B. Any and all other names you have used or by which you have been known.
C. Date of your birth.
D. Full name of your spouse, if one.
E. Your residence and office addresses.
F. The name of your professional association or corporation, if any.
Interrogatory No. 2:
A. Please state your present marital status.
B. Please state the name and last known address of your spouse and every former spouse.
C. Please state the date of each such marriage.
D. As to previous marriages, please give the date, place and manner of each termination.
E. Please state the name, age and address of each of your children.
Interrogatory No. 3: Please state:
A. The name and location of each university, college, or other post-secondary institution that you have attended, the dates of such attendance, and any degrees you have received.
B. The name and location of each medical school you attended and the dates of attendance.
C. The name and location of each institution where you served as an intern and the dates of such internship.
D. The name and location of each institution where you were a medical resident or resident physician, the dates of each residency and the medical specialty which you studied during each residency.
E. The name and location of each institution where you have done a medical fellowship or other advanced study, the dates of such fellowship or study and the medical specialty which you studied.
Interrogatory No. 4: Please list each state or other jurisdiction in which you are, or have been, licensed to practice in the healthcare field, and in each instance, give:
A. The date on which you first received your license.
B. The name of the entity that issued such license.
C. The current status of each license.
D. The termination date and reason for termination for each license that is no longer in force
Interrogatory No. 5: Have you ever held yourself out to anyone as being specially qualified in any field of health care? ___ If so, please state:
A. The name of the specialty.
B. The date you first held yourself out as a specialist.
C. Whether you are board certified in such specialty.
D. The board which certified you.
E. The date you first became board certified.
F. The date you qualified to take the board certification examination.
G. The number of times and dates you took the oral and written exams.
Interrogatory No. 6: Have you ever taught any subject at any medical or healthcare institution? ___ If so, please state:
A. The name and address of the institution.
B. What position you held, if any, and the dates that you held each position.
C. The name of each subject taught by you.
Interrogatory No. 7: Have you ever written or collaborated in writing any treatises, papers or articles on any phase of medical practice or treatment? ___ If so, please state:
A. The title of each writing.
B. The citation for each writing.
C. Whether you have a copy of each such writing and, if not, where a copy might be obtained.
Interrogatory No. 8: Please list the name of every professional society or organization in which you have held membership, the inclusive dates of your membership, any positions which you have held, and the dates such positions were held.
Interrogatory No. 9: Please list the names of each hospital where you have had staff privileges in the last five years, any limitations on your privileges, any hospital staff or committee memberships that you have held, and the dates thereof.
Interrogatory No. 10: Have you ever testified in deposition, or in court, or in another tribunal in a negligence lawsuit? ___ If so, please state:
A. The name of the plaintiff(s).
B. The name of the defendant(s).
C. The cause number and court or other tribunal where filed.
D. The names of the lawyers for the parties.
E. The subject matter of your testimony (e.g., standard of care, causation, damages).
F. The allegations of negligence in the suit.
G. The name and address of the person presently having possession of each transcript of any testimony you gave.
II. RECORDS OF HEALTH CARE
Interrogatory No. 11: With regard to each occasion on which you saw the injured person/decedent in your office, please state the following:
A. Any history taken.
B. The precise physical examination performed and a detailed listing of all findings upon this physical examination.
C. Any other diagnostic aids employed.
D. Any other diagnoses or diagnostic impressions which were reached.
E. Any modalities of treatment selected.
F. Any and all conversations with the injured person/decedent.
Interrogatory No. 12: With regard to each occasion on which you saw the injured person/decedent in the hospital, nursing home, or other institution, please state the following:
A. Any history taken.
B. The precise examination performed and a detailed listing of all findings upon this physical examination.
C. Any other diagnostic aids employed.
D. Any diagnoses or diagnostic impressions which were rendered.
E. Any modalities of treatment selected.
F. Any and all conversations with the injured person/decedent.
Interrogatory No. 13: Please state whether you ever indicated or suggested to anyone that the injured person/decedent was an unsatisfactory patient, or made any other critical representations concerning the injured person/decedent. ___ If you answer yes, please state the following with respect to each such representation:
A. A general description of the representation.
B. The date and place where it was made.
C. The name and address of each person to whom this representation was made.
Interrogatory No. 14: Do you contend that any entries in the medical records/chart at issue are incorrect or inaccurate? ___ If so, please state:
A. The precise entry(ies) that you think are incorrect or inaccurate.
B. What you contend the correct or accurate entry(ies) should have been.
C. The name, present or last known address and telephone number and present or last known employer of each and every person who has knowledge pertaining to A and B.
D. A description, including the author and title, of each and every document that you claim supports your answer to A and B.
E. The name, present or last known address and telephone number of each and every person you intend to call as a witness in support of your contention.
Interrogatory No. 15: Are you aware of any medical records, reports or letters from health care providers, or other written or recorded information or photographs concerning the medical, mental or physical condition of the injured person/decedent prior to the incident in question? ___ If so, please state:
A. The nature and subject of each such item.
B. The date each item was prepared.
C. The name, present or last known address of the person or persons preparing each item.
D. The name, present or last known address of the person who presently has custody or control of each item.
E. Whether you are in possession of copies of each or any item.
III. INVESTIGATION
Interrogatory No. 16: Are you aware of the existence of any oral, written or recorded statement or admission made or claimed to have been made by any party or witness? ___ If so, please state:
A. The name, present or last known address and telephone number of the person making the statement or admission.
B. The date of the statement or admission.
C. The name, present or last known employer, occupation, and present or last known address and telephone number of the person or persons taking or hearing the statement or admission.
