(Amended May 30, 2008, eff. immediately)
1. State your full name, professional and residence addresses, and attach a current copy of your curriculum vitae (CV). In the event you do not have a CV, state in detail your professional qualifications, including your education by identifying schools from which you graduated and the degrees granted and dates thereof, your medical internships and residencies, fellowships and a bibliography of your professional writing(s).
2. State whether you have held any position on a committee or with an administrative body at any hospital. If so, state when you held such position(s) and the duties and responsibilities involved in such position(s).
3. Have you ever been named as a defendant in a lawsuit arising from alleged malpractice or professional negligence? If so, state the court, the caption and the case number for each lawsuit.
4. Since the institution of this action, have you been asked to appear before or attend any meeting of a medical committee or official board of any medical society or other entity for the purpose of discussing this case? If so, state the date(s) of each such meeting and the name and address of the committee, society or other entity conducting each meeting.
5. Have you ever testified in court in a medical malpractice case? If so, state the court, the caption and the case number of each such case, the approximate date of your testimony, whether you testified as a treating physician or expert and whether you testified on your own behalf or on behalf of the defendant or the plaintiff.
6. Has your license to practice medicine ever been suspended or has any disciplinary action ever been taken against you in reference to your license? If so, state the specific disciplinary action taken, the date of the disciplinary action, the reason for the disciplinary action, the period of time for which the disciplinary action was effective and the name and address of the disciplinary entity taking the action.
7. State the exact dates and places on and at which you saw the plaintiff for the purpose of providing care or treatment.
8. State the name, author, publisher, title, date of publication and specific provision of all medical texts, books, journals or other medical literature which you or your attorney intend to use as authority or reference in defending any of the allegations set forth in the complaint.
9. Were you named or covered under any policy or policies of liability insurance at the time of the care and treatment alleged in the complaint? If so, state for each policy:
a. The name of the insurance company;
b. The policy number;
c. The effective policy period;
d. The maximum liability limits for each person and each occurrence, including umbrella and excess liability coverage; and
e. The named insured(s) under the policy.
10. Are you incorporated as a professional corporation? If so, state the legal name of your corporation and the name(s) and address(es) for all shareholders.
11. If you are not incorporated as a professional corporation, state whether you were affiliated with a corporate medical practice or partnership in any manner on the date of the occurrence alleged in the complaint. If so, state the name of the corporate medical practice or partnership, the nature of your affiliation and the dates of your affiliation.
12. Were you at any time an employee, agent, servant, shareholder or partner of [NAME OF HOSPITAL]? If so, state the date(s) and nature of your relationship.
13. State whether there were any policies, procedures, guidelines, rules or protocols for [THE PROCEDURE COMPLAINED OF] that were in effect at [NAME OF THE HOSPITAL WHERE PROCEDURE WAS PERFORMED] at the time of the care and/or treatment alleged in the complaint. If so, state:
a. Whether such policies, guidelines, rules or protocols are published and by whom;
b. The effective date of said policies, guidelines, rules or protocols;
c. Which medical professionals are bound by said policies, guidelines, rules or protocols;
d. Who is the administrator of any such policies, procedures, guidelines, rules and/or protocols; and
e. Whether the policies, guidelines, rules or protocols in effect at the time of the occurrence alleged in the complaint have been changed, amended, or altered since the occurrence. If so, state the change(s) and the date(s) of any such change(s).
14. Were any photographs, movies and/or videotapes taken of the plaintiff or of the procedures complained of? If so, state the date(s) on which such photographs, movies and/or videotapes were taken, who is displayed therein, who now has custody of them, and the name, address, occupation and employer of the person taking them.
15. Do you know of any statements made by any person relating to the care and treatment or the damages described in the complaint? If so, give the name and address of each such witness and the date of the statement, and state whether such statement was written or oral and if written the present location of each such statement.
16. Do you have any information:
a. That any plaintiff was, within the 10 years immediately prior to the care and treatment described in the complaint, confined in a hospital and/or clinic, treated by a physician and/or other health professional, or x-rayed for any reason other than personal injury? If so, state the name of each plaintiff so involved, the name and address of each such hospital and/or clinic, physician, technician and/or health-care professional, the approximate date of such confinement or service and state the reason for such confinement or service.
b. That any plaintiff has suffered any serious personal injury and/or illness within 10 years prior to the date of the occurrence? If so, state the name of each plaintiff so involved and state when, where and how he or she was injured and/or ill and describe the injuries and/or illness suffered.
c. That any plaintiff has suffered any serious personal injury and/or illness since the date of the occurrence? If so, state the name of each plaintiff so involved and state when, where and how he or she was injured and/or ill and describe the injuries and/or illness suffered.
d. That any other suits have been filed for any plaintiff’s personal injuries? If so, state the name of each plaintiff involved, the nature of the injuries claimed, the court(s) and caption(s) in which filed, the year(s) filed, and the title(s) and docket number(s) of the suit(s).
e. That any claim for workers’ compensation benefits has been filed for any plaintiff? If so, state the name and address of the employer, the date(s) of the accident(s), the identity of the insurance company that paid any such benefits and the case number(s) and jurisdiction(s) where filed.
17. Have you (or has anyone acting on your behalf) had any conversations with any person at any time with regard to the manner in which the care and treatment described in the complaint was provided, or have you overheard any statement made by any person at any time with regard to the injuries complained of by the plaintiff or the manner in which the care and treatment described in the complaint was provided? If so, state the following:
a. The date or dates of such conversation(s) and/or statement(s);
b. The place of such conversation(s) and/or statements(s);
c. All persons present for the conversation(s) and/or statement(s);
d. The matters and things stated by the person in the conversation(s) and/or statement(s);
e. Whether the conversation(s) was oral, written and/or recorded; and
f. Who has possession of the statement(s) if written and/or recorded.
18. Pursuant to Illinois Supreme Court Rule 213(f), provide the name and address of each witness who will testify at trial and all other information required for each witness.
19. Identify any statements, information and/or documents known to you and requested by any of the foregoing interrogatories which you claim to be work product or subject to any common law or statutory privilege, and with respect to each interrogatory, specify the legal basis for the claim as required by Illinois Supreme Court Rule 201(n).
20. List the name and addresses of all persons (other than yourself and persons heretofore listed) who have knowledge of the facts regarding the care and treatment complained of in the complaint filed herein and/or of the injuries claimed to have resulted therefrom.
|STATE OF ILLINOIS||)|
|COUNTY OF _________________||)|
_______________________________________, being first duly sworn on oath, deposes and states that he/she is a plaintiff defendant in the above-captioned matter; that he/she has read the foregoing document, and the answers made herein are true, correct and complete to the best of his/her knowledge and belief.
SUBSCRIBED and SWORN to before me this
_____ day of ___________________, 20___.