JOHN HILL

home | vita | retain | email | valuations |  ethics | press

 P.O. Box 21
Abilene, Texas 79604

750 N. Judge Ely Blvd.
Abilene, Texas 79601

university office: (325) 670-5871
personal office: (325) 672-4807
cell: (325) 721-4428
facsimile: (325) 677-3500

Questionnaire for the determination of loss associated with injury: If possible, this form should be completed by the injured individual. Ideally, this form would be completed by both the injured individual and the attorney or their support staff who has retained me to make determination on the individual's loss. Please answer all appropriate questions. If you do not understand a question, please contact me using the above information. 
I. General information regarding the injured individual
 
name:  
  date of birth:   ,
  marital status:  
  gender:  
  race:   
  street address:  
  city, state and zip code:  
  contact phone for family:  
  contact email for family:  
  highest level of education:  
  years of education:   
  special licenses or skills:  
  case name:   
 
II. Family members living of injured individual
 

  

 name of spouse:  
  spouse's date of birth:    ,
  name of first child:   
first child's date of birth:     ,
  name of second child:   
  second child's date of birth:     ,
  name of third child:   
third child's date of birth:     ,
  name of fourth child:   
  fourth child's date of birth:     ,
  other information about family:     
 
III. Naure of injury
 
  date of injury:    ,
  describe nature of injury:   
  limitations due to injury:   
  describe health care needs:   
  timeline of dates relevant to injury:   
  evaluated by medical doctor?     yes     no
  evaluated by vocational analyst?     yes     no
 

III.  Pre-injury employment
 

  

 name of employer:   
  start date of employment:    ,
  last date of employment:     ,
  nature of work performed:    
  income:      paid 
hours worked per week:    
  overtime worked per week:    
promotions:     
  life insurance:     yes     no
  individual health insurance:    yes     no
  family health insurance:    yes     no
  long-term disability insurance:  yes     no
  short-term disability insurance:    yes     no
  employer 401k match:    yes     no 
  pension plan:    yes     no
bonus plan:    yes     no
  stock option:    yes     no
  paid vacation:     yes     no
  other benefits:  
  anticipated age at retirement:  
 
IV. Post-injury employment
 

  

 name of employer:   
  start date of employment:    ,
  nature of work performed:    
  income:      paid 
hours worked per week:    
  overtime worked per week:    
promotions:     
  life insurance:     yes     no
  individual health insurance:    yes     no
  family health insurance:    yes     no
  long-term disability insurance:  yes     no
  short-term disability insurance:    yes     no
  employer 401k match:    yes     no 
  pension plan:    yes     no
bonus plan:    yes     no
  stock option:    yes     no
  paid vacation:     yes     no
  other benefits:  
  anticipated age at retirement:  
 
IV. Household services performed by injured in hours per week
 
  Pre-injury household services
 
  meal preparation:   
laundry:  
  auto repair:  
  child care:  
  yard work:  
  home repair:  
  cleaning:  
  manage home (ex. bill paying):  
  other (describe & include hours):
 
  Post-injury household services
 
  meal preparation:   
laundry:  
  auto repair:  
  child care:  
  yard work:  
  home repair:  
  cleaning:  
  manage home (ex. bill paying):  
  other (describe & include hours):
 
 
V. Contact information for counsel
 

  

 attorney:  
  alternate contact:  
  street address:  
  city, state, & zip code:  
  phone:  
  facsimile:  
  email: