In Re: Gardasil Products Liability Litigation

OCR transcription for search; preserved printed pages are authoritative

UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF NORTH CAROLINA

CHARLOTTE DIVISION
3; 22-mad-03086-RJ C

)
IN RE: GARDASIL PRODUCTS LIABILITY ) MDL No. 3086
LITIGATION )

) ‘THIS DOCUMENT RELATES TO

) ALL CASES

)

)

)

)

PLAINITFF FACT SHEETS ORDER

I. SCOPE OF ORDER

This Plaintiff Fact Sheets Order (““PFSO”) governs the form and schedule for service of
Plaintiff Fact Sheets (‘PFS’) in all cases that were (1) transferred to this Court by the Judicial
Panel on Multidistrict Litigation (“JPML”) pursuant to its August 4, 2022 Order (2)
subsequently transferred to MDL 3036 by the JPML pursuant to Rule 7.4 of the Rules of
Procedure of that Panel; or (3) originally filed in or transferred to, removed to, or reassigned to
MDL 3036. Collectively, these cases shall be referred to as “Subject Actions.” The obligation
to comply with this PFSO and to provide a PFS shall fall solely to the individual counsel
representing a plaintiff. As with all case-specific discovery, the members of the Plaintiffs’
Steering Committee (“PSC”’) or Plaintiffs’ Executive Committee (“PEC”) are not obligated
to conduct case-specific discovery for Plaintiffs whom they have not been individually
retained.

Il. PLAINITFF FACT SHEETS
A. PFS Requirements

1

INFORMATION

2
1. Form of PFS
Every plaintiff is required to complete a PFS, consisting of four parts. The four-part form
of PFS that shall be used in MDL 3036 for all Subject Actions is attached as Exhibit A.
The PFS is a convenient form of propounding interrogatories and request for production of
documents. All responses in a plaintiff’s completed PFS or any amendment thereto are binding
on the plaintiff as if they were contained in responses to interrogatories under Federal Rule of Civil
Procedure 33 and responses to requests for production of documents under Federal Rule of Civil
Procedure 34, and each PFS shall be supplemented in accordance with Federal Rule of Civil
Procedure 26. The completed PFS will be governed by the standards applicable to written
discovery under Federal Rule of Civil Procedure 26 through 37.
2. Instruction for Completing PFS
The questions and requests for production contained in the PFS are non-objectionable and
shall be answered fully, unless information is privileged or protected by the attorney-client
privilege.
a. Part I of the PFS requires some basic case information and the production of all medical
and pharmacy records collected by the plaintiff or on the plaintiff’s behalf, including
(but not limited to) collections made by counsel who represent the plaintiff in this
litigation and counsel who represented the plaintiff in the United States Court of
Federal Claims (hereinafter “Vaccine Court”), except that Mental Health Records only
need to be produced if: (a) mental health records were submitted in the plaintiff’s
Vaccine Court proceeding, (b) the plaintiff is making, or made in Vaccine Court, a
claim for mental or psychological injury (excluding a claim solely based on pain and
suffering, emotional distress, and/or mental anguish), (c) the plaintiff is claiming, or
claimed in Vaccine Court, that she/he/they have POTS, orthostatic intolerance, brain
fog, chronic fatigue syndrome, hypotension, hallucinations, severe insomnia, excessive
sleep (more than 15 hours per day), non-epileptic seizures, movement disorder, or
functional neurologic disorder (FND), (d) Counsel for the plaintiff and Counsel for
Merck agree that the Mental Health Records of the plaintiff are discoverable or (e) the
Court so orders. It also requires the production of any documents or filings made on
a plaintiff’s behalf in Vaccine Court, except that attorney billing records submitted to
the Vaccine Court may be excluded. The plaintiff shall identify the attorney billing
records by Vaccine Court docket number and provide the title of each identified filing.
Moreover, if the plaintiff asserts that the “Vaccine Court file contains expert reports,
Case 3:22-md-03036-KDB Document 78 Filed 03/10/23 Page 2 of 42

