This form is a critical document required by the court. It is absolutely imperative that you complete this document. You must answer as thoroughly and as accurately as possible, and your prompt response is required so that your case can proceed. Be prepared to give yourself at least 30 minutes (if not more) to complete the form. All information shared via this form is secure, confidential and will be transmitted directly to our law offices.

Click "NEXT" to proceed.

Form Instructions (1 of 3)

Save your form as you progress so you don't lose your work. Click the "Save" button icon near the bottom of the screen and following the instructions.

Form Instructions (1 of 3)

If at any time you need to save and come back later, first click the progress area at the bottom, then click the save icon to have a link emailed to you. 

Form Instructions (2 of 3)

Note: Required questions/fields are marked with a red asterisk like this: *

You must complete all required questions/fields before you are allowed to progress to the next screen!

After you fill in all the required fields for a question, click "NEXT" (or right arrow) at the lower-right corner to continue. You can always go back to the prior questions by clicking "PREVIOUS" (or left arrow).

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Form Instructions (3 of 3)

If at any time you require help in filling out the form or want to speak to one of our team members for assistance, please contact our Client Care Team via phone or email and indicate you need assistance with the "PAQ form":  

• 1 (832) 568-7435
• shenaqpc@case-updates.com

[For Office Use Only] IMPORTANT AGENT REMINDER!!

GENERAL AGENT NOTES:

• For free-text fields, if a user doesn’t recall, enter “does not recall”
• For multiple choice questions, if “Do Not Recall” is an option, we don’t have to push for a YES/NO answer. But "Do Not Recall" is perfectly ok on a multiple choice question.
• Year selections – if user says “early 80s” then choose 1980. And list in a text box on the form “year is approximated”. If they say “late 80s” then choose 1989 and indicate “year is approximated” in a text box

[For Office Use Only] IMPORTANT AGENT REMINDER!!

III. RESIDENTIAL HISTORY, AGENT NOTES:

If client “does not know” when symptoms began, then go from date of diagnosis and work 10 years back. Also note, all we require here is the 10 years of residence prior to symptoms starting – don’t have to list all residences to today (though the over-sharing isn’t a problem).

[For Office Use Only] IMPORTANT AGENT REMINDER!!

IV. EMPLOYMENT HISTORY, AGENT NOTES:

If client “does not know” when symptoms began, then go from date of diagnosis and work 10 years back. Also note, all we require here is the 10 years of work history prior to symptoms starting – don’t have to list all work to today (though the over-sharing isn’t a problem). If a user doesn’t recall for a text field (i.e. Supervisor Name) then type “do not recall”.

[For Office Use Only] IMPORTANT AGENT REMINDER!!

VI. MILITARY SERVICE, AGENT NOTES:

If client served in military, let them know in the last section XXIV. AUTHORIZATIONS, they MUST sign the “military records release” form.

[For Office Use Only] IMPORTANT AGENT REMINDER!!

VII. FAMILY HISTORY, AGENT NOTES:

For date of diagnosis, have client provide as much info as possible (year, year/month, etc) if exact date unknown.

[For Office Use Only] IMPORTANT AGENT REMINDER!!

VIII. MEDICAL HISTORY - PART 1, AGENT NOTES:

• NOTE: You cannot enter “does not recall” for a physician name as this field is a must!
• If client “does not know” when symptoms began, then go from date of diagnosis and work 10 years back.
• Also note, all we require here is the 10 years of physician info prior to symptoms starting – don’t have to list all physicians to today (though the over-sharing isn’t a problem).
• If “Primary Care Provider” and “No Diagnosis,” then record for year enter the year when they visited the primary care provider. Note: “Name of Facility” might be the same of the doctor themselves if it is a small medical provider… But it might be something like “Veterans’ Hospital”, etc.
• For Physician Name, if they can't remember it, ask the client if they think they would be able to pick it out of a list if we follow up with them on a separate call…

[For Office Use Only] IMPORTANT AGENT REMINDER!!

VIII. MEDICAL HISTORY - PART 2, AGENT NOTES:

• NOTE: You cannot enter “does not recall” for a physician name as this field is a must!
• Generally speaking, the attorneys don’t expect many answers of “YES” here, and that’s ok.