D. The name and present or last known address of the person now in possession of a written or recorded statement or admission.
Interrogatory No. 17: Have any drawings, diagrams, photographs, motion pictures, digital images or videotapes been prepared or taken of any object or person involved in the incident? ___ If so, please state:
A. What is depicted by each drawing, diagram, photograph, motion picture, digital image and/or videotape.
B. The date on which each drawing, diagram, photograph, motion picture, digital image or videotape was taken.
C. The name, present or last known address of the person preparing the drawing or diagram and/or the photographer of each photograph, motion picture, digital image or videotape.
D. The name, present or last known address and telephone number of the person who now has custody of the drawing, diagram, photograph, motion picture, digital image and/or videotape.
Interrogatory No. 18: Please state whether any meetings or hearings were held by any committee, or any other group, at which the injured person/decedent or any of the incident(s) in question were discussed. ___ If so, please state the following with respect to each such meeting or hearing:
A. The date and place where it was held.
B. The name of each person present.
C. Whether any written memoranda or minutes were made of the meeting.
D. Each written or documentary item submitted to the committee or organization.
E. As to each item set forth in subsections (A) and (D) above, please state whether you contend the item is privileged (i.e., not subject to discovery) and the precise basis of the claim.
IV. WITNESSES AND EXHIBITS
Interrogatory No. 19: Are you aware of any person you may call as a witness at the trial of this action who may have or claims to have any information concerning the medical, mental, or physical condition of the injured person/decedent prior to the incident(s) in question? ___ If so, please state:
A. The name and present or last known address and telephone number of each such person.
B. The occupation and present or last known employer of each such person.
C. The subject and substance of the information each such person claims to have.
Interrogatory No. 20: Other than as disclosed above, are you aware of any person who may have or claims to have knowledge of the history or background of the injured person/decedent whom you may call as a witness in this action? (The “history or background of the injured person/decedent” as used in this interrogatory is intended to have the broadest possible reference to the injured person/decedent's background, including, but not limited to any of the following that may apply: the injured person/decedent's personal, employment, academic, military, criminal, financial, religious, social or marital background.) ___ If so, please state:
A. The name and address of each person.
B. The occupation and employer of each person.
C. The nature and substance of the information concerning the injured person/decedent of which each person has knowledge.
Interrogatory No. 21: Other than as described above, are you aware of any written or recorded information relating to the history or background of the injured person/decedent (as defined in the previous interrogatory) which you may offer as exhibits in this action? ___ If so, please state:
A. The nature of each such item of written or recorded information with sufficient particularity to identify it.
B. The date of each such item.
C. The name, present or last known address and telephone number of the author or preparer of each such item.
D. The name, present or last known address and telephone number of the person presently having possession of each such item or any copy thereof.
Interrogatory No. 22: Please list the names, present or last known addresses and telephone number, official titles, if any, and other identification of all persons, not previously identified, who:
A. Were known to be present at the events in question;
B. Claimed to have information concerning the events in question;
C. Were reported to have information concerning the events in question;
D. Have knowledge of any pre-existing medical problems or medical treatment received by the injured person/decedent prior to the events in question;
E. Have knowledge of the medical problems or medical treatment received by the injured person/decedent from the events in question up to the present time;
F. Participated in any investigation concerning this incident in question of any party or witness thereto;
G. Participated in any surveillance of the injured person/decedent.
As to each such person, please state:
1. His or her name, present or last known address and telephone number.
2. Present or last known address of any employer.
3. The subject and substance of the information each such person claims to have.
4. The present whereabouts of such person and the telephone number.
Interrogatory No. 23: Do you know of any person who is skilled in any particular field whom you may call as a witness at trial of this action and who has expressed an opinion on any issue of this action? ___ If so, please state:
A. The name, present or last known address and telephone number of each person.
B. The field in which each such person is sufficiently skilled to enable him (or her) to express opinion evidence in this action.
C. A complete list of all actions, in any tribunal, in which each person has rendered an opinion, whether by written report, deposition testimony or trial testimony, including:
1. The name of the case.
2. The court or other tribunal in which filed.
3. The docket number assigned.
4. Whether each person rendered his (or her) opinion by written report, deposition testimony, trial testimony or a combination thereof.
5. Whether you have a copy of such report or testimony and, if not, who you believe would have such copies.
D. Whether such person will base his (or her) opinion:
1. In whole or in part upon the facts acquired personally by him (or her) in the course of an investigation or examination of any of the issues of this case, or
2. Solely upon information as to facts provided him (or her) by others.
E. If your answer to D (above) discloses that any such person has made a personal investigation or examination relating to any of the issues of this case, please state the nature and dates of such investigation or examination.
F. Each and every fact, and each and every document, item, photograph or other tangible object supplied or made available to such person.
