Questionnaire - Florida Lawsuit Updates

Join the Lawsuit

If you are not participating in the lawsuit and would like to be included, please fill out the below form to send us an auto generated PDF or download and complete the questionnaire.

If downloading and filling out the form manually please return the completed form to Aaron Cambell or Kristen Burke. The Client Intake Form is also available.

BSCO Questionnaire

Name

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

Name(Required)

SSN(Required)

Current address, email and telephone:(Required)

Address of significant other or close contact in case we cannot reach you:(Required)

Are you currently incarcerated? If so location/date of incarceration:(Required)

Were you incarcerated in the Bay County Jail DURING Hurricane Michael?(Required)

Yes

If you were NOT incarcerated in the Bay County Jail DURING Hurricane Michael, list dates in which you were incarcerated before Hurricane Michael:

If you were NOT incarcerated in the Bay County Jail DURING Hurricane Michael, list dates in which you were incarcerated After Hurricane Michael:

List all dorms you were in during and after Hurricane Michael:(Required)

If moved list dates of All movement:

If you were moved, did you ever go back to your original dorm?

When you were incarcerated in The Bay County Jail during and after Hurricane Michael, list the conditions/circumstances/and the length of time in which you were personally subjected to such conditions/circumstances due to Hurricane Michael. Make sure to describe conditions/circumstances related to each dorm you were house in during and after Hurricane Michael:

How long was the jail without power, water, plumbing and air conditioner?

If you were in the Bay County Jail DURING Hurricane Michael, when did you get out of the Bay County Jail after the hurricane and give each location including periods of incarceration in DOC and other jails since leaving the Bay County Jail.(Required)

Do you believe that you have any medical condition RESULTING from your incarceration DURING or AFTER the hurricane and if so, what is/are those conditions:(Required)

Please list any and all injuries you have sustained during and after your incarceration in the Bay County Jail since Hurricane Michael:(Required)

Please list all places and dates of incarceration from October 2018 to present:(Required)

If you are experiencing health problems that you BELIEVE ARE THE RESULT OF YOUR INCARCERATION DURING HURRICANE MICHAEL, what are your symptoms? (1)

If you are experiencing health problems that you BELIEVE ARE THE RESULT OF YOUR INCARCERATION DURING HURRICANE MICHAEL, what are your symptoms? (2)

If you are experiencing health problems that you BELIEVE ARE THE RESULT OF YOUR INCARCERATION DURING HURRICANE MICHAEL, what are your symptoms? (3)

If you are experiencing health problems that you BELIEVE ARE THE RESULT OF YOUR INCARCERATION DURING HURRICANE MICHAEL, what are your symptoms? (4)

If you are experiencing health problems that you BELIEVE ARE THE RESULT OF YOUR INCARCERATION DURING HURRICANE MICHAEL, what are your symptoms? (5)

Have you seen a doctor or other medical professional for these symptoms? List the name and address of any doctor you have seen for the symptoms listed above: (1)

Have you seen a doctor or other medical professional for these symptoms? List the name and address of any doctor you have seen for the symptoms listed above: (2)

Have you seen a doctor or other medical professional for these symptoms? List the name and address of any doctor you have seen for the symptoms listed above: (3)

Have you seen a doctor or other medical professional for these symptoms? List the name and address of any doctor you have seen for the symptoms listed above: (4)

Have you seen a doctor or other medical professional for these symptoms? List the name and address of any doctor you have seen for the symptoms listed above: (5)

List all doctors (with addresses) you have seen for the past ten years: (1)

List all doctors (with addresses) you have seen for the past ten years: (2)

List all doctors (with addresses) you have seen for the past ten years: (3)

List all doctors (with addresses) you have seen for the past ten years: (4)

List all doctors (with addresses) you have seen for the past ten years: (5)

List all doctors (with addresses) you have seen for the past ten years: (6)

List all doctors (with addresses) you have seen for the past ten years: (7)

List all doctors (with addresses) you have seen for the past ten years: (8)

List all doctors (with addresses) you have seen for the past ten years: (9)

List all doctors (with addresses) you have seen for the past ten years: (10)

Current Date(Required)

Signature (This is an Electronic Signature)(Required)

Printed name(Required)

Via Mail

Kristen A. Burke
Marie A. Mattox, P.A.
203 North Gadsden Street
Tallahassee, Florida 32301

Or By Email

aaron@mattoxlaw.com

Kristen@mattoxlaw.com