photographs, pictures, diagrams, or films were made of the product, machine, or substance which injured you? __________________________________

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27. Were any photographs taken of you, either at the scene of the accident, while you were hospitalized, or while you were recuperating? If so, who took the pictures, and when and where were they taken? _______________________________________________________________

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28. Have you received any medical, insurance, or workers’ compensation benefits as a result of the accident? If so, from whom? _________________________________________________

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29. Has the defendant’s insurance carrier made any settlement offer to you? If so, was it oral or written, who made it, when and in what amount was it made? _________________________

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Client Interview Questionnaire: Medical Malpractice Cases

1. Identify all health care providers you believe caused your injury. _______________________

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The condition for which you were being treated: _____________________________________

When did you first consult each health care provider for this condition? ___________________

Date of the incident: ____________________________________________________________

Day of the week: _______________________________________________________________

Time of day: __________________________________________________________________

2. Describe the location of the incident (e.g., hospital, doctor’s office, emergency room). _____

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3. Describe in detail how and why you believe the incident occurred. Include in your response the source of this information or belief. ____________________________________________

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4. List the name and address of all health care providers (doctors, nurses, hospitals, technicians or other hospital or medical personnel) who were involved with the incident. ______

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5. Were you referred to these health care providers by anyone? If so, by whom? ___________

6. List the name and address of all health care providers (doctors, nurses, hospitals, technicians or other hospital or medical personnel) who were involved with the incident._______

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7. Did you have any previous contact with any of the same doctors, nurses, technicians, medical or hospital personnel before the day the incident occurred? ____________________

If so, give details. ____________________________________________________________

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8. Were you asked to sign any waiver forms, implied consent forms, or other documents before or after the incident? __________________________________________________________

If so, did you sign? ___________________________________________________________

Do you have a copy of the document? ____________________________________________

9. Were any of the persons involved your regular treating physician? ____________________

If so, give his/her name and address. _____________________________________________

10. List the name and address of all doctors, nurses, technicians, medical or other hospital personnel who came in contact with or treated you after the incident. ____________________

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11. Did you give a history to anyone?______________________________________________

If so, to whom? _______________________________________________________________

12. If you yourself did not give a history, did anyone give a history on your behalf?___________

If so, who gave the history? ______________________________________________________

To whom? ___________________________________________________________________

13. List the name and address of the defendant’s insurance carrier, and describe how you acquired this information. _______________________________________________________

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14. List the name and address of the defendant’s insurance adjuster, and describe how you acquired this information. ________________________________________________________

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15. Have you communicated with the adjuster?______________________________________

If so, when? __________________________________________________________________

16. Have you received any documents from the health care providers, their insurance carriers, or their adjusters concerning the incident?________________________________________

If so, when? _________________________________________________________________

17. Did you give any statements to anyone concerning the incident? ____________________

If so, to whom did you give the statement, where and when did you give the statement and do you have a copy? _____________________________________________________________

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18. List the names and addresses of all witnesses to the incident. Include any persons who accompanied you to the hospital or doctor’s office. ___________________________________

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19. Have you spoken to any of the defendants, their agents, or to any other person about the incident? _____________________________________________________________________

If so, give details. ______________________________________________________________

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20. Have you applied for any medical or insurance benefits as a result of the incident? _______

If so, to whom did you apply and what was the response to your application? _______________

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21. Have you received any medical or insurance benefits as a result of the incident? ________

If so, when and what was the amount? _____________________________________________

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22. Have any of the defendants (or their insurance carriers) made any settlement offer to you? If so, was the offer oral or written, who made it, when was it made and what was the amount? ___

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23. Were any photographs, pictures or films taken of you after the incident? If so, who took them, when and where? ________________________________________________________

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Do you have a copy? __________________________________________________________

24. Were you being treated at the time of the incident for a condition or injury which you sustained in the course of your employment? _______________________________________

25. Has any other health care provider ever told you that malpractice was committed? _______

If so, identify, the health care provider. _____________________________________________

Provide the date that you were first given this knowledge. ______________________________

What did the health care provider tell you? __________________________________________

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Do you have anything in writing from this health care provider? _________________________

26. Provide any additional information you consider important but which has not been asked for above. ______________________________________________________________________

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Ronald G. Bankston is a partner in the Houston, Texas office of the litigation firm of Godwin Pappas Ronquillo, LLP, and has been a practicing trial lawyer for 30 years. Mr. Bankston is Board-Certified in Personal Injury Trial Law by the Texas Board of Legal Specialization. He was first certified in 1985, and has been re-certified every five years since, most recently in 2005.