3
opinions, or other documentation from experts that Plaintiffs will retain ‘in anticipation
of litigation or to prepare for trial and who [are] not expected to be called as []
witness[es]’ pursuant to Federal Rule of Civil Procedure 26(b)(4)(D),” the plaintiff
must identify those filings by Vaccine Court file docket number and provide the title
of those filing. See Third Pretrial Order (Doc. No. 58). Pursuant to the Third Pretrial
Order (Doc. No. 58), the plaintiff must simultaneously file a motion with the Court
regarding those expert reports, opinions, or other documentation from experts that the
plaintiff identifies. Finally, Part I of the PFS also requires that the plaintiff provide
authorizations and other required documentation to Merck and its vendor that enables
Merck and its vendor to collect certain relevant records. The requirements related to
authorizations are described more fully in Section II.A.3, below.
b. Part II of the PFS requires the plaintiff to provide relevant information. Each question
below must be answered truthfully and completely to the best of plaintiff’s knowledge,
information, and belief. Plaintiff has an obligation to provide information that is
available to plaintiff or under the plaintiff’s control (including medical records
collected on plaintiff’s behalf) and cannot limit the answers simply to what is within
the plaintiff’s own knowledge. PFS – Part II also requires the plaintiff to provide
additional authorizations for various entities. The Declaration in Section IV of PFS –
Part II must be signed and dated by the plaintiff or plaintiff representative. For Mental
Health Records (as that term is defined in the Plaintiff Fact Sheet) collected by Merck
using an authorization or subpoena, Plaintiffs shall have 15 days from the date the
records are obtained to redact appropriate third-party personal information and/or non-
discoverable protected information including, but not limited to, private third party
information, bank account information, and employment information related to non-
parties. Redactions must be made in accordance with the terms of any ESI order entered
in this case. Absent agreement among the parties or a motion to extend the time filed
by Plaintiff, Merck shall be granted access to the Mental Health Records obtained by
authorization or subpoena after the fifteen (15) day period expires. Plaintiffs will bear
the costs of any redactions or related processing of materials redacted pursuant to this
paragraph. In the event of an inadvertent production of private third-party information,
the parties will cooperate to resolve the issue. In the event of a dispute regarding Mental
Health Records redactions, Merck may request additional information about any
redactions that have been made, and the parties shall meet and confer before addressing
any issue with the Court.
c. Part III of the PFS requires the plaintiff to produce documents other than those
produced in response to PFS – Part I. The plaintiff must produce all responsive
documents requested in the PFS – Part III, to the extent the documents are in the
plaintiff’s possession, custody, or control, and not otherwise privileged or protected by
the attorney-client privilege.
d. Part IV of the PFS must be completed once the plaintiff’s case is selected for a
bellwether pool or is otherwise selected for individual case work up. Part IV requires
the plaintiff to produce documents other than those produced in response to PFS – Part
I and PFS – Part III, to the extent the documents are in the plaintiff’s possession,
custody, or control.
Case 3:22-md-03036-KDB Document 78 Filed 03/10/23 Page 3 of 42

4
The above does not prohibit a plaintiff from withholding or redacting information on the
basis of a recognized privileged. To the extent any plaintiff withholds or redacts any information
on the grounds of privilege, the plaintiff shall identify the privilege being asserted in his/her/their
PFS in a privilege log to be produced pursuant to the Privilege Log Protocol to be negotiated and
entered in MDL 3036.
Nothing in the PFS shall be deemed to limit the scope of inquiry at depositions or the
admissibility of evidence at trial. Additionally, once a case is selected for a bellwether pool or is
otherwise selected for individual case work up, Merck may serve additional discovery requests.
3. Plaintiff’s Obligation to Provide Signed Authorizations
Contemporaneous with the submission of PFS – Part I and PFS – Part II, each plaintiff
shall also produce various signed authorizations. Attached as Exhibit 1 to the PFS – Part I is an
authorization for the release of a plaintiff’s Vaccine Court file to Merck’s counsel and/or Merck’s
medical records collection vendor, Litigation Management, Inc. (“LMI”). Each plaintiff must
complete and sign that authorization and provide with it a copy of the plaintiff’s valid, non-expired
government-issued ID (e.g., a driver’s license or passport). Attached as Exhibits 2-3 to the PFS –
Part I and attached as Exhibit A-C to the PFS – Part II, are authorizations for the release to Merck’s
counsel and/or LMI of medical, insurance, employment, educational, Medicare, and Social
Security records. The authorizations attached to the PFS may be amended or substituted over time
should they become outdated and to the extent that additional form authorizations would facilitate
the collection of records in the Subject Actions. These authorizations, once signed by the plaintiff,
constitute permission for Merck’s counsel and/or LMI to obtain the records specified in the
authorizations from the records custodians. In the case of the Vaccine Court file, Merck will submit
a signed authorization together with a copy of the plaintiff’s valid, non-expired government-issued
ID to the Department of Justice, at which point the Department of Justice will also sign an
Case 3:22-md-03036-KDB Document 78 Filed 03/10/23 Page 4 of 42

