McLeroy, Litzler, Rutherford, Bauer & Friday, P.C.

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* First Name
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Your Social Security #	( optional )
Your Date of Birth
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Home Street Address
Mailing Address
City
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Spouse's Information
First Name
Middle Name
Social Security #	( optional )
Date of Birth
Place of Birth

Dependant Information Please provide us with the names, addresses and birth dates of all children:
Name	Address	Date of Birth

Job Sites Please provide us with a list of the job sites that you have worked. Approximate dates & years you worked at each site, and please list any co-workers that you worked with.
Site	Years	Co-Workers

Major Contractors / Sub-Contractors Please list all contractors that you have worked for.
Contractor	Dates	Types of Work

Types of Welding Processes Please indicate which welding processes you used or worked around.
	Yes	No
Shielded Metal Arc Welding (SMAW, stick)
Gas Metal Arc Welding (GMAW, MIG)
Gas Tungsten Arc Welding (GTAW, TIG)
Flux Colored Arc Welding (FCAW)
Plasma Arc Welding (PAC, PAW)
Submerged Arc Welding (SAW)
Carbon Arc Welding (CAW)
Electro Slag Welding (ESW)
Electro Gas Welding (EGW)
Stand Alone Welding
Oxycetylene Welding
Beddon Plate Welding
Torch Brazing
Oxygen Cutting
Air Carbon Arc Cutting

Work History Details
Estimated days per week that you welded
Estimated hours per day that you spent welding
Was your primary exposure to welding from co-workers	Yes or No
IF Yes, answer the following questions
Estimated number of hours around welders
How close were you working to the welders

Welding Rod Manufacturers

Please Complete the following List

	Did you used these welding rods	How often did you use their rods?		Please list rod model numbers you worked with
		Frequently	Occasionally
Air Products
Airco
Ancos
Alloy Rods
Amsco
Coast Metals
Enterprise
Haynes Stellite
Hobart
Lincoln Electric
Lindo
Mariquette
McKay Co.
Mid States
Murex
National Standard
Paje
Rankin
Reid-Avery Co. RACO
Rexano
Stoody
Tri-Mark
Unibraze
Victon
Wall Comony
Westinghouse
Dual Shield
Gulf Wire Corp
Select Arc
Spool Arc
Atom Arc
Shield Bright
Magnolia Welding

Health			Have you ever smoked? Yes No
If yes, what year did you start smoking?
If yes, what did you smoke?
Cigarettes	Brand Name:
Cigars	How many:
Pipes	How many bowls:
How old were you when you started smoking?
How many packs did you smoke per day?
Did you stop smoking?		Yes No
On average, how much alcohol do you/did you drink?
Did not drink
0-3 drinks/wk	3-6 drinks/wk
6-12 drinks/wk	12+ drinks/wk

	Yes	No
Do you experience a feeling of weakness in your legs?
Do you have difficulty walking downhill?
Do you sometimes lose your balance?
Do your fingers or hands shake?
Does performing heavy work make you feel weak?
Have you noticed any changes in the way you speak?

Please check any of the symptoms listed below that you have experienced:

	Cramps in legs or arms		Muscle rigidity or tenseness
	Increased tiredness		Increased and abnormal reflexes
	Feelings of aggressiveness		Irregular handwriting
	Insomnia		Poor memory
	Mental Confusion		Impaired hearing
	Impotence		Double vision
	Loss of desire to talk		Restlessness
	Irritability		Visual hallucinations
	Excessive sweating		Excessive salivation
	Headaches

Has a doctor ever diagnosed you with any of the following:

	Date Diagnosed	Name of doctor, clinic or hospital	Address
Parkinson's disease
Parkinsonism
Manganism
Neuropathy
Pneumonitis
Asthma
Emphysema
Asbestosis
Silicosis
Heart Disease
Hypertension or High Blood Pressure
Osteoporosis
Anemia
Malaria
Avitaminosis
Liver dysfunction

Have any family members ever been diagnosed with Parkinson's Disease, Parkinson's Syndrome or Parkinsonism?	Yes No
If yes, please list that person's name, age at diagnosis, occupation and relationship to you.
Name:
Age at Diagnosis:
Occupation:
Relationship:

By submitting the above request I understand that I have not entered into an Attorney-Client relationship,
and that at this time I am only requesting information. I understand that I can only retain an attorney if
and when it is determined that I have a lawsuit. I also understand that this form is not a promise of
compensation.

The information you provide will be kept private and used only to screen your claim.

If you agree to the above statement please type YES below.

When Completed Click Submit.

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The information you obtain at this site is not, nor is it intended to be, legal advice. You should consult an attorney for individual advice regarding your own situation.

Copyright © 2002 by McLeroy, Litzler, Rutherford, Bauer & Friday, P.C. All rights reserved. You may reproduce materials available at this site for your own personal use and for non-commercial distribution. All copies must include this copyright statement.

Welding Claim Screening Form