Questionnaires for Economic Analysis

Questionnaires for

Economic Analysis Streamline your document collection process

with the Brandt Forensic questionnaires

Phone: 206-201-3033 Cell: 206-949-0773

Collection of reliable data is essential to an accurate analysis:

General questionnaire

Household Services questionnaire

Interview with attorney and/or client

Income and Employment Documentation

Any necessary follow up

Bill has worked with attorneys, claimants and insurance companies in financial analysis and loss claim calculations for the following types of claims:

Personal Injury

Wrongful Death

Wrongful Termination

Malpractice Claims

Lifecare Plan Valuation

Disability

Product Liability Claims

PIP Losses

Business Interruption

Partner Disputes

Breach of Contract

Shareholder Disputes

Disputes Involving Business Valuation

Analysis of Opposing Expert Reports

Personal Injury Questionnaire (Source: Martin, Determining Economic Damages, 2011, James Publishing)

1. Plaintiff’s name, address and phone number _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. Sex and race _______________________________________________________________________ 3. Date of birth _______________________________________________________________________ 4. Date of injury ______________________________________________________________________ 5. Plaintiff’s level of education __________________________________________________________ 6. If plaintiff is a minor, provide minor’s grade level at date of injury and pre-injury occupational plans, and

list occupations and education levels of parents __________________________________________________________________________________________________________________________________________________________________________________________

7. Plaintiff’s pre-injury job description, employer name, and length of time in occupation _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

8. Plaintiff’s pre-injury income history for as many years as available (attach tax returns, forms W-2, Schedule C’s, payroll records, or check stubs) __________________________________________________________________________________________________________________________________________________________________________________________

9. Employer paid benefits and amount paid by employer (e.g., social security, life insurance, health insurance, and pension plans) _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

10. If plaintiff has a union contract, provide name and phone number of union agent (attach copy of union contract) __________________________________________________________________________________________________________________________________________________________________________________________

11. Plaintiff’s post-injury jobs, including starting dates, pay, and employer paid benefits (if plaintiff held multiple post-injury jobs, provide inclusive dates for each)___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

12. Expectation of future work, cost of retraining. starting date of retraining, length of retraining program, type of work plaintiff will perform after retraining, and future earnings (attach supporting medical and/or rehabilitation reports) _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

13. Medical expenses incurred to date for which a loss claim is being made __________________________________________________________________________________________________________________________________________________________________________________________

14. Expected future medical expense items, including current cost and number of years they will by incurred (attach Life Care Planner’s report, if applicable) _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

15. If plaintiff cannot perform the same amount of services to the home and family as performed prior to the injury (e.g., cooking. mowing lawn, washing clothes. home repairs, etc.) state reduction in services as a percentage

(e.g., 20% less than before) _________________________________________________________________________________________________________________________________________________________________________________________(Note: It is not necessary to list individual services.)

16. If a claim is being made for the loss of personal property (e.g., a car) list each property item and value of

loss _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

17. If plaintiff must live in a health care facility, or hire a live-in or visiting home attendant, provide current annual cost _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

18. If medical evidence indicates plaintiff will have a reduced life expectancy, provide estimate of reduction _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

19. If uninjured spouse lost work time and earnings while out of work caring for injured spouse, provide information on loss if a claim is being made _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

20. Provide any additional information regarding economic losses not covered above (attach supporting documentation) _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

21. Is this a medical malpractice case? ______________ (Note: The purpose of this question is to determine whether a schedule of periodic payments may be required.) If so, and disability payments will be considered mitigating income, provide amount and duration of payments, and date payments began _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

22. Names and birthdates of spouse and all children living at home _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

23. Date and location of trial _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

24. Name and address of opposing counsel _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

25. Name and address of opposing economist _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

26. Name of person providing answers to this questionnaire and date questionnaire completed ____________________________________________________________________________________________________________________________________________________________________

Household Service Value Questionnaire (Source: Martin, Determining Economic Damages) In most personal injury suits it is necessary to determine the loss of income resulting from the injury. This

includes not only the individual’s wages but also the value of what are commonly called “non-market services.” Non-market services are defined as those services produced by an individual which have an economic value to the person and/or to the person’s family but for which he/she does not receive any pay. Such services are often characterized as “do-it-yourself” types of services, and they would include such things as household chores, lawn and garden work, home improvements, etc. It is necessary to determine what the individual usually did before the accident and what, if any, services he or she can still perform.

