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Akwesasne Mohawk PCB Settlement Questionnaire

If you are interested in participating in the Akwesasne Mohawk PCB
Settlement, please complete and return this questionnaire.

* Name:
* Address:
* City:
* State:
* Zip:
* County:
Date of Birth:
* Home Telephone:
Cellular Telephone:
E-mail:
Occupation:
Work Address:
Work City
Work State
Work Zip
Work Telephone:
For how long?
How long have you lived at Akwesasne?
Have you ever worked at the GM, Alcoa or Reynolds plants? Yes | No
If yes, when?
Do you believe that you were exposed to PCBs while living at Akwesasne?  Please circle:   Yes | No
How do you believe that you were exposed to PCBS at Akwesasne?

Have you ever been tested for PCBs or participated in any health studies?

 Yes | No

If yes, which studies or tests did your participate in?

Mount Sinai study
Breast milk study
Caffeine breath study
Thyroid study of Mohawk youth
PCB blood testing
Other studies
Were you ever advised that you had PCBs in your blood? Yes | No
If yes, when and how were you advised?
Did you know about fish advisories warning against fish consumption from local rivers? Yes | No

Has any doctor or other health care provider advised you that you have suffered health effects   relating to exposure to PCBs?

 Yes | No
If yes, who?

Have you ever received benefits from any of the following?
Social Services Dates of Benefits:
Medicaid to
Medicare  
Social Services Disability  

Do you now, or have you in the past, suffered from any of the following disorders
(please check all that apply and identify dates of illness):
Disorder:   Dates of Illness:
Diabetes to
Thyroid problems  
Heart Disease  
Asthma  
High blood   
Elevated Pressure  
Elevated Cholesterol  
Learning Disability   
Attention Deficit  
Acne/Skin Rashes  
  Other
 

*Please note that neither submission of this form nor contacting us by e-mail establishes an attorney-client relationship.

  


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