COVID LAWSUIT PLAINTIFF INTAKE QUESTIONNAIRE Please fill out all sections to the best of your abilities. Name First Last PhoneEmail Home Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Job Description:SelectMilitaryFederal Civilian EmployeeFederal ContractorBranch of Military:SelectOFFICER AIRFORCEENLISTED AIRFORCEOFFICER ARMYENLISTED ARMYOFFICER MARINESENLISTED MARINESOFFICER NAVYENLISTED NAVYOFFICER COAST GUARDENLISTED COAST GUARDRank Unit Duty Station Employer GS (15)/Step(10) Position/Title Duty station/Work address Service Disabled Veteran or other veteran? Yes No Union/Non-UnionSelectUnionNon-UnionWork Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Veteran Status End of Contract Date MM slash DD slash YYYY Option Year End Date MM slash DD slash YYYY Years of Service Combat Tours Medals/Citations Awards Reviews General Vaccination Guidance/OrdersDescribe and provide supporting documentation for any guidance or orders you have received regarding vaccination requirements, deadlines, refusal/non-compliance, exemptions, booster shots, disciplinary actions, compliance with HIPPA, etc. For example, immediate termination, placed on administrative unpaid leave but not terminate.Personal Vaccination Guidance/Orders/CorrespondencePlease provide any guidance, orders or correspondence from commander, supervisor or HR regarding same issues as above, including verbal conversations, recollections, or word of mouthHave you had COVID? Yes No Upload your lab / test results including any antibody results Drop files here or Select files Max. file size: 1 MB, Max. files: 3. Do you have pre existing medical issues or disabilities? Yes No Vaccination Status: Vaccinated Not Vaccinated Any adverse reactions (allergic reaction, heart, myocarditis/pericarditis, Bells Palsy, etc.)? Have you requested a religious waiver from the COVID vaccine? Yes No Waiver Status:SelectGrantedDeniedPendingDid your command or company provide guidance or direction on how to file a religious waiver? Yes No At the link below, please provide any guidance your command provided on how to file a RA waiver and a copy of your RA waiver request, and responses you have received Drop files here or Select files Max. file size: 1 MB, Max. files: 3. Has anyone in a position of leadership (supervisor, Chaplain) told you that there was a small chance of obtaining a waiver? Yes No What did they say?Have you submitted a medical exemption waiver request? Yes No At the link below please provide a copy of the medical waiver request you submitted and any responses you have received Drop files here or Select files Max. file size: 1 MB, Max. files: 3. Did your command or employer provide guidance or direction on how to file a medical waiver? Yes No Waiver Status:SelectGrantedDeniedPendingAre there any current, pending or threatened disciplinary or counseling actions? Yes No DescribeHave you been terminated from your position due to a COVID vaccination mandate? Yes No If you were to be terminated, how does that impact your life and or retirement?Are you at risk of being discharged with a characterization with anything other than honorable? Yes No Does not apply Did your employer provide you with any information on which to make an informed consent decision? Yes No Did your Command or employer provide you with any information on which to make an informed consent decision? Yes No What was it and how did it impact your decision?What was it and how did it impact your decision?Has your Command or employer created a hostile work environment because you are unvaccinated? Yes No Please DescribeAre you willing to be publicly named as a Plaintiff? Yes No Alternatively, are you willing to disclose identity under a protective order (i.e., not disclosed publicly but only to defense counsel)? Yes No Please provide any Other Documents/Materials/Presentations that maybe relevant to your case. Drop files here or Select files Max. file size: 1 MB, Max. files: 5. Required* Please note, any submission to Defending the Republic (DTR) does not constitute an engagement unless expressly agreed and confirmed as such. DTR receives a high volume of requests for assistance and engages with those priority cases that it is best positioned to assist.