5
authorization to permit the release of the plaintiff’s Vaccine Court file. Both authorizations will
be submitted to the Clerk’s Office for the United States Court of Federal Claims, which will then
transmit the plaintiff’s Vaccine Court file to LMI. Any docket entries identified by plaintiff in the
PFS – Part I containing attorney billing records will not be made available to Merck’s counsel.
Additionally, any document entries identified by plaintiff in the PFS – Part I containing “expert
reports, opinions, or other documentation from experts that Plaintiffs will retain ‘in anticipation of
litigation or to prepare for trial and who [are] not expected to be called as [] witness[es]’ pursuant
to Federal Rule of Civil Procedure 26(b)(4)(D)” will not be made available to counsel for Merck
and Merck’s counsel will only be provided access to those documents in accordance with any
ruling made by the Court on the plaintiff’s motion related to those submissions. The Parties will
work together to ensure that the relevant docket entries related to attorney billing records and
expert reports are handled in accordance with the Court’s direction.
If Merck wishes to obtain records from any custodian of records whose records were
submitted in Vaccine Court or whom the plaintiff identified in the PFS, including, but not limited
to, any who will not accept authorizations in the form that a plaintiff executed pursuant to this
PFSO, the plaintiff will cooperate with Merck and provide the necessary authorization(s). If
additional authorizations are required for a specific provider or facility identified in the PFS, the
plaintiff shall provide the additional executed authorizations within ten (10) days of receipt of a
written request to provide such additional authorizations. If the plaintiff does not provide the
authorization within ten (10) days, Merck may then submit to the Court a motion to compel.
If Merck wishes to obtain records from a source not identified in the Vaccine Court file or
public docket or in the PFS, Merck shall provide plaintiff’s counsel of record in that particular case
with written notice of its request for an authorization, attaching the authorization required by that
Case 3:22-md-03036-KDB Document 78 Filed 03/10/23 Page 5 of 42

6
provider or facility. Within ten (10) days of receiving that notice, plaintiff’s counsel shall either
object to Merck’s request or provide an executed authorization. If plaintiff’s counsel objects to
Merck’s request, plaintiff’s counsel and Merck’s counsel shall meet and confer within five (5)
business days of the date of the objection to attempt to resolve the objection. If plaintiff’s counsel
fails to object to the request or provide the requested authorization within ten (10) days, or if
counsel are unable to resolve the objection after a meet-and-confer has been held over an objection,
Merck may file a motion to compel.
If a Health Care Provider and/or records custodian refuses to comply with a request for
production of records or refuses to speak to LMI in a particular case, the plaintiff’s principal
attorney must meet and confer with counsel for Merck. Merck may request that the individual
plaintiff’s counsel attempt to confer with the Health Care Provider and/or records custodian’s
office to mediate its refusal.
B. Schedule for Service of PFS
1. Subject Actions Currently Pending in MDL 3036
As agreed by the Parties, all plaintiffs whose cases are currently pending in MDL 3036 as
of the date of this PFSO must serve Merck with:
a. a complete PFS – Part I, including all responsive documents and authorizations,
by March 9, 2023 (irrespective of whether this Order is entered by the Court on
that date);
b. a complete and verified PFS – Part II, including all authorizations, by March 30,
2023 (irrespective of whether this Order is entered by the Court on that date);
c. a complete PFS – Part III, including all responsive documents, by April 20, 2023
(irrespective of whether this Order is entered by the Court on that date); and
Case 3:22-md-03036-KDB Document 78 Filed 03/10/23 Page 6 of 42

