NEC Intake Questionnaire

Section 1: Parent Contact Information

What is your first name? *

What is your middle name?

What is your last name? *

Did you have a different name at the time of the child's birth? *

If yes, what was that name?

What is your Date of Birth? *

What is your gender? *

What is your relationship to the child? *

If not the mother, Please provide the mother’s first name.

If not the mother, please provide the mother's middle name.

If not the mother, please provide the mother's last name.

If not the mother, please fill in the box below with Other.

What is your cell phone number? *

What is your email address? *

Do you have legal authority to sign on the injured party's behalf? *

Section 2: Injured Child's Information

What is the child's first name? *

What is the child's middle name?

What is the child's last name? *

Has the child gone by any other name(s)? Example: Baby Girl Different Last Name or Twin A Last Name *

If yes, what was that name? (child)

What is the child's date of birth? *

Did [Child’s Name] pass away? True=Yes, False=No *

IF DECEASED: What was their date of death?

IF DECEASED: Does the death certificate state the cause of death as NEC?

What is the child's gender? *

What is the street Name & Number where the child currently lives? *

Is there an apartment number? If yes, enter here.

What is the city where the child currently lives? *

What is the state where the child currently lives? *

What is the zip code where the child currently lives? *

Section 3: NEC & Hospital Information

What was your child’s gestational age at birth? *

What was your child’s weight at birth? *

What brand of formula was provided to the child (MUST be Enfamil or Similac)? *

Who provided the formula the child was fed in the hospital? *

What is the name of the hospital or facility where your child was fed the formula? *

What date did the child first receive that formula? *

What date did the child last receive that formula? *

After being fed the formula, what was the child diagnosed with? (You can copy because it must be typed out: Necrotizing Enterocolitis *

Was your child diagnosed with NEC? *

When was your child diagnosed with NEC? *

What hospital was your child diagnosed with NEC? Please list out Hospital Name. *

Street Number and Street Name of Diagnosis hospital? *

Secondary Street Name (if necessary)

City of Diagnosis Hospital *

State of Diagnosis Hospital *

Zip Code of Diagnosis Hospital *

Type of Diagnosis Hospital *

What hospital did your child receive treatment for NEC? Please list out Hospital Name and Address. *

How did the medical staff treat your child for NEC? *

Did the child develop any other conditions or issues of any kind as a result of NEC? *

What happened over the next few weeks after the medical staff treated your child for NEC? *

If your child had surgery, what type of surgery did they have? *

What type of treatment did the child have? *

Section 4: Other Hard Qualifiers

Did the mother use tobacco during the pregnancy? *

Did the mother use any illegal drug during the pregnancy (e.g., cocaine, methamphetamine, phencyclidine, phenyl cyclohexyl piperidine opioids (PCP), etc.)? *

Has any lawyer represented the child or the mother in connection with the child’s NEC? *

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