G. The general subject upon which each such person may express an opinion.
H. The substance of the facts and opinions to which such person is expected to testify.
I. Whether such persons have rendered written reports. ___ If so, please state:
1. The dates of each report.
2. The name, present or last known address and telephone number of the custodian of such reports.
Interrogatory No. 24: With respect to every lay witness whom you intend to or may call to testify, please state:
A. The name, present or last known address and telephone, occupation and present or last known employer of each such person.
B. What documents or facts such person has provided or communicated to you.
C. The substance of the testimony of such person.
Interrogatory No. 25: Please list specifically and in detail each and every exhibit you intend to use, or believe you may use, at trial in this matter.
Interrogatory No. 26: At the time of trial, do you intend to use or refer to any textbook, periodical or other publication during direct examination of your witnesses. ___ If so, please provide the citation for any text or periodical you intend to use.
V. MISCELLANEOUS
Interrogatory No. 27: Is it your contention that the injured person/decedent's injuries/death was/were caused in whole or in part by the fault of some person or persons other than yourself, whether named as a party in this action or not, or that some such other person or persons may have or share in the legal responsibility for the injuries set forth in injured person/decedent's pleadings? ___ If so, please state:
A. The name and present or last known address and telephone number of each such person or entity.
B. Each act or omission by which you contend such person is at fault for causing injured person/decedent's injuries.
C. The relationship of each person or entity, if any, to you or to any other party in this action.
Interrogatory No. 28: Have you entered into any agreement or covenant with any other person or entity in any way compromising, settling, and/or limiting the liability or potential liability for any party to the claim arising out of the occurrence alleged in the injured person/decedent's pleadings? ___ If so, please set forth the following:
A. The name and present or last known address and telephone number of each person or entity with whom such agreement or covenant was made.
B. The date of each such agreement or covenant.
C. Is the agreement or covenant in writing? ___ If so, state the name and present or last known address and telephone number of the individual who has custody and control of a copy of each such agreement or covenant.
D. The terms of each such agreement or covenant.
E. The consideration paid for each such agreement or covenant.
F. Whether you claim that the agreement or covenant is confidential and, if so, the legal and factual basis for such claim.
Interrogatory No. 29: As to any affirmative defenses you allege, please state the factual basis of and describe each such affirmative defense, the evidence which will be offered at trial concerning any such alleged affirmative defense, including the names, present or last known addresses and telephone numbers of any witnesses who will testify in support of the defense, and the descriptions of any exhibits which will be offered to establish each such affirmative defense.
Interrogatory No. 30: Have you ever been a party to a civil action or arbitration proceeding? ___ If so, please state:
A. The names and designations (Plaintiff, Defendant, intervenor, garnishee, etc.) of all parties to each such action;
B. The cause number, state, and tribunal where each such action was filed;
C. The names and address of any lawyers representing any parties to each such action;
D. The general nature of the claims and defenses, including any allegations made against you; and
E. How the claims against you were resolved.
Interrogatory No. 31: Please state the name of any insurance company or any other person or entity who might be liable to satisfy part or all of a judgment which may be entered in favor of the injured party/decedent and/or against you, or to indemnify or reimburse for payments made to satisfy the judgment.
With respect to each such entity listed above, please state the following:
A. The date on which any policy was issued, or other contract executed.
B. The period for which the policy was issued, or the duration of any contractual obligation of indemnity or reimbursement.
C. The policy or monetary limits for any liability and medical pay coverage.
D. Whether any person or entity asserts any policy defenses or other defenses to its liability to you with regard to any claim made by the injured party/decedent.
E. Whether any claim made by the injured party/decedent is being defended under a reservation of rights.
F. Each and every factual basis for any defense under a reservation of rights.
G. The exact language of the policy which provided the basis for any reservation of rights, or attach a copy of the policy language in question.
H. If more than one entity is listed, state whether any entity asserts, by contract or otherwise, that its obligations are “secondary” to any other entity, or otherwise contingent on any event or occurrence.
SET B. (TO INSTITUTIONAL HEALTH CARE PROVIDER)
I. INVESTIGATION
Interrogatory No. 1: Please state the name of any and all witnesses or purported witnesses who are believed or understood by you to have any knowledge concerning the activities and/or medical treatment received by the injured party/decedent during his/her stay/treatment at __________. As to each such person, please state the following:
A. Name, present or last known address and telephone number.
B. Present or last known employer.
C. Please set forth the subject and substance of the information each such person claims to have.
D. The present whereabouts of such person.
Interrogatory No. 2: Are you aware of the existence of any oral, written or recorded statement or admission made or claimed to have been made by any party or witness? ___ If so, please state:
A. The name, present or last known address and telephone number of the person making the statement or admission.
B. The date of the statement or admission.
C. The name, present or last known employer, occupation, and present or last known address and telephone number of the person or persons taking or hearing the statement or admission.
D. The name and present or last known address and telephone number of the person now in possession of a written or recorded statement or admission.
Interrogatory No. 3: Have any drawings, diagrams, photographs, motion pictures, digital images or video-tapes been prepared or taken of any object or person involved in the incident? ___ If so, please state:
A. What is depicted by each drawing, diagram, photograph, motion picture, digital image and/or video-tape.
B. The date on which each drawing, diagram, photograph, motion picture, digital image or video-tape was taken.
C. The name, present or last known address and telephone number of the person preparing the drawing or diagram and/or the photographer of each photograph, motion picture, digital image or video-tape.