7
d. a complete PFS – Part IV, including all responsive documents, within thirty (30)
days from the date the case is selected for a bellwether pool or is otherwise selected
for individual case work up.
2. Subject Actions Later Made Part of MDL 3036
For any plaintiff whose case is not pending in MDL 3036 as of the date of this PFSO, but
whose case is later filed in, transferred to, removed to, or reassigned to MDL 3036, such plaintiff
must serve Merck with:
a. a complete PFS – Part I, including all responsive documents and authorizations,
within thirty (30) days of the date the complaint is filed or within thirty (30) days
of the receipt of the case in the Western District of North Carolina, whichever is
later;
b. a complete and verified PFS – Part II, including all authorizations, within sixty
(60) days of the date the complaint is filed or within forty-five (45) days of the
receipt of the case in the Western District of North Carolina, whichever is later;
c. a complete PFS – Part III, including all responsive documents, within seventy-five
(75) days of the date the complaint is filed or within sixty (60) days of the receipt
of the case in the Western District of North Carolina, whichever is later; and
d. a complete PFS – Part IV, including all responsive documents, within thirty (30)
days from the date the case is selected for a bellwether pool or is otherwise selected
for individual case work up.
C. Service of PFS
Each Part of the PFS, all responsive documents, and all authorizations shall be served
electronically on Defendants’ Counsel at the following email address:
Case 3:22-md-03036-KDB Document 78 Filed 03/10/23 Page 7 of 42

8
GardasilFactSheets@venable.com. The production of responsive documents should comply with
the requirements of any ESI order entered in this matter.
Concurrent with service to Merck, the plaintiff shall serve each Part of the PFS, all
responsive documents, and all authorizations upon the Plaintiffs’ Lead Counsel and Liaison
Counsel by sending an email to GardasilPFS@lanierlawfirm.com.
Should a Health Care Provider and/or records custodian require an authorization with an
original signature, Merck’s counsel will notify the plaintiff’s counsel of record, who will provide
Merck with a hard copy of the authorization within ten (10) days of receipt of the request from
Merck’s counsel.
D. Substantial Completion
In completing the PFS, every plaintiff is required to provide a PFS that is substantially
complete in all respects. For a PFS to be “substantially complete in all respects,” the responding
plaintiff must: (1) answer the questions contained in the PFS truthfully and completely to the best
of plaintiff’s knowledge, information, and belief; and (2) comply with the instructions set forth in
Section II.A.2-3 above.
E. Non-Compliance with PFS Requirements
1. Non-Compliance with PFS – Part I Requirements
If Merck has not received from the plaintiff or the plaintiff’s representative a substantially
complete PFS – Part I fulfilling the requirements of Section II.A.2.a of this PFSO by the due date
set forth in Section II.B.1.a or II.B.2.a of this PFSO, Merck may send a “Alert of Non-Compliance
with PFS – Part I Requirements” by email to plaintiff’s counsel of record using the email
address(es) identified on the individual case docket in the U.S. District Court for the Western
District of North Carolina’s ECF system. A courtesy copy of the email shall be sent via email to
Case 3:22-md-03036-KDB Document 78 Filed 03/10/23 Page 8 of 42