Mr. Bankston is admitted to practice by the State Bar of Texas and Supreme Court of Texas, the U.S. District Courts for Southern and Eastern Districts of Texas, U.S. Court of Appeals for the Fifth Circuit and the U.S. Court of Claims in Washington, D.C. He is a member of the American Board of Trial Advocates (ABOTA), a Life Fellow in the Texas and Houston Bar Foundations, a Sustaining Member of American Association for Justice and Texas Trial Lawyers’ Association, a Member and Past Director of Houston Trial Lawyers’ Association, and a Member of the Attorney-Mediators Institute and the Association of Attorney-Mediators.

In addition to his private practice, Mr. Bankston has also served as Special Assistant Disciplinary Counsel for the Texas Commission on Lawyer Discipline. He is also Academic Advisor and Lead Instructor at Rice University in the Rice University Paralegal Certificate Program.

A veteran as lead counsel in more than 100 jury trials, Mr. Bankston has spent his adult life counseling and representing individuals, families, small businesses, professionals, corporations and governmental entities. As a trained mediator, Mr. Bankston is often selected as a mediator by opposing parties and their attorneys, and he receives frequent appointments as a mediator by District Judges in Houston. He has provided mediation services to a wide variety of parties and attorneys, and his experienced “voice of reason” and patient persistence has facilitated the resolution of many especially difficult, complex disputes.

Mr. Bankston has served and been recognized as a Distinguished Faculty Member for the Houston Bar Association Continuing Legal Education Program, and a Guest Lecturer and Instructor in Trial Advocacy at the University of Houston Law Center. Mr. Bankston has also been an invited Lecturer on Personal Injury, Mediation, Product Liability, Premises Liability, Construction Liability, Water Park and Aquatic Safety Liability and Rental Equipment Liability.

Featured in Who’s Who in American Law, Mr. Bankston is also AV-rated by the national Martindale-Hubbell Legal Rating System, the highest rating for legal ability and ethical conduct, and has also been recognized nationally by Martindale-Hubbell as a Preeminent Attorney in the fields of Personal Injury, Product Liability and Toxic Tort.

John A. Tarantino is a trial attorney and principal in the law firm of Adler Pollock & Sheehan P.C. with offices in Providence, Rhode Island and Boston, Massachusetts. He has served as Chair of the firm’s Litigation and Executive Committees and presently holds the office of President. Mr. Tarantino lectures frequently on trial techniques in national, state and local bar and trial lawyer associations, from both the plaintiff and the defense perspective, and is the author of several legal texts including Litigating Neck & Back Injuries, Trial Evidence Foundations, Commercial Premises Liability, Premises Security: Law & Practice, Strategic Use of Scientific Evidence, Personal Injury Trial Handbook, Estimating & Proving Personal Injury Damages and Environmental Liability Transaction Guide. He has authored over 200 articles, columns, essays and reviews on discovery, procedure, trial strategy, product liability, liquor liability, premises security, forensic evidence, commercial law, criminal law, legal ethics, professionalism, environmental law and insurance coverage.

Mr. Tarantino is a member of the United States Supreme Court, Rhode Island and Massachusetts bars, the ABA, ATLA (Defense Member), DRI, American Judicature Society, the National Association of Criminal Defense Lawyers, the American Inns of Court (holding the rank of Barrister), the American Law Institute, the Defense Counsel of Rhode Island, the National Italian-American Law Society, the Justinian Society and the St. Thomas More Society. He is also a member of the Trial Practice and Litigation Sections of the ABA, serves on the ABA’s Subcommittee on Organizational Sentencing Guidelines and has served as Vice Chair of the ABA Committee on Scientific Evidence.

From 1984 through 1993, Mr. Tarantino served as Chair of the Public Relations Committee for the Rhode Island Bar Association. From 1997 through 1998, during the Rhode Island Bar Association’s Centennial Year, he served as President of the Rhode Island Bar and previously served as that Association’s President-Elect, Vice President and Treasurer. He is also a former Chair of the Rhode Island Bar Association’s Ethics and Professionalism Committee, has served as Chair of the Bar Association’s Ad Hoc Committee on Lawyer Advertising, and served as Co-Chair of the Committee on Judicial Independence. He continues to serve in the Rhode Island Bar Association’s House of Delegates. He served as President of the New England Bar Association from 2002 through 2003, and served as President of the Defense Counsel of Rhode Island from 2003 through 2004. He is a member of the National Conference of Bar Presidents.

Mr. Tarantino was named “Lawyer of the Year” for 2002 by Lawyers Weekly USA, one of the ten lawyers in the United States to receive this honor and recognition. He is also recognized in Best Lawyers of America in the fields of personal injury litigation, as well as commercial and business litigation; and he is recognized in Chambers USA America’s Leading Business Lawyers in the field of litigation. Additionally, his peers have honored him, selecting him as one of the “Best Lawyers in Rhode Island” in the field of litigation. He is a Fellow of the American College of Trial Lawyers and a Fellow of the International Academy of Trial Lawyers.