Name

Phone

Email

Address

Did this happen to you or someone else? Did this happen to you or someone else? Me Someone else

Have you or a loved one lived or worked within 2.5miles of the Denka plant in LaPlace, Louisina, between 2011 and today? Have you or a loved one lived or worked within 2.5miles of the Denka plant in LaPlace, Louisina, between 2011 and today? YES NO

Did the individual develop cancer or other severe medical condition/injury? Did the individual develop cancer or other severe medical condition/injury? YES NO