Alexander v. Abbott Laboratories Inc

Filing 709

ORDER re Show Cause Order (639 in 3:12-cv-00052-NJR-SCW), (651 in 3:12-cv-00052-NJR-SCW). See text of the Order for further detail. Signed by Judge Nancy J. Rosenstengel on 12/13/2016. (Attachments: # 1 Exhibit 1) Associated Cases: 3:12-cv-00052- NJR-SCW, 3:12-cv-00053-NJR-SCW, 3:12-cv-00057-NJR-SCW, 3:12-cv-00163-NJR-SCW, 3:12-cv-00694-NJR-SCW, 3:12-cv-00824-NJR-SCW, 3:12-cv-01091-NJR-SCW, 3:13-cv-00134-NJR-SCW, 3:13-cv-00622-NJR-SCW, 3:13-cv-01061-NJR-SCW, 3:13-cv-01312-NJR-SCW, 3:14-cv-00425-NJR-SCW, 3:14-cv-01248-NJR-SCW, 3:15-cv-00472-NJR-SCW. jmw

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Exhibit 1 DEPAKOTE CLAIM FORM DOB DOD (if applicable) Biological Cause Number (if filed) Name of Child Name of Mother Name of Guardian different from Biological Mother) (if Representing Law Firm: State of Residence Reason for Mother’s Depakote Use: ☐ Epilepsy ☐ Migraine ☐ Psychiatric ☐ Other: ___________________________________ * You must provide any records to support Depakote use during pregnancy. The records must be linked to this form. Please identify the child’s injuries and mark all defects the child has associated with the injury. Also indicate whether the injury is the primary injury (you can only specify one primary injury), and specify any secondary injuries. ANY ALLEGED INJURY, SURGERY, OR IMPAIRMENT MUST BE SUPPORTED BY RECORDS TO BE LINKED TO THIS FORM. ☐ SPINA BIFIDA ☐ Primary ☐ Secondary ☐ Hydrocephalus ☐ Neurogenic Bladder/Bowel ☐ Syringomelia ☐ Chiari Malformation (I or II) ☐ Tethered Cord ☐ Complete or Partial Paralysis ☐ Other _____________________ Current physical disabilities and limitations: ________________________________________________ Current cognitive disabilities: ____________________________________________________________ □ Surgeries: List any surgeries ___________________________________________________________ 1 Exhibit 1 CRANIOFACIAL GROUP ☐ Primary ☒ ☐ Cleft Lip ☐ Cleft Palate ☐ Microtia ☐ Secondary ☐ Craniosynostosis (Metopic, Trigonocephaly, Plagiocephaly) ☐ Microcephaly ☐ Macrocephaly ☐ Larynogmalacia ☐ Tracheomalacia ☐ Eye Defect ( e.g., Strabismus, Exotropia, Esotropia) ‐Specify: __________________________________ ☐ Chiari Malformation (I or II) ☐ Hydrocephalus (without Spina Bifida) ☐ Facial Dysmorphism (Please list the dysmorphic features): ____________________________________ ☐ Fetal Valproate Syndrome (Please list the group of defects supporting this claim):_________________ _____________________________________________________________________________________ ☐ Other: _____________________________________________________________________________ ☐ Surgeries: List any surgeries ____________________________________________________________ ____________________________________________________________________________________ ☐ List any physical or cognitive impairment or limitations: ______________________________________ _____________________________________________________________________________________ HEART DEFECT GROUP ☐ Primary ☐ ☐ Atrial Septal Defect (ASD) ☐ ☐ Secondary Ventricular Septal Defect (VSD) ☐ Patent Foramen Ovale ☐ Patent Ductus Arteriosus ☐ Tetralogy of Fallot ☐ Trunctus Arteriosis ☐ Coarctation of the Aorta ☐ Interrupted Aortic Arch ☐ Heart Murmur ☐ Hypoplastic Left or Right Heart Syndrome ☐ Transposition of the Great Arteries ☐ Double Outlet Left or Right Ventricle ☐ Heart Valve Deformity (e.g., Bicuspid Aortic Valve, Pulmonary Stenosis, Pulmonary Atresia) ‐ Specify: _____________________________________________________________________________________ ☐ Other: _____________________________________________________________________________ 2 Exhibit 1 □ Surgeries: List any surgeries ____________________________________________________________ ____________________________________________________________________________________ □ List any physical or cognitive impairment or limitations: ______________________________________ ____________________________________________________________________________________ LIMB/SKELETAL GROUP ☐ Primary ☐ Secondary ☐ ☐ Club Foot ☐ Club Hand ☐ Spinal Kyphosis ☐ Scoliosis ☐ Radial Ray Anomaly ☐ Sacral Agenesis ☐ Digit Deformities of the Hand or Foot‐ Specify:_______________________________________ ☐ Hib/Rib or Other Bone Deformity – Specify:__________________________________________ ☐ Other_________________________________________________________________________ □ Surgeries: List any surgeries ____________________________________________________________ ____________________________________________________________________________________ □ List any physical or cogni ve impairment or limita ons: ______________________________________ ____________________________________________________________________________________ UROGENITAL/ABDOMINAL GROUP ☐ Primary ☐ ☐ Hypospadias ☐ Undescended Testes ☐ Gastrochisis ☐ Secondary ☐ Omphalocele ☐ Congenital Hernia ☐ Neurogenic Bowel/Bladder (without Spina Bifida) ☐ Other :_____________________________________________________________________________ □ Surgeries: List any surgeries ___________________________________________________________ ____________________________________________________________________________________ □ List any physical or cognitive impairment or limitations: _____________________________________ ____________________________________________________________________________________ 3 Exhibit 1 COGNITIVE/BEHAVIORAL IMPAIRMENT ☐ Primary ☐ Secondary ☐ Please describe nature and level of impairment e.g. provide IQ score, what grade is child in, if child has had an IEP, etc. (Must be supported by records linked to this form)_____________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ CERTIFICATION of MEDICAL RECORDS ☐ Plaintiffs’ counsel certifies all medical records in counsel’s possession for both the biological mother and the injured child, including affidavits of no records, have been produced. _______________________________ ATTORNEY SIGNATURE 4

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