Thomas Carroll & Associates

WE SPECIALIZE IN

FORENSIC STATISTICS & LITIGATION SUPPORT

Phone: (702) 263-8044

Fax: (702) 263-8740

Lost Earnings Questionnaire

Lost Earnings Evaluation: General

Plaintiff's Information

First Name: Last Name:

Street Address:

City: State: Zip Code:

Phone: (i.e. 702-263-8044)

Email:

Demographic Information

Date of Birth: (i.e. YYYY/MM/DD)

Race: Citizenship:

If Others, please specify:

Gender: Marital Status:

Highest grade of school completed/degrees received:

Children?

Pre-termination Occupation(s) and Employer(s):

Current Occupation and Employer:

Other Post-termination Occupation(s) and Employer(s):

Date of Termination: (i.e. YYYY/MM/DD)

Last Day Working: (i.e. YYYY/MM/DD)

Additional Information

Please limit to less than 200 words... Also, specify dates and period unemployed and if applicable date of reemployment. Applicable additional information may include but not limited to the following: 1. Earnings history (pre & post incident) 2. Fringe benefits (pre & post incident) 3. Incidental cost in job search 4. Job relocation or retraining cost 5. Relevant deposition documents

Prognosis for Recovery

Has the victim retuned to work?

Are there any pre-existing medical conditions or disabilities?

Does the medical conditions or disabilities restrict any type or amount of work the victim can perform?

Has the victim started any vocational training and or rehabilitation?

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