The following information is needed for an appraisal of these services. Some of this information might be hard to remember. Make your best estimates, and please note that we are trying to determine the average amount of time spent. In each instance below choose the time frame which is easiest for you to estimate (i.e., per day, per week, or per month). For instance, it might be easiest to remember the hours per day spent preparing and cooking food, while outdoor chores might be easiest to estimate by hours per month.

If you find you have insufficient space, please attach additional sheets of paper. 1) Preparing and cooking food

A) Pre-accident: Did you prepare and cook meals, set the table, preserve foodstuffs, etc.? If “yes,” what were the average hours per

Day ______ Week ______ Month ______ (choose one) B) After accident: Do you still perform these chores? If so, what are the average hours per

Day ______ Week ______ Month ______ (choose one) Does anyone else do this work that you used to do? Yes ___ No ___ If “yes,” how does this work compare to what you previously did (where 1 is much worse and 5 is as

good as what you did)? 1 ___ 2 ___ 3 ___ 4 ___ 5 ___ (choose one) 2) Dishwashing and kitchen cleaning

A) Pre-accident: Did you wash dishes and clean the kitchen? If so, what were the average hours per: Day ______ Week ______ Month ______ (choose one)

B) After accident: Do you still perform these chores? If so, what are the average hours per Day ______ Week ______ Month ______ (choose one)

Does anyone else do this work that you used to do? Yes ___ No ___ If “yes,” how does this work compare to what you previously did (where 1 is much worse and 5 is as

good as what you did)? 1 ___ 2 ___ 3 ___ 4 ___ 5 ___ (choose one) 3) Housework

A) Pre-accident: Did you do housework such as vacuuming, dusting, making beds, picking up, taking out trash, fall/spring cleaning, cleaning bathrooms, washing floors, windows, walls and cabinets, etc.? If so, what were the average hours per

Day ______ Week ______ Month ______ (choose one) B) After accident: Do you still perform these chores? If so, what are the average hours per

Day ______ Week ______ Month ______ (choose one) Does anyone else do this work that you used to do? Yes ___ No ___ If “yes,” how does this work compare to what you previously did (where 1 is much worse and 5 is as

good as what you did)? 1 ___ 2 ___ 3 ___ 4 ___ 5 ___ (choose one) 4) Laundry, ironing, putting clothes away

A) Pre-accident: Did you do the laundry chores? If so, what were the average hours per Day ______ Week ______ Month ______ (choose one)

B) After accident: Do you still perform these chores? If so, what are the average hours per Day ______ Week ______ Month ______ (choose one)

Does anyone else do this work that you used to do? Yes ___ No ___ (Laundry, etc., continued) If so, how does this work compare to what you previously did (where 1 is

much worse and 5 is as good as what you did)? 1 ___ 2 ___ 3 ___ 4 ___ 5 ___ (choose one) 5) House maintenance

A) Pre-accident: Did you do house maintenance tasks such as repainting the interior or exterior, putting up storm windows, repairing electric appliances, minor or major carpentry, house remodeling, plumbing, repairing driveway, roof repair or replacement, furniture repair, etc.? If so, what were the average hours per

Day ______ Week ______ Month ______ (choose one) B) After accident: Do you still perform these chores? If so, what are the average hours per

Day ______ Week ______ Month ______ (choose one) Does anyone else do this work that you used to do? Yes ___ No ___ If “yes,” how does this work compare to what you previously did (where 1 is much worse and 5 is as

good as what you did)? 1 ___ 2 ___ 3 ___ 4 ___ 5 ___ (choose one) 6) Vehicle maintenance

A) Pre-accident: Did you do vehicle maintenance, including boats and recreational vehicles? If so, what were the average hours per

