Please complete the following questionnaire regarding your Hair Relaxer case.

Chemical Hair Relaxer Questionnaire

Instructions

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
Current Address
Your Date of Birth
DO NOT file bankruptcy during pending litigation without first consulting your Attorney as it may impact your ability to recover settlement proceeds.
If you are married, please list your spouse’s full name.

Hair Relaxer Product Information

Please select all hair relaxer products that you have used in the past 10 years. Note: these are Brand-Name products. Your hair relaxer product could be the same product on the list but marketed under a different name.

Medical Information

Please list all injuries you believe may be related to your exposure to Chemical Hair Relaxers:
Check all that apply and list approximate date of diagnosis in the “Other” field below.
Please list the names of all known doctors and medical facilities that provided medical treatment for your injuries/conditions mentioned above, along with the approximate dates of treatment. Ex: Dr. John Doe, Boston University Hospital, Chemotherapy (2015-2017)

Miscellaneous

This field is for validation purposes and should be left unchanged.