D. The name, present or last known address and telephone number of the person who now has custody of the drawing, diagram, photograph, motion picture, digital image and/or video-tape.
Interrogatory No. 4: Are you aware of any medical records, reports or letters from health care providers, or other written or recorded information or photographs concerning the medical, mental or physical condition of the injured person/decedent prior to the incident in question? ___ If so, please state:
A. The nature and subject of each such item.
B. The date each item was prepared.
C. The name, present or last known address and telephone number of the person or persons preparing each item.
D. The name, present or last known address and telephone number of the person who presently has custody or control of each item.
E. Whether you are in possession of copies of each or any item.
Interrogatory No. 5: Other than as disclosed above, are you aware of any person who may have or claims to have knowledge of the history or background of the injured person/decedent whom you may call as a witness in this action? (The “history or background of injured person/decedent)” as used in this interrogatory is intended to have the broadest possible reference to the injured person/decedent's background, including, but not limited to, any of the following that may apply: injured person/decedent's personal, employment, academic, military, criminal, financial, religious, social or marital background.) ___ If so, please state:
A. The name, present or last known address and telephone number of each person.
B. The occupation and present or last known employer of each person.
C. The nature and substance of the information concerning the injured person/decedent of which each person has knowledge.
Interrogatory No. 6: Other than as described above, are you aware of any written or recorded information relating to the history or background of the injured person/decedent (as defined in the previous interrogatory) which you may offer as exhibits in this action? ___ If so, please state:
A. The nature of each such item of written or recorded information with sufficient particularity to identify it.
B. The date of each such item.
C. The name, present or last known address and telephone number of the author or preparer of each such item.
D. The name, present or last known address and telephone number of the person presently having possession of each such item or any copy thereof.
Interrogatory No. 7: Please state whether any person engaged in the administration or management of the institution, or engaged in supervision of any staff that provides health care was consulted at any time from the date of admission to the date of discharge concerning the injured person/decedent. ___ If so, please state:
A. The name, present or last known address and telephone number of the person who was contacted.
B. The name, address, telephone number and present or last known employer of the person who made the contact.
C. Whether any written memoranda or minutes were made of this meeting and, if so, the name, present or last known address and telephone number of the person who presently has custody of such documents.
Interrogatory No. 8: Please list the names, present or last known addresses and telephone numbers, official titles, if any, and other identification of all persons, not previously identified, who:
A. Were known to be present at the events in question;
B. Claimed to have information concerning the events in question;
C. Were reported to have information concerning the events in question;
D. Have knowledge of any pre-existing medical problems or medical treatment received by injured person/decedent prior to the events in question;
E. Have knowledge of the medical problems or medical treatment received by injured person/decedent from the events in question up to the present time;
F. Participated in any investigation concerning this incident in question of any party or witness thereto;
G. Participated in any surveillance of the injured person/decedent. As to each such person, please state:
1. Name, present or last known, address and telephone number.
2. Present or last known address of any employer.
3. The subject and substance of the information each such person claims to have.
4. The present whereabouts of such person and the telephone number.
II. GENERAL
Interrogatory No. 9: Please identify by name, present or last known address, telephone number, and present or last known employer each and every registered nurse, licensed practical nurse, nurses' aide, nursing assistant, orderly, or other health care provider or care giver who had anything to do with the care of injured person/decedent during the following shifts: __________
Interrogatory No. 10: Please state the name, present or last known address and telephone number and present or last known employer of any person engaged in the supervision of any staff that provided health care for the shifts set forth in the preceding interrogatory.
Interrogatory No. 11: Please state the number of beds at the __________ as of the present time.
Interrogatory No. 12: Please state the number of beds at the __________ as of the time in question.
Interrogatory No. 13: Please state the number of beds in the __________ [e.g., OB ward] section or unit as of the present time.
Interrogatory No. 14: Please state the number of beds in the __________ [e.g., OB ward] section or unit as of the time in question.
III. RECORDS
Interrogatory No. 15: Do you contend that any entries in the medical records/chart at issue are incorrect or inaccurate? ___ If so, please state:
A. The precise entry(ies) that you think are incorrect or inaccurate.
B. What you contend the correct or accurate entry(ies) should have been.
C. The name, present or last known address and telephone number and present or last known employer of each and every person who has knowledge pertaining to A and B.
D. A description, including the author and title, of each and every document that you claim supports your answer to A and B.
E. The name, present or last known address and telephone number of each and every person you intend to call as a witness in support of your contention.
Interrogatory No. 16: Were any incident reports, quality assurance reports, written memoranda, or other reports made which relate to any aspect of the injured person/decedent's care while the injured person/decedent was a patient or resident of the institution or which concerns the injuries/death or cause of injury/death of the injured person/decedent or concerning an investigation into injured person/decedent's injury/death? ___ If yes, please state for each such report:
A. The name, present or last known address and telephone number and title of the person who made it.
B. The date and time it was made.
C. The name, present or last known address, telephone number and title of each person who has custody of the written report or any copy thereof.