Day ______ Week ______ Month ______ (choose one) B) After accident: Do you still perform these chores? If so, what are the average hours per

Day ______ Week ______ Month ______ (choose one) Does anyone else do this work that you used to do? Yes ___ No ___ If “yes,” how does this work compare to what you previously did (where 1 is much worse and 5 is as

good as what you did)? 1 ___ 2 ___ 3 ___ 4 ___ 5 ___ (choose one) 7) Outside chores

A) Pre-accident: Did you do outside chores such as yard work, raking leaves, mowing grass, snow shoveling, cleaning garage, cutting wood, flower or vegetable gardening, weeding, etc.? If so, what were the average hours per

Day ______ Week ______ Month ______ (choose one) B) (Outside chores continued) After accident: Do you still perform these chores? If so, what are the

average hours per Day ______ Week ______ Month ______ (choose one)

Does anyone else do this work that you used to do? Yes ___ No ___ If “yes,” how does this work compare to what you previously did (where 1 is much worse and 5 is as

good as what you did)? 1 ___ 2 ___ 3 ___ 4 ___ 5 ___ (choose one) 8) Animal care

A) Pre-accident: Did you care for animals — doing such things as playing, feeding house pets, feeding and caring for domestic animals such as chickens, cows, pigs, etc., and taking animals to the vet? If so, what were the average hours per

Day ______ Week ______ Month ______ (choose one) B) After accident: Do you still perform these chores? If so, what are the average hours per

Day ______ Week ______ Month ______ (choose one) Does anyone else do this work that you used to do? Yes ___ No ___ If “yes,” how does this work compare to what you previously did (where 1 is much worse and 5 is as

good as what you did)? 1 ___ 2 ___ 3 ___ 4 ___ 5 ___ (choose one)

9) Time spent obtaining goods and services A) Pre-accident: Did you do any of the following: shopping for food, clothing, and all other personal and

household needs; taking and picking up dry cleaning; obtaining medical services for self or family members, financial activities (banking, paying bills, going to accountant, tax office, loan agency, insurance, etc.); getting professional car care taken care of including buying gasoline; getting other repair services (tailor, furnace, appliance, etc.); going to the dump; travel related to all of the above; and writing and doing paperwork for the household, including paying bills, balancing checkbook, making lists, getting mail, and working on budget? If so, what were the average hours per

Day ______ Week ______ Month ______ (choose one) B) After accident: Do you still perform these chores? If so, what are the average hours per

Day ______ Week ______ Month ______ (choose one) Does anyone else do this work that you used to do? Yes ___ No ___ (Shopping, etc., continued) If so, how does this work compare to what you previously did (where 1 is

much worse and 5 is as good as what you did)? 1 ___ 2 ___ 3 ___ 4 ___ 5 ___ (choose one) 10) Child care

A) Pre-accident: In the years immediately before the accident did you spend time on child care? If so, what were the average hours per

Day ______ Week ______ Month ______ (choose one) B) After accident: Do you still provide child care? If so, what are the average hours per

Day ______ Week ______ Month ______ (choose one) If the reduction in hours is due mainly to changes in ages or numbers of children cared for, please

explain. ____________________________________________________________________________________________________________________________________________

Does anyone else do this work that you used to do? Yes ___ No ___ If “yes,” how does this work compare to what you previously did (where 1 is much worse and 5 is as

good as what you did)? 1 ___ 2 ___ 3 ___ 4 ___ 5 ___ (choose one) 11) Child guidance

A) Pre-accident: In the years immediately before the accident did you spend time teaching children (instructing on life activities in general or on school work), giving instructions, disciplining, reading to, participating in medical care, first aid, coordinating social and after school activities, and meeting or helping with child/youth/family organizations? If so, what were the average hours per

Day ______ Week ______ Month ______ (choose one) B) After accident: Do you still provide child guidance? If so, what are the average hours per

Day ______ Week ______ Month ______ (choose one) If the reduction in hours is due mainly to changes in ages or numbers of children cared for, please

explain. Does anyone else do this work that you used to do? Yes ___ No ___ If “yes,” how does this work compare to what you previously did (where 1 is much worse and 5 is as

good as what you did)? 1 ___ 2 ___ 3 ___ 4 ___ 5 ___ (choose one) 12) Time spent playing with children

