IN THE UNITED STATES DISTRICT COURT 

FOR THE DISTRICT OF ARIZONA 

MDL No. 2641 

In Re Bard IVC Filter Products Liability Litigation 

In completing this Plaintiff Profile Form, you are under oath and must provide information that 

is true and correct to the best of your knowledge. The Plaintiff Profile Form shall be completed 

in accordance with the requirements set forth in the applicable Case Management Order. 

1. CASE INFORMATION 

Caption: Date: ----------------- -----------

Docket No.:-----------------------------

Plaintiff's attorney and Contact information: 

2. PLAINTIFF INFORMATION 

Name: ______________________________ _ 

Maiden Name: ----------------------------

Address: _____________________________ _ 

Date of birth:----------------------------

Social Security No.:--------------------------

Occupation:----------------------------

Spouse: _____________________________ _ 

Is Spouse Making Claim for Loss of Consortium? DY es D No 

3. DEVICE INFORMATION 

A. Filter Model (e.g., Recovery®, G2®, etc.):----------------

B. LotNumber: -------------------------

C. Date of Bard IVC Filter implant: ------------------

D. Attach medical evidence of product identification and operative report for filter 

placement. 

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E. Please check all the reasons why you believe your Bard Filter was placed: 

0 Filter Placed After Being Diagnosed with Deep Vein Thrombosis/Pulmonary 

Embolism 

0 Filter Placed in Conjunction with or before Orthopedic Procedure 

D Filter Placed in Conjunction with Trauma Situation/Motor vehicle accident 

0 Filter Placed in Conjunction with or before Bariatric Procedure 

0 Other Reason(s) for implant (explain): ----------------

0 Unknown 

0 See medical records attached 

F. Provide the name and address of both the doctor who implanted the Bard Filter and 

the hospital or medical facility at which the filter was placed: 

Doctor: ____________________________ _ 

Hospital/MedicalFacility: ______________________ _ 

~ " 

4. FAILURE MODE ALLEGED 

Please check all failure mode(s) that you allege apply to your Bard Filter: 

D Fracture 

0 Perforation of filter strut(s) into organs 

O Migration of entire filter to heart 

0 Tilt with filter embedded in wall of the IVC 

0 Device unable to be retrieved 

0 Bleeding 

0 Other failure mode(s) 

If other, please describe---------------------

5. REMOVAL INFORMATION 

A. Has your Bard Filter been removed? 

DY es 

DNo 

2 

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D Unknown 

B. If your Bard Filter has been removed or a doctor has attempted to remove your 

Filter, please check all that apply regarding the removal or attempted removal 

procedure(s): 

DRemoved percutaneously 

D Removed via an open abdominal procedure 

D Removed via an open chest procedure 

D Attempted but unsuccessful percutaneous removal procedure 

D Attempted but unsuccessful open abdominal procedure 

D Attempted but unsuccessful open chest procedure 

D Unknown 

D See medical records attached 

C. Provide the name(s) and address( es) of both the doctor(s) who removed your Bard 

Filter (or attempted to remove it) and the hospital or medical facility where 

removal/attempted removal occurred: 

Filter Removal/ Attempted Removal #1 

Doctor: ____________________________ _ 

Hospital/MedicalFacility: _____________________ _ 

Filter Removal/Attempted Removal #2 

Doctor: ____________________________ _ 

Hospital/MedicalFacility: _____________________ _ 

6. FRACTUREDSTRUTS 

A. Do you claim that your Bard Filter fractured? 

D Yes 

DNo 

If you answered YES, answer the below questions in this section. 

If you answered NO, skip the rest of Section 6 and go below to section 7 - "Outcome 

Attributed to Device." 

3 

Case 2:15-md-02641-DGC Document 876-2 Filed 02/23/16 Page 3 of 5
B. Are any fractured filter struts retained in your body? 

D Yes 

DNo 

D Unknown 

If yes, identify the location(s) within your body of each retained filter strut. 

C. Have any fractured filter struts been removed from your body? 

D Yes 

DNo 

D Unknown 

D. If any fractured filter strut has been removed (or a doctor has attempted to remove 

any strut), please check all that apply regarding the removal I attempted removal 

procedure(s): 

D Removed percutaneously 

D Removed via an open abdominal procedure 

D Removed via an open chest procedure 

D Attempted but unsuccessful percutaneous removal procedure 

D Attempted but unsuccessful open abdominal procedure 

D Attempted but unsuccessful open chest procedure 

D Unknown 

E. Provide the name and address of both the doctor who removed (or attempted to 

remove) the filter strut(s) and the hospital or medical facility at which it was 

removed (or attempted to be removed) 

Filter Strut Removal/Attempted Removal #1 

Doctor: ____________________________ _ 

4 

Case 2:15-md-02641-DGC Document 876-2 Filed 02/23/16 Page 4 of 5
Hospital/MedicalFacility: -----------------------

Filter Strut Removal/Attempted Removal #2 

Doctor: ----------------------------~ 

Hospital/MedicalFacility: ______________________ _ 

7. OUTCOME ATTRIBUTED TO DEVICE 

A. Do you claim to be suffering from any bodily injuries, including psychological 

injuries that are above and beyond usual pain and suffering and mental anguish, 

related to the Filter? 

D Yes 

DNo 

If your answer is "Yes," please list all symptoms and injuries you claim to have suffered: 

Of the injuries/symptoms you listed above, which do you claim to be suffering from at 

the current time: 

*** 

Plaintiff reserves the right to supplement any and all responses upon the receipt of additional 

information. 

Date 

Date 

5 

Signature of Plaintiff 

Signature of Plaintiff - Spouse (signature only 

necessary if Loss of Consortium is alleged) 

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