Interrogatory No. 17: Please state whether any meetings or hearings were held by any committee, or other group, at which the injured person/decedent or any of the incident(s) in question were discussed. ___ If so, please state the following with respect to each such meeting or hearing:
A. The date and place where it was held.
B. The name of each person present.
C. Whether any written memoranda or minutes were made of the meeting.
D. Each written or documentary item submitted to the committee or group.
E. As to each item set forth in subsections (A) and (D) above, please state whether you contend the item is privileged (i.e., not subject to discovery)and the precise basis of the claim.
IV. WITNESSES AND EXHIBITS
Interrogatory No. 18: Are you aware of any person you may call as a witness at the trial of this action who may have or claims to have any information concerning the medical, mental, or physical condition of the injured person/decedent prior to the incident(s) in question? ___ If so, please state:
A. The name, present or last known address and telephone number of each such person.
B. The occupation and present or last known employer of each such person.
C. The subject and substance of the information each such person claims to have.
Interrogatory No. 19: Do you know of any person who is skilled in any particular field whom you may call as a witness at trial of this action and who has expressed an opinion on any issue of this action? ___ If so, please state:
A. The name, present or last known address and telephone number of each person.
B. The field in which each such person is sufficiently skilled to enable him (or her) to express opinion evidence in this action.
C. A complete list of all actions in any tribunal, in which each person has rendered an opinion, whether by written report, deposition testimony or trial testimony, including:
1. The name of the case.
2. The court or other tribunal in which filed.
3. The docket number assigned.
4. Whether each person rendered his (or her) opinion by written report, deposition testimony, trial testimony or a combination thereof.
5. Whether you have a copy of such report or testimony and, if not, who you believe would have such copies.
D. Whether such person will base his (or her) opinion:
1. In whole or in part upon the facts acquired personally by him (or her) in the course of an investigation or examination of any of the issues of this case, or
2. Solely upon information as to facts provided him (or her) by others.
E. If your answer to D (above) discloses that any such person has made a personal investigation or examination relating to any of the issues of this case, please state the nature and dates of such investigation or examination.
F. Each and every fact, and each and every document, item, photograph or other tangible object supplied or made available to such person.
G. The general subject upon which each such person may express an opinion.
H. The substance of the facts and opinions to which such person is expected to testify.
I. Whether such persons have rendered written reports. ___ If so, please state:
1. The dates of each report.
2. The name, present or last known address and telephone number of the custodian of such reports.
Interrogatory No. 20: With respect to every lay witness whom you intend to or may call to testify, please state:
A. The name, present or last known address, telephone number, occupation and present or last known employer of each such person.
B. What documents or facts such person has provided or communicated to you.
C. The substance of the testimony of such person.
Interrogatory No. 21: Please list specifically and in detail each and every exhibit you intend to use, or believe you may use, at trial in this matter.
Interrogatory No. 22: At the time of trial, do you intend to use or refer to any textbook, periodical or other publication during direct examination of your witness? ___ If so, please provide the citation for any text or periodical you intend to use.
V. MISCELLANEOUS
Interrogatory No. 23: Is it your contention that the injured person/decedent's injuries/death were/was caused in whole or in part by the fault of some person or persons other than yourself, whether named as a party in this action or not, or that some such other person or persons may have or share in the legal responsibility for the injuries set forth in Plaintiff(s)' pleadings? ___ If so, please state:
A. The name, present or last known address and telephone number of each such person or entity.
B. Each act or omission by which you contend such person is at fault for causing the injured person/decedent's injuries/death.
C. The relationship of each person or entity, if any, to you or to any other party in this action.
Interrogatory No. 24: Have you entered into any agreement or covenant with any other person or entity in any way compromising, settling, and/or limiting the liability or potential liability for any party to the claim arising out of the occurrence alleged in Plaintiff(s)' pleadings? ___ If so, please set forth the following:
A. The name, and present or last known address and telephone number of each person or entity with whom such agreement or covenant was made.
B. The date of each such agreement or covenant.
C. Is the agreement or covenant in writing? ___ If so, please state the name, present or last known address and telephone number of the individual who has custody and control of a copy of each such agreement or covenant.
D. The terms of each such agreement or covenant.
E. The consideration paid for each such agreement or covenant.
F. Whether you claim that the agreement or covenant is confidential and, if so, the legal and factual basis for such claim.
Interrogatory No. 25: As to any affirmative defenses you allege, please state the factual basis of and describe each such affirmative defense, the evidence which will be offered at trial concerning any such alleged affirmative defense, including the names of any witnesses who will testify in support of the defense, and the descriptions of any exhibits which will be offered to establish each such affirmative defense.
Interrogatory No. 26: Please state whether the institution has been sued for negligence (including but not limited to malpractice or professional negligence) within the past ten years. ___ If so, please state:
A. The name of the Plaintiff(s).
B. The name of any and all other Defendant(s).
C. The cause number and court where filed.
Interrogatory No. 27: Give the name, present or last known address and telephone number of every person, physician, staff member or employee of the institution or representative of any insurance company who has been permitted to see, examine, investigate or copy any of the records of the injured person/decedent. (This interrogatory does not apply to any persons whose review/copying of the records was conducted as part of peer review, as set forth in A.R.S. § 35-445.01, § 36-2401, et seq., or § 36-441, or as a part of formal quality assurance procedures.)
