Please complete the following questionnaire regarding your Camp Lejeune Toxic Water case.

Camp Lejeune Toxic Water Questionnaire


Please answer all questions fully to the best of your ability. Some questions may not apply to your specific case. In that situation, simply put ‘N/A’ as your entry. If you do not know the answer to a particular question, you should state ‘Unknown' as your entry.

Personal Information

Your Name

Claimant Information

The Claimant is the person who was exposed to the toxic water.
Name of Claimant (If Different)
Claimant's Date of Birth
Where Did Claimant Reside at Camp Lejeune?

Decedent Information (If Applicable)

If Claimant is not deceased, you may skip this section.
Claimant's Date of Death

Injury Information

Claimant's Injuries
Please select the injuries that you believe may be related to Claimant’s exposure to the toxic water at Camp Lejeune (check all that apply).

Medical Information

Please list the names of all known prescribed medications that Claimant took over the course of their lifetime, along with the approximate dates of use. (Ex: Zantac, 2018 - Present)
Please list the names of all known doctors and medical facilities that Claimant treated with over the course of their lifetime, along with the approximate dates of treatment. (Ex: Dr. John Doe, Montgomery Clinic, Chemotherapy 2015-2017)


Please provide any other facts or information that you believe may be relevant to this case.
If you have copies of Claimant's DD214s, Medical Records, Death Certificate (If Applicable), Last Will (If Applicable), or other relevant documents, please upload them here. If you are unable to upload, please email the files to or mail physical copies to our Mobile, AL office located at 1 St. Louis St., Suite 1002, Mobile, AL 36602.
Drop files here or
Max. file size: 256 MB.
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