A) Pre-accident: In the years immediately before the accident did you do such things as play with babies or children indoors or outdoors, play sports with them, go for walks or bicycle rides? If so, what were the average hours per

Day ______ Week ______ Month ______ (choose one) B) After accident: Do you still spend time playing with children? If so, what are the average hours per

Day ______ Week ______ Month ______ (choose one) If the reduction in hours is due mainly to changes in ages or numbers of children cared for, please

explain.

______________________________________________________________________________________________________________________________________________Does anyone else do this work that you used to do? Yes ___ No ___

If “yes,” how does this work compare to what you previously did (where 1 is much worse and 5 is as good as what you did)?

1 ___ 2 ___ 3 ___ 4 ___ 5 ___ (choose one) 13) Transporting children

A) Pre-accident: In the years immediately before the accident, did you transport children to school, school-related activities, social or sporting events, medical appointments, etc.? If so, what were the average hours per

Day ______ Week ______ Month ______ (choose one) B) After accident: Do you still transport children? If so, what are the average hours per

Day ______ Week ______ Month ______ (choose one) If the reduction in hours is due mainly to changes in ages or numbers of children cared for, please

explain. _______________________________________________________________________________________________________________________________________________Does anyone else do this work that you used to do? Yes ___ No ___

If “yes,” how does this work compare to what you previously did (where 1 is much worse and 5 is as good as what you did)?

1 ___ 2 ___ 3 ___ 4 ___ 5 ___ (choose one) 14) Providing care to others

A) Pre-accident: In the years immediately before the accident did you provide care to other family members not mentioned above (such as parents)? If so, what were the average hours per

Day ______ Week ______ Month ______ (choose one) B) After accident: Do you still provide care to others? If so, what are the average hours per

Day ______ Week ______ Month ______ (choose one) If the reduction in hours is due mainly to changes in ages or numbers of persons cared for, please

explain. ________________________________________________________________________________________________________________________________________________Does anyone else do this work that you used to do? Yes ___ No ___

If “yes,” how does this work compare to what you previously did (where 1 is much worse and 5 is as good as what you did)?

1 ___ 2 ___ 3 ___ 4 ___ 5 ___ (choose one) 15) What difficulties, if any, do you have caring for your own personal needs (e.g., grooming, dressing,

cleaning, etc.)? Do you require any type of assistance? If YES, please explain. __________________________________________________________________________________________________________________________________________________________________________________________

16) What help, if any, do you need to get out of your home for personal needs or socializing? __________________________________________________________________________________

__________________________________________________________________________________ 17) Have your social activities changed since your condition began? _______________________ 18) Do you have problems concentrating? If so, please explain and give examples.

_____________________________________________________________________________________ _____________________________________________________________________________________________19) When you begin a task or chore do you ever have trouble finishing the job? If so, please explain and give examples.__________________________________________________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________

20) What type of difficulty, if any, do you have in following written or verbal instructions (i.e., cooking,

appliance manuals, someone giving directions, etc.)? _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

21) Please explain (in general terms if not already apparent from the above) how your condition keeps you from doing all of the above tasks. ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Wrongful Death Questionnaire

1. Name, address and phone number of plaintiff _______________________________________________________________________________________________________________________________________________________________________________________________________________

2. Name of deceased __________________________________________________________________ 3. Sex and race of deceased ____________________________________________________________ 4. Date of birth of deceased ___________________________________________________________ 5. Date of death ______________________________________________________________________ 6. Date of injury (if different from date of death) ___________________________________________ 7. Names and birthdates of surviving spouse and children living at home

__________________________________________________________________________________________________________________________________________________________________________________________

8. Address and phone number of decedent’s spouse __________________________________________________________________________________________________________________________________________________________________________________________

9. Decedent’s level of education and level of education planned for decedent’s children ________________________________________________________________________________________________________________________________________________________________________