Interrogatory No. 28: Please state the name of any insurance company or any person or entity who might be liable to satisfy part or all of a judgment which may be entered in favor of Plaintiff and/or against you, or to indemnify or reimburse for payments made to satisfy the judgment.
With respect to each such person or entity listed above, please state the following:
A. The date on which any policy was issued, or other contract executed.
B. The period for which the policy was issued, or the duration of any contractual obligation of indemnity or reimbursement.
C. The policy or monetary limits for any liability and medical pay coverage.
D. Whether any person or entity asserts any policy defenses or other defenses to its liability to you with regard to any claim made by the Plaintiff.
E. Whether any claim made by the Plaintiff is being defended under a reservation of rights.
F. Each and every factual basis for any defense under a reservation of rights.
G. The exact language of the policy which provided the basis for any reservation of rights or attach a copy of the policy language in question.
H. If more than one person or entity is listed, state whether the person or entity asserts, by contract or otherwise, that its obligations are “secondary” to any other entity, or otherwise contingent on any event or occurrence.
SET C. (TO AN INDIVIDUAL)
(These interrogatories should be answered to provide information regarding each person claiming damages in this action and also regarding the decedent if a wrongful death action.)
I. GENERAL INFORMATION & BACKGROUND
Interrogatory No. 1:
A. Please state your full name, address and date of birth.
B. Please state any and all other names which you have ever used or by which you have been known.
Interrogatory No. 2:
A. Please state your present marital status.
B. Please state the name and last known address of your spouse and every former spouse.
C. Please state the date of each such marriage.
D. As to previous marriages, please give the date, place and manner of each termination.
E. Please state the name, age and address of each of your children.
Interrogatory No. 3: Have you ever been a party to a civil action or arbitration proceeding? ___
If so, please state:
A. The names and designations (Plaintiff, Defendant, intervenor, garnishee, etc.) of all parties to each such action;
B. The cause number, state, and tribunal where each such action was filed;
C. The names and address of any lawyers representing any parties to each such action;
D. The general nature of the claims and defenses, including any allegations made against you; and
E. How the claims against you were resolved.
Interrogatory No. 4: Have you ever been convicted of a felony? ___
If so, please state:
A. The original charge made against you.
B. The charge of which you were convicted.
C. Whether you pled guilty to the charge, or were you convicted after trial.
D. The name and address of the court where the proceedings took place.
E. Date of conviction or date plea entered.
II. EDUCATION, EMPLOYMENT, ACTIVITIES AND IMPAIRMENT
Interrogatory No. 5: Please state the highest grade of formal schooling completed by you and any certificate or degrees received.
Interrogatory No. 6: Please list each job or position of employment, including self-employment, held by you on the date of and since the incident in question, stating as to each:
A. Name and address of employer.
B. Date of commencement and date of termination.
C. Nature of employment and duties performed.
D. Name and address of immediate supervisor.
E. Rate of pay or compensation received.
F. The reason for termination.
Interrogatory No. 7: Please list each job or position of employment, including self-employment, held by you for the five (5) years before the incident in question, stating as to each:
A. Name and address of employer.
B. Date of commencement and date of termination.
C. Place of employment.
D. Nature of employment and duties performed.
E. Name and address of immediate supervisor.
F. Rate of pay or compensation received.
G. Reason for termination.
Interrogatory No. 8: Do you claim to have lost any time from gainful employment as a result of the incident in question? ___
If so, please state:
A. The specific condition which you claim caused the loss of time.
B. The amount of time lost.
C. The rate of pay or compensation regularly received from each such gainful employment.
D. The total amount and your method of computation of damage, if any, as a result of the time lost.
E. Whether you have in your possession or control any records or other written memoranda which show or purport to show any or all of the amount of your income for the five (5) years preceding the incident in question to the present time, including a brief description of each such record or memorandum and the person who has it or controls it.
Interrogatory No. 9: Do you claim your earning capacity will be impaired as a result of the incident in question? ___
If so, please state:
A. The manner in which the condition will impair your ability to work.
B. Name and address of each person who had advised you concerning the impairment.
Interrogatory No. 10: Have you received any special education or training for any type of work? ___
If so, please state:
A. The names and addresses of the training or education institutions attended and the dates of attendance.
B. The names, addresses and inclusive dates of employment by employers from whom you received on-the-job training.
Interrogatory No. 11: Do you claim that as a result of the incident in question you have lost any opportunities for advancement or promotion in your employment? ___
If so, please state:
A. What opportunities would have been available had the incident in question not occurred.
B. When would each opportunity have been available.
C. The amount of monetary damages you allege you have lost as a result of said lost opportunity, and how you calculate those damages.
III. INVESTIGATION
Interrogatory No. 12: Have you or anyone acting on your behalf interviewed or spoken with any party, or its agents, servants or employees, about the events in question? ___
If so, please state who was present, when and where such conversation took place and the substance of any such conversations including, but not limited to, any statement or admission made by a party.
Interrogatory No. 13: Are you aware of the existence of any oral, written or recorded statement or admission made or claimed to have been made, by any party or witness? ___
If so, please state:
A. The name, present or last known address and telephone number of each person making the statement or admission.
B. The date of the statement or admission.
C. The name, present or last known employer, occupation and present or last known address of the person or persons taking or hearing the statement or admission.