[For Office Use Only] IMPORTANT AGENT REMINDER!!

VIII. MEDICAL HISTORY - PART 3, AGENT NOTES:

• NOTE: You cannot enter “does not recall” for a physician name as this field is a must!
• Claimant doesn't have to re-list doctors already listed in prior VIII Part 1/Part 2 sections, but list any other doctors they’ve seen since symptoms began (if they aren’t already in VIII Part 1, 2).

[For Office Use Only] IMPORTANT AGENT REMINDER!!

IX. INSURANCE AND CLAIM INFORMATION, AGENT NOTES:

As a matter of process, many times a Social Security disability claim is denied initially… If the END RESULT WAS THAT IT WAS EVENTUALLY APPROVED, then the answer to “Was your application denied?:” is NO!

[For Office Use Only] IMPORTANT AGENT REMINDER!!

X. FARMING HISTORY, AGENT NOTES:

• For multiple choice entry related to CROPS, ensure the claimant is looking at their workbook copy on the corresponding printed page to review all possible available answers.

• This is supposed to be…

  1.     A new entry for each location
  2.     A new entry for each chemical
  3.     Same entry for multiple crops

  Ex: If you farmed at Farm Alpha, and used Chemicals X, Y and Z, these would be three separate entries for: Farm Alpha – Chem X, Farm Alpha – Chem Y, Farm Alpha – Chem Z

• If a user is confused by the instruction statement: “If you harvested multiple crops and applied the same chemicals at a single location, please use the Other Crops Planted field to delineate the additional crops.” Just tell them to ignore it! And use the multi-check boxes.

• For Business (Farm) City – user may just say “outside (closest city) limits, in county X…”

[For Office Use Only] IMPORTANT AGENT REMINDER!!

XI. TRAINING, CERTIFICATION, LICENSING, AGENT NOTES:

Really push for a year at least. But some may say “unknown” for the person/entity.

[For Office Use Only] IMPORTANT AGENT REMINDER!!

XII. WORKPLACE PARAQUAT EXPOSURE, AGENT NOTES (1 of 2):

• For multiple choice entry related to CROPS and PERSONAL PROTECTIVE EQUIPMENT WORN, ensure the claimant is looking at their workbook copy on the corresponding printed page to review all possible available answers.
• If a user is confused by the instruction statement: “. If you use Paraquat on multiple crops at a single location, please use the Other Crops Used On field to delineate the additional crops” Just tell them to ignore it! And use the multi-check boxes.
• For City of Specific Location's – user may just say “outside (closest city) limits, in county X…”
• For “Used on Approximately How Many Acres?” and “Approximately How Many Gallons Used?” push to get an actual approximation (instead of just “I don’t recall”). But if they really can’t recall, then accept “I don’t recall”.
• For “Name of Product:” have them list specific brand name if they recall (and if they don’t recall specific brand name, ensure it was Paraquat they used and list “Paraquat”)

[For Office Use Only] IMPORTANT AGENT REMINDER!!

XII. WORKPLACE PARAQUAT EXPOSURE, AGENT NOTES (2 of 2):

• For example in “How Many Days Per Year on Average Was It Applied?” if user says something like “once a week” or “twice a week” you don’t have to do the math to calculate the number of times per year!

• If “Do you possess records of purchase of product?” YES, ask them to MAKE A COPY and send it in the return mailer. If they CAN’T make a copy and it’s the ONLY ORIGINAL IN EXISTENCE, then make a note for Shenaq/Smith to follow up directly on best way to receive.

• “Personal Protective Equipment Worn: (Check all that apply)” 6/7/8 for PANTS/SLEEVES/EYEWEAR should be a no-brainer!! And should definitely be included. Sunglasses are part of 8 eyewear, and this is for “at any time when you were working” (not everyday use).

[For Office Use Only] IMPORTANT AGENT REMINDER!!

XIII. OTHER PARAQUAT EXPOSURE, AGENT NOTES:

For “Where did your paraquat exposure originate?” it’s more specificity around the 1. checkbox question.

[For Office Use Only] IMPORTANT AGENT REMINDER!!