10. If decedent was a minor, provide decedent’s occupational plans and grade level at date of death, and decedent’s parents’ education levels __________________________________________________________________________________________________________________________________________________________________________________________

11. Name of decedent ‘s employer, job title, and length of time in occupation __________________________________________________________________________________________________________________________________________________________________________________

12. Income history for as many years as available (attach supporting documentation including tax returns, Forms W-2, Schedule C’s, payroll records, or check stubs) __________________________________________________________________________________________________________________________________________________________________________________________

13. List all employer paid benefits and the amount paid for each (e.g., social security, health insurance premiums, life insurance premiums, and pension plan contributions) __________________________________________________________________________________________________________________________________________________________________________________________

14. Name and phone number of union agent, if applicable (attach copy of union contract) __________________________________________________________________________________________________________________________________________________________________________________________

15. List all medical, funeral, and burial expenses _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

16. Did decedent provide the “average” amount of services for the family and home (e.g., cooking, washing, house repair, bookkeeping, lawn care, shopping, etc. Do not list individual items)____________________________________________________________________________________________________________________________________________________________________

17. Provide any additional information regarding economic losses not covered above, and provide supporting documentation, including personal property, such as a car, if a claim is being made _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

18. Date and location of trial ___________________________________________________________

19. Name(s) of opposing attorney(s) ______________________________________________________ 20. Name of opposing economist _______________________________________________________ 21. Name of person completing this questionnaire and date completed

__________________________________________________________________________________________________________________________________________________________________________________________

Household Service Value Questionnaire for Wrongful Death Claims Prepared by: _____________________ Relationship to Decedent: _____________________

Household Service Value Questionnaire for Wrongful Death Claims In many wrongful death suits it is necessary to determine the loss of income associated with the claim. This in-

cludes not only the decedent’s wages but also the value of what are commonly called “non-market services.” Non-market services are defined as those services produced by an individual which have an economic value to the person and/or to the person’s family but for which he/she does not receive any pay. Such services are often characterized as “do-it-yourself” types of services, and they would include such things as household chores, lawn and garden work, home improvements, etc. It is necessary to determine what the decedent usually did before the accident.

The following information is needed for an appraisal of these services. Some of this information might be hard to remember. Make your best estimates, and please note that we are trying to determine the average amount of time spent. In each instance below choose the time frame which is easiest for you to estimate (i.e., per day, per week, or per month). For instance, it might be easiest to remember the hours per day spent preparing and cooking food, while outdoor chores might be easiest to estimate by hours per month.

If you find you have insufficient space, please attach additional sheets of paper. 1) Preparing and cooking food

Pre-accident: Did the decedent prepare and cook meals, set the table, preserve foodstuffs, etc.? If “yes,” what were the average hours per

Day ______ Week ______ Month ______ (choose one) Does anyone else do this work that the decedent used to do? Yes ___ No ___ If “yes,” how does this work compare to what the decedent previously did (where 1 is much worse and

5 is as good as what the decedent did)? 1 ___ 2 ___ 3 ___ 4 ___ 5 ___ (choose one) 2) Dishwashing and kitchen cleaning

Pre-accident: Did the decedent wash dishes and clean the kitchen? If so, what were the average hours per: Day ______ Week ______ Month ______ (choose one)

Does anyone else do this work that the decedent used to do? Yes ___ No ___ If “yes,” how does this work compare to what the decedent previously did (where 1 is much worse and

5 is as good as what the decedent did)? 1 ___ 2 ___ 3 ___ 4 ___ 5 ___ (choose one) 3) Housework

Pre-accident: Did the decedent do housework such as vacuuming, dusting, making beds, picking up, taking out trash, fall/spring cleaning, cleaning bathrooms, washing floors, windows, walls and cabinets, etc.? If so, what were the average hours per

Day ______ Week ______ Month ______ (choose one) Does anyone else do this work that the decedent used to do? Yes ___ No ___ If “yes,” how does this work compare to what the decedent previously did (where 1 is much worse and

5 is as good as what the decedent did)? 1 ___ 2 ___ 3 ___ 4 ___ 5 ___ (choose one) 4) Laundry, ironing, putting clothes away