D. The name and present or last known address and telephone number of the person now in possession of a written or recorded admission.
IV. INJURIES & DAMAGES
Interrogatory No. 14: Please describe in detail all injuries, complaints and symptoms, whether physical, mental or emotional, each person claiming damages in this action has experienced since the incident in question and which is claimed to have been caused, aggravated or otherwise contributed to by the incident in question.
Interrogatory No. 15: Do you claim any of your injuries are permanent? ___
If so, please state:
A. What, if any, pains do you contend such injuries will cause in the future.
B. Whether you believe the pains will be alleviated (and if so, when), or whether the pains are permanent.
C. What, if any, disabilities do you contend such injuries will cause.
D. Whether you believe the disabilities are permanent or, if not, when they might be resolved.
E. The name, profession and specialty, if any, of any medical practitioner who has provided you with any of the information given in answers (A) through (D).
V. PRIOR AND SUBSEQUENT INJURIES/TREATMENT
Interrogatory No. 16: Have you been in a medical institution since the incident in question? ___
If so, please state:
A. The person.
B. The name and location of each medical institution in which each person stayed.
C. The dates of each stay.
D. The conditions treated during each stay.
E. The nature of the treatment rendered during each stay.
Interrogatory No. 17: Has any health care provider or any person claiming damages in this action criticized any medical care or treatment given to you during or after the incident in question? ___ If so, for each criticism, please state:
A. A description of the criticism.
B. The name, address and qualifications of the person who made the criticism.
C. The date, time and place it was made.
Interrogatory No. 18: Please list each injury, symptom or complaint for which damages are claimed in this action from which you suffered at any time before the incident in question.
Interrogatory No. 19:
Please state:
A. The name and address of each health care provider who examined or treated you for any physical or emotional condition during the past ten years.
B. The conditions or complaints for which the examination or treatment was performed.
C. The date of each examination or treatment performed.
D. Whether or not the symptoms caused by conditions described in your answer to paragraph (B) of this interrogatory were completely relieved and, if so, the date of relief.
Interrogatory No. 20: Since the incident in question, have you suffered any injuries? ___
If so, please state:
A. The date and place.
B. How the injury was sustained.
C. A detailed description of each injury received.
D. The name and address of each medical practitioner rendering treatment.
E. The nature and extent of any permanent disability.
F. The name and address of each person or organization against whom a claim was made, and/or from whom payments were received, for any such injury.
Interrogatory No. 21: Have you ever made any claim for money damages against anyone, group, organization, corporation, industrial commission or any entity for any reason? ___
If so, for each claim please state:
A. The complete caption of any lawsuit, arbitration, or other judicial or non-judicial proceeding in which the claim was made.
B. The current status of the claim (pending, settled, on appeal, etc.).
C. The amount of any compensation you received, if any, related to the claim.
Interrogatory No. 22: Please identify each health-care provider who has records pertaining to your health care that was rendered during the seven years prior to the incident in question.
A. With respect to each provider identified above, please state whether you will obtain and produce the records.
B. With respect to any records you will not obtain and produce, please state the specific reason or reasons for nonproduction.
VI. MATTERS CONCERNING THE CONDUCT OF PARTIES
Interrogatory No. 23: In this action, you have characterized certain acts or conduct on the part of other parties as being below the standard of care. As to such acts and conduct, please state:
A. Each specific act or acts, failure or failures to act which you contend fell below the standard of care.
B. Specifically what conduct you claim would have complied with the standard of care.
C. Each and every fact upon which you rely when you claim:
1. That any health care provider negligently performed its professional duties to you.
2. That any health care provider's negligent performance of its professional duties to you proximately caused you injury.
Interrogatory No. 24: Do you allege that any agent, servant or employee of any party violated or failed to follow any rule, regulation, policy or procedure of a health care institution or of some other authority? ___ If so, please state:
A. The identity of said rule, regulation, policy or procedure.
B. How and by whom you allege said rule, regulation, policy or procedure was violated.
C. How you allege said violation proximately caused injury to you.
Interrogatory No. 25: Do you contend that any agent, servant or employee of any party neglected to inform, instruct or warn you as to any matters relating to your condition, care or treatment? ___ If so, for each matter, please state:
A. A description of what agent, servant or employee neglected to inform, instruct or warn you.
B. Whether such failure or neglect contributed to any injury of which you complain, and if so, in what way and to what extent.
Interrogatory No. 26: Do you know of any person who is skilled in any particular field whom you may call as a witness at trial of this action and who has expressed an opinion on any issue of this action? ___
If so, please state:
A. The name, present or last known address and telephone number of each person.
B. The field in which each such person is sufficiently skilled to enable him [or her] to express opinion evidence in this action.
C. A complete list of all actions in which each person has rendered an opinion, whether by written report, deposition testimony or trial testimony, including:
1. The name of the case.
2. The court or other tribunal in which filed.
3. The docket number assigned.
4. Whether each person rendered his [or her] opinion by written report, deposition testimony, trial testimony or a combination thereof.
