3M Earplug-Questionnaire

GET HELP AT NO COST: Fill out the form below to see if you are eligible to join. If you qualify, an attorney will contact you to discuss the details of your potential case at no charge to you.

Name *

First

Middle

Last

Date of birth

Address

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Phone

Email *

Did you serve in the U.S. military between 2003 and 2015? YesNo

At any point throughout 2003 and 2015, did you receive earplugs and wear them? YesNo

Which of the following conditions apply to you? Mark all the apply.

• Total hearing loss.
• Partial hearing loss.
• Tinnitus (ringing or other sounds in ears).
• Any other hearing issues.

If you selected “any other hearing issues” please include additional details here:

Submit