Pre-accident: Did the decedent do the laundry chores? If so, what were the average hours per Day ______ Week ______ Month ______ (choose one)

Does anyone else do this work that the decedent used to do? Yes ___ No ___ (Laundry, etc., continued) If so, how does this work compare to what the decedent previously did

(where 1 is much worse and 5 is as good as what the decedent did)? 1 ___ 2 ___ 3 ___ 4 ___ 5 ___ (choose one) 5) House maintenance

Pre-accident: Did the decedent do house maintenance tasks such as repainting the interior or exterior, put-ting up storm windows, repairing electric appliances, minor or major carpentry, house remodeling,

Household Service Value Questionnaire for Wrongful Death Claims

plumbing, repairing driveway, roof repair or replacement, furniture repair, etc.? If so, what were the av-erage hours per

Day ______ Week ______ Month ______ (choose one) Does anyone else do this work that the decedent used to do? Yes ___ No ___ If “yes,” how does this work compare to what the decedent previously did (where 1 is much worse and

5 is as good as what the decedent did)? 1 ___ 2 ___ 3 ___ 4 ___ 5 ___ (choose one) 6) Vehicle maintenance

Pre-accident: Did the decedent do vehicle maintenance, including boats and recreational vehicles? If so, what were the average hours per

Day ______ Week ______ Month ______ (choose one) Does anyone else do this work that the decedent used to do? Yes ___ No ___ If “yes,” how does this work compare to what the decedent previously did (where 1 is much worse and

5 is as good as what the decedent did)? 1 ___ 2 ___ 3 ___ 4 ___ 5 ___ (choose one) 7) Outside chores

Pre-accident: Did the decedent do outside chores such as yard work, raking leaves, mowing grass, snow shoveling, cleaning garage, cutting wood, flower or vegetable gardening, weeding, etc.? If so, what were the average hours per

Day ______ Week ______ Month ______ (choose one) Does anyone else do this work that the decedent used to do? Yes ___ No ___ If “yes,” how does this work compare to what the decedent previously did (where 1 is much worse and

5 is as good as what the decedent did)? 1 ___ 2 ___ 3 ___ 4 ___ 5 ___ (choose one) 8) Animal care

Pre-accident: Did the decedent care for animals — doing such things as playing, feeding house pets, feed-ing and caring for domestic animals such as chickens, cows, pigs, etc., and taking animals to the vet? If so, what were the average hours per

Day ______ Week ______ Month ______ (choose one) Does anyone else do this work that the decedent used to do? Yes ___ No ___ If “yes,” how does this work compare to what the decedent previously did (where 1 is much worse and

5 is as good as what the decedent did)? 1 ___ 2 ___ 3 ___ 4 ___ 5 ___ (choose one) 9) Time spent obtaining goods and services

Pre-accident: Did the decedent do any of the following: shopping for food, clothing, and all other personal and household needs; taking and picking up dry cleaning; obtaining medical services for family mem-bers, financial activities (banking, paying bills, going to accountant, tax office, loan agency, insurance, etc.); getting professional car care taken care of including buying gasoline; getting other repair services (tailor, furnace, appliance, etc.); going to the dump; travel related to all of the above; and writing and doing paperwork for the household, including paying bills, balancing checkbook, making lists, getting mail, and working on budget? If so, what were the average hours per

Day ______ Week ______ Month ______ (choose one) Does anyone else do this work that the decedent used to do? Yes ___ No ___ (Shopping, etc., continued) If so, how does this work compare to what you previously did (where 1 is

much worse and 5 is as good as what the decedent did)? 1 ___ 2 ___ 3 ___ 4 ___ 5 ___ (choose one) 10) Child care

Pre-accident: In the years immediately before the accident did the decedent spend time on child care? If so, what were the average hours per

Household Service Value Questionnaire for Wrongful Death Claims

Day ______ Week ______ Month ______ (choose one) Does anyone else do this work that the decedent used to do? Yes ___ No ___ If “yes,” how does this work compare to what the decedent previously did (where 1 is much worse and