5. Whether you have a copy of such report or testimony and, if not, who you believe would have such copies.
D. Whether such person will base his [or her] opinion:
1. In whole or in part upon facts acquired personally by him [or her] in the course of an investigation or examination of any of the issues of this case, or
2. Solely upon information as to facts provided him [or her] by others.
E. If your answer to (D) above discloses that any such person has made a personal investigation or examination relating to any of the issues of this case, please state the nature and dates of such investigation or examination.
F. Each and every fact, and each and every document, item, photograph or other tangible object supplied or made available to such person.
G. The general subject upon which each person may express an opinion.
H. The substance of the facts and opinions to which such person is expected to testify.
I. Whether such persons have rendered written reports.
If so, please state:
1. The dates of each report.
2. The name, present or last known address and telephone number of the custodian of such reports.
VII. DAMAGES
Interrogatory No. 27: Please state each and every expense, debt or obligation you have incurred, amount expended and item of special damage you will claim at trial as a result of the incident in question. This Interrogatory includes, but is not limited to: medical expense, ambulance expense, transportation expense, physiotherapist expense, psychologist fees, psychiatric fees, laboratory charges, hospital costs and x-ray costs.
VIII. WITNESSES & EXHIBITS
Interrogatory No. 28: With respect to every lay witness whom you intend to or may call to testify, please state:
A. The name, present or last known address and telephone number, occupation and present or last known employer of each such person.
B. What documents or facts such person has provided or communicated to you.
C. The substance of the testimony of such person.
Interrogatory No. 29: Please list the names, addresses, official titles, if any, and other identification of all witnesses whom you contemplate will be called upon to testify in support of your claim in this action at trial indicating the nature and substance of the testimony which is expected will be given by each such witness, and stating the relationship, if any, to you.
Interrogatory No. 30: Please list specifically and in detail each and every exhibit you intend to use, or believe you may use, at trial in this matter.
Interrogatory No. 31: At the time of trial, do you intend to use or refer to any textbook, periodical or other publication during direct examination of your witnesses? ___
If so, please provide the citation for any text or periodical you intend to use.
IX. COLLATERAL SOURCE
Interrogatory No. 32: Have you received, are you now receiving, or are you entitled to receive, collateral source benefits as enumerated in A.R.S. § 12-565?
If so, please state:
A. The amount of each and every payment.
B. Schedule or frequency of such payments/benefits.
C. If the payments have stopped, the date and reason the payments stopped.
D. If the payments are still being received, the length of time you expect to receive these payments.
E. If the benefits are stopped at some future time, please state when and under what circumstances the payments will terminate.
F. The amount of payments you expect to receive in the future.
X. MISCELLANEOUS
Interrogatory No. 33: Have you entered into any agreement or agreements or covenants with any other person or entity in any way compromising, settling or in any way limiting such persons or entity's liability or potential liability for any claim, or part of any claim, arising out of the incident in question? ___
If so, please state:
A. The name and address of each person or entity with whom such agreement or covenant was made.
B. The date of each such agreement or covenant.
C. Whether the agreements or covenants are in writing. ___ If so, state the name and address of the individual who has custody and control of a copy of each such agreement or covenant.
D. The terms of each such agreement or covenant.
E. The consideration paid for each such agreement or covenant.
Interrogatory No. 34: Have you asserted any claim against any person or entity, not a named party to this lawsuit, for any part of the loss or damage arising out of the incident in question? ___
If so, state:
A. The name and last known address of each such person or entity.
B. The basis upon which the claim was asserted.
Interrogatory No. 35: Does any insurance company or any other person or organization have any interest in this action or any recovery herein by way of subrogation, assignment, trust receipt or otherwise, or has any such claim been asserted? ___ If so, please state the name and address of each such company, other person or organization and the nature and amount of any such claimed interest.
Interrogatory No. 36:
Do you contend that any entries in the medical records/chart at issue are incorrect or inaccurate?
If so, please state:
A. The precise entry (entries) that you think is/are incorrect or inaccurate.
B. What you contend the correct or accurate entry (entries) should have been.
C. The name, present or last known address and telephone number and present or last known employer of each and every person who has knowledge pertaining to (A) and (B).
D. A description, including the author and title of each and every document that you claim supports your answers to (A) and (B).
E. The name, present or last known address and telephone number of each and every person you intend to call as a witness in support of your contention.
Interrogatory No. 37: Please list the names, present or last known addresses and telephone numbers, official titles, if any, and other identification of all persons, not previously identified, who:
A. Were present at the events in question.
B. Claim to have information concerning the events in question.
C. Are reported to have information concerning the events in question.
D. Have knowledge of any preexisting medical problems or medical treatment received by you prior to the events in question.
E. Have knowledge of medical problems or medical treatment received by you from the events in question up to the present time.
F. Participated in any investigation concerning the incident in question or of any party or witness thereto.
G. Participated in any surveillance of the injured person/decedent. As to each such person, please state:
1. His or her name, present or last known address and telephone number
2. Present or last known address of any employer.
3. The subject and substance of the information each such person claims to have.
4. The present whereabouts of such person and the telephone number.
Credits
Added Sept. 2, 2016, effective Jan. 1, 2017.
16 A. R. S. Rules Civ. Proc., Form 4, AZ ST RCP Form 4
State Court Rules are current with amendments received through April 1, 2024. The Code of Judicial Administration is current with amendments received through April 1, 2024.
