Please Provide More Detail
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth of Injured Party
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
On what date did the injury or, if applicable, the death occur? Please provide an approximate date if you are unsure.
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What type of injury occurred?
*
Anesthesia
Birth injury (OB management/HIE/delivery negligence)
Car accident
Catastrophic accident
Communication failure (hospital failure and/or communication breakdown)
Diagnosed but failed to treat
Delay in treatment or transfer
Failure or delay to diagnose
Medication/dosing error
Orthopedic injury
Surgical error (wrong site/breach/unnecessary risk)
Trucking accident
Other
Please tell us if any of the following occurred after your birth experience. You may select more than one option.
My child had whole body or head cooling
My child was resuscitated
My child required intubation
My child experienced seizures or was given medication to prevent seizures
My child was hypoxic or anoxic
My child had a head ultrasound
My child had a head CT
My child had or has a head MRI scheduled
My child had a stroke
None of the above occurred
Which option(s) best reflect the injury severity? Please select up to 3 options.
*
Temporary pain/injury
Ongoing or chronic pain/injury (lasting several months or expected to continue)
Serious injury without permanent disability (surgery, hospitalization, fractures, internal injuries, etc.)
Traumatic brain injury
HIE (hypoxic-ischemic encephalopathy)
Stroke
Paralysis or major mobility loss
Major organ loss
Amputation
Death
How much functional loss/disability resulted from the injury?
*
None
Not sure
Temporary impairment
Partial but chronic limitation
Permanent loss of ADL (activities of daily living) & independence
The injured is deceased
Can you briefly describe the incident in your own words?
What is the age range of the injured party?
*
0-17
18-40
41-65
66+
Does the injured party have the ability to work?
*
No impact (unemployed, retired, or not old enough to work)
No impact (still working)
Returned to work but with limitations/light duty
Loss of part-time work or reduced hours & productivity
Loss of full-time employment/total incapacity
Injured party is deceased
Was an autopsy performed?
No
In progress
Yes
Which hospital treated the injured party?
*
Cincinnati Children's Hospital
The Christ Hospital
Norton Hospital
Miami Valley Hospital
Other
What is the status of the injured party's medical records?
*
Ready
Requested
Not requested
Gating Form ID
Please verify that you are human
*
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