Please Provide More Detail
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Date of Birth of Injured Party
-
Month
-
Day
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
Date
What type of injury occurred?
*
Anesthesia
Birth injury (OB management/HIE/delivery negligence)
Car accident
Catastrophic accident
Communication failure (hospital failure, 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
Which option(s) best reflect the injury severity?
*
Temporary pain/injury (fully resolved or expected to resolve)
Ongoing or chronic pain/injury (lasting several months or expected to continue)
Serious injury without permanent disability (surgery, hospitalization, fractures, internal injuries, etc.)
Lifelong brain injury/HIE/stroke
Paralysis/major mobility loss
Major organ loss/amputation
Wrongful death
How much functional loss/disability resulted from the injury?
*
Permanent loss of ADL (activities of daily living) & independence
Partial but chronic limitation
Temporary impairment
None
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?
Not applicable
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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