5 is as good as what the decedent did)? 1 ___ 2 ___ 3 ___ 4 ___ 5 ___ (choose one) 11) Child guidance

Pre-accident: In the years immediately before the accident did the decedent spend time teaching children (instructing on life activities in general or on school work), giving instructions, disciplining, reading to, participating in medical care, first aid, coordinating social and after school activities, and meeting or helping with child/youth/family organizations? If so, what were the average hours per

Day ______ Week ______ Month ______ (choose one) Does anyone else do this work that you the decedent to do? Yes ___ No ___ If “yes,” how does this work compare to what the decedent previously did (where 1 is much worse and

5 is as good as what the decedent did)? 1 ___ 2 ___ 3 ___ 4 ___ 5 ___ (choose one) 12) Time spent playing with children

Pre-accident: In the years immediately before the accident did the decedent do such things as play with ba-bies or children indoors or outdoors, play sports with them, go for walks or bicycle rides? If so, what were the average hours per

Day ______ Week ______ Month ______ (choose one) Does anyone else do this work that the decedent used to do? Yes ___ No ___ If “yes,” how does this work compare to what the decedent previously did (where 1 is much worse and

5 is as good as what the decedent did)? 1 ___ 2 ___ 3 ___ 4 ___ 5 ___ (choose one) 13) Transporting children

Pre-accident: In the years immediately before the accident, did you transport children to school, school-related activities, social or sporting events, medical appointments, etc.? If so, what were the average hours per

Day ______ Week ______ Month ______ (choose one) Does anyone else do this work that the decedent used to do? Yes ___ No ___ If “yes,” how does this work compare to what the decedent previously did (where 1 is much worse and

5 is as good as what the decedent did)? 1 ___ 2 ___ 3 ___ 4 ___ 5 ___ (choose one) 14) Providing care to others

Pre-accident: In the years immediately before the accident did the decedent provide care to other family members not mentioned above (such as parents)? If so, what were the average hours per

Day ______ Week ______ Month ______ (choose one) Does anyone else do this work that the decedent used to do? Yes ___ No ___ If “yes,” how does this work compare to what the decedent previously did (where 1 is much worse and

5 is as good as what you did)? 1 ___ 2 ___ 3 ___ 4 ___ 5 ___ (choose one) 15) Please address any other significant services performed on behalf of family members by the decedent.

In the years immediately before the accident did the decedent provide care to other family members not mentioned above (such as parents)? If so, what were the average hours per

Day ______ Week ______ Month ______ (choose one) _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Wrongful Termination Questionnaire 1. Plaintiff’s name, address and phone number

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. Sex and race _______________________________________________________________________ 3. Date of birth _______________________________________________________________________ 4. Level of education _________________________________________________________________ 5. Date of termination ________________________________________________________________ 6. Name and address of pre-termination employer, job title, and length of time with

employer___________________________________________________________________________________________________________________________________________________________________________________

7. Provide pre-termination income history for as many years as available (attach supporting documentation including tax returns, Forms W-2, check stubs, or payroll records) __________________________________________________________________________________________________________________________________________________________________________________________

8. Did plaintiff receive severance pay? ___________ If so, state amount ___________________ 9. List all pre-termination employer paid benefits and the amount of employer’s contribution, if known (e.g.,

social security, health and/or life insurance premiums, pension plan contributions) _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

10. If plaintiff had a union contract, provide name and phone number of union agent (attach copy of union contract) _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

11. List all post-termination jobs including beginning and ending dates, pay, and any employer paid benefits for each job _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

12. List all expenses incurred in obtaining a new job _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

13. Add any additional information regarding economic losses not covered above (e.g., unemployment benefits) and whether these are considered mitigating income or collateral source _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

14. Is plaintiff using a vocational rehabilitation expert? ______________ (If so, attach copy of vocational rehabilitation report.) _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

15. Date and location of trial ___________________________________________________________ 16. Name(s) of opposing attorney(s) ______________________________________________________ 17. Name of opposing economist ________________________________________________________ 18. Name of person completing this questionnaire and date completed

_____________________________________________________________________________________________