Roundup Questionnaire - Do You Qualify for Legal Action?

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A Case for Justice is working closely with Roundup lawyers to help those who were diagnosed with non-Hodgkin's Lymphoma after using Roundup. Bayer has set aside billions to handle future Roundup lawsuits.

Don’t miss out: complete our survey to start your lawsuit now.

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Who Are You Contacting Us About?

Who are you contacting us about?*

Myself

My spouse

My parent

My sibling

Other family member

Please explain*

First name of loved one*

Last name of loved one*

Their Date of Birth*

Do any of the following apply?*

Power of attorney

Executor of the estate

Next of kin

Other

Please explain

Is that person deceased?*

Yes

When did they pass away? If you are unsure, an approximate date is fine.

Month Passed

Month

Year Passed*

Year

What was their cause of death?*

Do you have a copy of the death certificate to provide to the firm?*

Yes

Will this person be able to sign on their own behalf?*

Yes

Other

Please explain why they cannot sign for themselves*

Roundup Exposure

Fill this section out according to who the patient is.

Was the person you're reaching out about directly exposed to Roundup (they used/sprayed it themselves)?*

Yes

Other

Please explain*

What year did the person start using Roundup?*

What year did the person stop using Roundup?*

Did they use Roundup at work or at home?*

Work

Home

Both Work and Home

Do you have any documentation of their use of Roundup at work?*

Y - Receipt(s)

Y - Photo(s) that include the product

Y - Receipt(s) and photo(s) that include the product

Please explain*

Please explain how Roundup was used at their work*

Please select the season(s) they used Roundup each year:

Spring

Summer

Fall

Winter

How often did they use Roundup during the seasons you selected?

Daily

Weekly

Monthly

Once or Twice

Approximately how many times in total did they use Roundup?*

1-9 times

10-19 times

More than 20 times

In which state(s) did they use Roundup?*

When did they see an advertisement for Roundup (the product, not the litigation)? Select all that apply

Never

Before Usage

During Usage

Around Time of Diagnosis

Unknown

About What's Wrong

Fill this section out according to who the patient is.

Diagnosis Details

Has the person you’re reaching out for been diagnosed with Non-Hodgkin Lymphoma?*

Yes

Unknown - please explain

Please explain*

What NHL subtype were they diagnosed with?*

Please describe*

Date of diagnosis:

Month diagnosis

Month

Year diagnosis*

Year

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(DEL) How old were they when they were diagnosed?

Please enter a number from 0 to 199.

In what state did they live in at the time of diagnosis?

Diagnosing doctor

Name of diagnosing or treatment facility*

Location of diagnosing or treatment facility (address if you know it, city & state)*

Date of most recent appointment there

Month most recent appt

Month

Year most recent appt*

Year

Were there additional medical facilities they went to?*

Yes

Please list the details of any additional facilities and the dates they were there

Have they had a recurrence (the cancer came back) of their NHL?*

Yes

Unknown

Date of recurrence diagnosis

Month recurrence diagnosis

Month

Year recurrence diagnosis*

Year

Diagnosing doctor

Diagnosing facility name*

Diagnosing facility location (address if you know it, city & state)*

What treatment have they received for their NHL? Select all that apply

Biopsy

Chemotherapy

Imaging (CT Scan, PET Scan, etc.)

Immunotherapy (such as Monoclonal Antibody Therapy or Targeted Therapy)

Radiation

Surgery

Other - please explain

Unknown

None

Please explain*

Are you currently pursuing a cancer diagnosis?

Yes

Date of next doctor appointment

Month next doctor appt

Month

Year next doctor appt

Year

Name of doctor

Any other details?

Medical History Prior to NHL Diagnosis

Did they ever receive an organ transplant prior to their NHL diagnosis?

Yes

Were they treated with immunosuppressant drugs?*

Yes

Were they diagnosed with any other cancer prior to their NHL diagnosis?

Yes

Unknown

What kind of cancer?

When was it diagnosed?

Month other cancer dx

Month

Year other cancer dx

Year

Were they ever treated with chemotherapy prior to their NHL diagnosis?

Yes

Unknown

Have they ever been diagnosed with an autoimmune disorder? Select all that apply:

Lupus

HIV

Hepatitis

Epstein Barr

Rheumatoid Arthritis

Type 2 Diabetes

Other - please explain

No - never dignosed with an autoimmune disorder

Please explain

When were the autoimmune disorder(s) diagnosed?

Month autoimmune dx

Month

Year autoimmune dx

Year

Military and Benefits History

Have they served in the military?

Yes

Unknown

What year(s) did they serve?

What military base(s)?

Are they currently receiving VA benefits?

Yes

Unknown

What type?

Disability benefits

Other - please explain

Please explain*

Have they received benefits from Workers Compensation or a prior lawsuit regarding cancer?

Yes

Please describe*

Have they been exposed to Agent Orange, other industrial chemicals or carcinogens (to your knowledge)?

Yes

What year(s) were they exposed?

Please describe what they were exposed to and how

Anything Else

We know you've already given us a lot of info, but is there anything else we should know, or anything you think is important or weren’t able to touch on in previous sections?

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Convert DX to full date

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Date

MM slash DD slash YYYY

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Diff DX and DOB Other

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Contact Info

Fill this section out according to who we should contact in regards to this case.

Your Full Legal Name

Your First Name*

Your Middle Name

Your Last Name*

Maiden Name or Other Names Used, if applicable

Email*

Phone*

Mailing Address*

Street Address City ZIP / Postal Code

State*

Date of Birth*

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Diff DX and DOB Self

Is there anyone else appropriate to contact if the firm can't get in touch with you?

Their Name

Their Phone Number

Their Email Address

Their relationship to you

Legal Spouse

Unmarried Partner

Parent

Child

Sibling

Friend

Other

Have you or your loved one hired a lawyer connected with Camp Lejeune or their injuries?*

Note: This does not pertain to any suit against a doctor or hospital/facility.

Yes

Unknown - please explain

We're so happy that you're standing up for yourself, and everyone hurt by using Roundup. You can only have one firm working for you on this kind of legal action. This is a national issue, and we're working with firms combating this on the national level. Whoever you choose, make sure they have the resources and experience to represent you.

We're so happy you're interested in standing up for yourself, and everyone hurt by using Roundup. Just so you know, you can only have one firm working for you on this kind of legal action. This is a national issue, and we're working with firms combating this on the national level. Whoever you choose, make sure they have the resources and experience to represent you.

Please explain*

Newsletter

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Yes

IPQS

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

Questions? Call us at (214) 612-7354.

A Case for Justice's Roundup initiative is currently sponsored by Wagstaff Law Firm with Goldwater Law Firm. The firm is headquartered at 940 N. Lincoln Street, Denver, Colorado 80203. The lead attorney is Aimee Wagstaff. This firm may be affiliated with select other A Case for Justice and A Case for Women initiatives. The contents of this website should not be construed as legal advice and the receipt of such information does not create an attorney-client relationship. Additionally, prior results do not guarantee future outcomes. If there is no recovery (compensation), no fees or costs are charged by these law firms. No representation is made that the quality of the legal services to be performed is greater than the quality of the legal services to be performed is greater than the quality of legal services performed by other lawyers.

The information contained on A Case for Justice website is for general guidance on your rights and responsibilities and is not legal advice. A Case for Justice does not provide legal advice and is not a law firm.

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