Questionnaires for              Economic Analysis                  Streamline your document collection process            ...
Collection of reliable data is essential to an accurate analysis:      General questionnaire      Household Services que...
Personal Injury Questionnaire (Source: Martin, Determining Economic Damages, 2011, James Publishing)     1. Plaintiff’s na...
(e.g., 20% less than before)______________________________________________________________________________________________...
Household Service Value Questionnaire (Source: Martin, Determining Economic Damages)    In most personal injury suits it i...
Does anyone else do this work that you used to do? Yes ___ No ___        (Laundry, etc., continued) If so, how does this w...
9)   Time spent obtaining goods and services     A) Pre-accident: Did you do any of the following: shopping for food, clot...
___________________________________________________________________________________            ___________________________...
appliance manuals, someone giving directions, etc.)?______________________________________________________________________...
Wrongful Death Questionnaire    1. Name, address and phone number of plaintiff____________________________________________...
19. Name(s) of opposing attorney(s) ______________________________________________________   20. Name of opposing economis...
Household Service Value Questionnaire for Wrongful Death Claims                                Prepared by: ______________...
Household Service Value Questionnaire for Wrongful Death Claims        plumbing, repairing driveway, roof repair or replac...
Household Service Value Questionnaire for Wrongful Death Claims                 Day ______        Week ______      Month _...
Wrongful Termination Questionnaire    1. Plaintiff’s name, address and phone number_______________________________________...
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Questionnaires for Economic Analysis

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Streamline document collection for your Personal Injury, Wrongful Death, or Household Services case

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Questionnaires for Economic Analysis

  1. 1. Questionnaires for Economic Analysis Streamline your document collection process with the Brandt Forensic questionnairesPhone: 206-201-3033 Cell: 206-949-0773
  2. 2. 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 upBill has worked with attorneys, claimants and insurance companies in financialanalysis 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
  3. 3. 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, andlist 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 unioncontract)__________________________________________________________________________________________________________________________________________________________________________________________ 11. Plaintiff’s post-injury jobs, including starting dates, pay, and employer paid benefits (if plaintiff heldmultiple post-injury jobs, provide inclusive dates foreach)___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 12. Expectation of future work, cost of retraining. starting date of retraining, length of retraining program, typeof work plaintiff will perform after retraining, and future earnings (attach supporting medical and/or rehabilitationreports)_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 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 theinjury (e.g., cooking. mowing lawn, washing clothes. home repairs, etc.) state reduction in services as a percentage
  4. 4. (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 ofloss_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 17. If plaintiff must live in a health care facility, or hire a live-in or visiting home attendant, provide currentannual 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, provideinformation on loss if a claim is being made_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 20. Provide any additional information regarding economic losses not covered above (attach supportingdocumentation)_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 21. Is this a medical malpractice case? ______________ (Note: The purpose of this question is to determinewhether a schedule of periodic payments may be required.) If so, and disability payments will be consideredmitigating 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____________________________________________________________________________________________________________________________________________________________________
  5. 5. 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. Thisincludes 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 theperson and/or to the person’s family but for which he/she does not receive any pay. Such services are oftencharacterized as “do-it-yourself” types of services, and they would include such things as household chores, lawnand garden work, home improvements, etc. It is necessary to determine what the individual usually did before theaccident 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 hardto remember. Make your best estimates, and please note that we are trying to determine the average amount of timespent. In each instance below choose the time frame which is easiest for you to estimate (i.e., per day, per week, orper month). For instance, it might be easiest to remember the hours per day spent preparing and cooking food, whileoutdoor 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)
  6. 6. 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)
  7. 7. 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.
  8. 8. ___________________________________________________________________________________ ___________________________________________________________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 giveexamples._______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 20) What type of difficulty, if any, do you have in following written or verbal instructions (i.e., cooking,
  9. 9. appliance manuals, someone giving directions, etc.)?_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 21) Please explain (in general terms if not already apparent from the above) how your condition keeps youfrom doing all of the above tasks.______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
  10. 10. 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, anddecedent’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 insurancepremiums, 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 individualitems)____________________________________________________________________________________________________________________________________________________________________ 17. Provide any additional information regarding economic losses not covered above, and provide supportingdocumentation, including personal property, such as a car, if a claim is being made_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 18. Date and location of trial ___________________________________________________________
  11. 11. 19. Name(s) of opposing attorney(s) ______________________________________________________ 20. Name of opposing economist _______________________________________________________ 21. Name of person completing this questionnaire and date completed__________________________________________________________________________________________________________________________________________________________________________________________
  12. 12. 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 personand/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 hardto remember. Make your best estimates, and please note that we are trying to determine the average amount of timespent. In each instance below choose the time frame which is easiest for you to estimate (i.e., per day, per week, orper month). For instance, it might be easiest to remember the hours per day spent preparing and cooking food, whileoutdoor 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,
  13. 13. 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
  14. 14. 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)_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
  15. 15. 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 withemployer___________________________________________________________________________________________________________________________________________________________________________________ 7. Provide pre-termination income history for as many years as available (attach supporting documentationincluding 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 unioncontract)_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 11. List all post-termination jobs including beginning and ending dates, pay, and any employer paid benefitsfor 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., unemploymentbenefits) and whether these are considered mitigating income or collateral source_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 14. Is plaintiff using a vocational rehabilitation expert? ______________ (If so, attach copy of vocationalrehabilitation 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_____________________________________________________________________________________________

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