XIV. USE OF OTHER INDUSTRIAL/AGRICULTURAL CHEMICALS, AGENT NOTES:

• For multiple choice entry related to CHEMICALS and PERSONAL PROTECTIVE EQUIPMENT (PPE) WORN, ensure the claimant is looking at their workbook copy on the corresponding printed page to review all possible available answers.
• Note: Roundup is not considered a "restricted" chemical!
• Make sure user answers PPE options 6/7/8 accurately!

[For Office Use Only] IMPORTANT AGENT REMINDER!!

XVI. OCCUPATIONAL WELDING HISTORY, AGENT NOTES:

• For multiple choice entry related to METALS, ensure the claimant is looking at their workbook copy on the corresponding printed page to review all possible available answers.
• "Did you weld for a living?" is the intent of this question. Just a welding once-in-a-while or occasionally as a hobby doesn’t apply here.

[For Office Use Only] IMPORTANT AGENT REMINDER!!

XVII. HISTORY OF HEAD INJURIES, AGENT NOTES:

This is only for TREATED and/or DIAGNOSED concussions/head injuries. If someone is just “pretty sure they had a concussion” but never got it checked out or examined, then they would answer NO here.

[For Office Use Only] IMPORTANT AGENT REMINDER!!

XVIII. KNOWLEDGE REGARDING LAWSUIT, AGENT NOTES:

It’s very unexpected that a user would answer YES to this section. Indicate to the claimant to ensure they save that document! And firm will follow up to receive it from them.

[For Office Use Only] IMPORTANT AGENT REMINDER!!

XIX. WAGE LOSS, AGENT NOTES:

• So if this person decided to stop working as a result of the symptoms/injuries because they were already close to retirement age, but the symptoms put them over the top on their decision, then have them indicate YES to this question.
• Also answer YES if they stayed with the same employer BUT had to take on a different job role as a result of symptoms/injuries.
• If they had to change anything they were doing with work as a result of Parkinson’s Disease or symptoms, then the answer is YES.

[For Office Use Only] IMPORTANT AGENT REMINDER!!

XXI. COMMUNICATIONS REGARDING DEFENDANTS, AGENT NOTES:

NOTE: It is VERY unlikely that there would be a YES answer to this next question…

[For Office Use Only] IMPORTANT AGENT REMINDER!!

XXII. BANKRUPTCY, AGENT NOTES:

If year is approximated, then indicate in a clear text field "year is approximated."

[For Office Use Only] IMPORTANT AGENT REMINDER!!

XXIII. DOCUMENTATION, AGENT NOTES:

Per statement "you are not required to obtain records from third party entities (such as insurance carriers or medical providers):" this just means the claimant doesn’t personally have to track these down. So they can answer "I do not have this doc".

For each doc they have in their possession, tell them to return it in the pre-paid return envelope to Shenaq firm. Ask them to MAKE A COPY and send it in the return mailer. If they CAN’T make a copy and it’s the ONLY ORIGINAL IN EXISTENCE, then make a note for Shenaq/Smith to follow up directly on best way to receive.

[For Office Use Only] IMPORTANT AGENT REMINDER!!

For the authorization signature pages, let the client know all we need them to do is *sign their signature, print their name, and write today's date down* for each signature form. They do NOT have to fill out the header sections at the top, and for the military records form, they only need to sign where it says "5. Signature" at the bottom. (Of course, if they were not ever in the military, they don't need to sign the military records form at all). AND OF COURSE, TELL THEM TO BE SURE TO MAIL THEM BACK IN, IN THE RETURN ENVELOPE!  

NOTE: To save your changes, you *MUST* click the "NEXT" button on the last screen, the XXIV. Authorizations "You're Almost Done!" page! If you do not click "NEXT" on the last page, then your changes are *NOT* saved!

You're Almost Done!

In this next and final section, please complete, sign, and provide the following Authorizations, as applicable:

• The PAQ Form Verification
• Authorization for Release of Health Information (Attachment A). For this authorization, include an authorization for release of records for all Health Care Providers listed in this Fact Sheet, including those listed in Sections VII and XVI.
• Authorization to Disclose Employment Information (Attachment B). For this authorization, include an authorization for release of records for all employers listed in Section III.
• Request Pertaining to Military Records (Attachment C).

Click "NEXT" to proceed to the authorization forms.

NOTE: Your form is not complete until you proceed and sign the final authorizations.