[Keller & Goggin FELA Attorney]
  Keller & Goggin   P.C.
1528 Walnut Street
Suite 900
Philadelphia, PA 19102
800.666.FELA 		  
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PCB Questionnaire

Please answer the questions below. After the information has been reviewed, someone from the Keller-Goggin Law Firm will be in touch with you.
If you know others who may have also been exposed, please have them visit our site, and fill out our questionnaire, or click here for a printable copy of the questionnaire so they can fill it out and mail, or fax, it to us.
 Note: In order to view the printable copy you will need Adobe Acrobat. A free download is available here.


Plaintiff Information (Person who may have been exposed)

Name
First    Last  

Address

Street             
City  
State  

  Zip 

 
Phone Number (including area code)              
Email   Verify email  

Union Information

Union   Local  
Your representative     

Personal History

Your Age  
Date Of Birth   Month/Day/Year (00/00/0000)
Place of Birth  
Social Security #   000-00-0000
Height/ Weight       Feet     Inches                     Weight            
Marital Status  
How many children do you have?   

Employment History

Years of Service  
Employee I.D. #  
Occupation / Duties  
Current Job Title  
How many years have you been in this job?  
Prior Job Titles  
Where did you work when you were exposed to PCB's?  
How often in your career have you worked at this location or interlocking?  
What type of work did you do there?  

Health Information
What types of sickness have you suffered from SINCE working at Fair Interlocking?
(Please check all the apply)

Cancer:
Skin Prostrate
Esophageal Carcinoma
Lung Non-Hodgkins Lymphoma
Breast Melanoma
Liver Stomach
         Other     

 

 

 

 

 

 

Other Disorders:
Diabetes Insomnia
Nerve Disorder Reproductive Disorders
Fetal Death Spontaneous Abortion
Irritability Malformed Children
Impotence Cognitive Impairment
Thyroid Hormonal Changes
Heart Disease Liver Damage
       Other     


 

 

 

 

 

 

 

Respiratory Symptoms: Increased Lipids:
Decreased Pulmonary Function Cholesterol
Secretion Triglycerides

 

 

 

Are there others who live in your household who
have had any of the above described problems?        Yes No
Name
Relationship
Please describe
the problem(s)