9
the PEC’s designee at GardasilPFS@lanierlawfirm.com. The email will state the basis for Merck’s
contention that the plaintiff has not complied with the obligations to provide a PFS – Part I.
Plaintiff will have an additional twenty (20) days to correct the alleged deficiency(ies) and
telephonically or virtually meet and confer with Merck’s counsel, if plaintiff chooses to do so.
Failure of plaintiff’s counsel to meet and confer does not delay Merck’s ability to file motions
under this Section with the Court. If, for good cause, plaintiff needs time beyond the twenty (20)
day period, counsel for plaintiff and counsel for Merck shall negotiate a reasonable extension of
this deadline.
If plaintiff has not provided a substantially complete PFS – Part I within twenty (20) days
after receiving the “Alert of Non-Compliance with PFS – Part I Requirements,” (i.e. (i) fail to
cure the stated deficiency(ies); (ii) fail to assert objection to same; (iii) fail to participate in
the meet and confer process; or (iv) otherwise fail to provide responses (including the
requested documents and/or signatures), and absent agreement of the Parties to further extend
the period for meeting and conferring, Merck may then file a Motion to Compel the allegedly
deficient discovery information. Any such filing shall be via ECF, with a courtesy copy via
email to plaintiff’s attorney of record and via email to the PEC’s designee at
GardasilPFS@lanierlawfirm.com. Any response to such motion shall be filed and served within
ten (10) days following the date of service. Any reply, if necessary, shall be filed within five (5)
days following the date of service of the opposition. The Parties agree that in the event that
plaintiff has failed to provide a substantially complete PFS – Part I, Merck may seek, as part of its
Motion to Compel, and the Court may grant, at its discretion, a dismissal of the case without
prejudice. If a plaintiff fails to timely respond to Merck’s Motion to Compel as required by this
Case 3:22-md-03036-KDB Document 78 Filed 03/10/23 Page 9 of 42

10
paragraph, absent agreement by the Parties, any request to dismiss will be deemed uncontested
and the plaintiff’s case will be dismissed without prejudice.
2. Non-Compliance with PFS – Part II, PFS – Part III, and PFS – Part IV
Requirements
If Merck has not received from the plaintiff or the plaintiff’s representative a substantially
complete PFS – Part II fulfilling the requirements of Section II.A.2.b, a PFS – Part III fulfilling
the requirements of Section II.A.2.c, or a PFS – Part IV fulfilling the requirements of Section
II,A.2.d of this PFSO by the due date set forth in Section II.B.1 – II.B.2 of this PFSO, or if Merck
receives a PFS, or a Part of a PFS, that contains deficient responses, Merck will send a Notice of
Overdue or Deficient Discovery (“Deficiency Notice”) to that plaintiff’s counsel of record using
the email address(es) identified on the individual case docket in the U.S. District Court for the
Western District of North Carolina’s ECF system. A courtesy copy of the email shall be sent via
email to the PEC’s designee at GardasilPFS@lanierlawfirm.com. The Deficiency Notice will
identify with specificity the overdue discovery or the deficiency(ies) and/or failure(s) identified in
the PFS. Such Deficiency Notice shall also state that, unless the plaintiff complies with the Court’s
discovery orders, the case may be subject to dismissal. Within thirty (30) days of Merck’s
transmittal to a plaintiff’s counsel of a Deficiency Notice, plaintiff’s counsel shall, if plaintiff
chooses to do so, initiate and participate in a meet and confer with Merck’s counsel on the
substance of the notice. This requirement, whether fulfilled or not, does not affect or toll the
deadlines set forth below.
At any time following the expiration of the thirty (30) day period after plaintiff
received the Deficiency Notice, absent agreement of the Parties to further extend the period
for meeting and conferring, Merck may file a Motion to Compel if the individual plaintiff has
(i) failed to cure the stated deficiency(ies) (ii) failed to assert objection to same; (iii) failed to
Case 3:22-md-03036-KDB Document 78 Filed 03/10/23 Page 10 of 42

11
participate in the meet and confer process; or (iv) otherwise fail to provide responses
(including the requested documents and/or signatures). Any such filing shall be via ECF, with
a courtesy copy via email to plaintiff’s attorney of record and via email to the PEC’s designee
at GardasilPFS@lanierlawfirm.com. The plaintiff shall have fourteen (14) days from the date of
Merck’s motion to file a response. Thereafter, Merck shall have seven (7) days to file a reply.
The Parties agree that in the event that plaintiff has failed to provide a substantially complete PFS
– Part II, III, or IV (as applicable), Merck may seek, as part of its Motion to Compel and the Court
may grant, at its discretion, a dismissal of the case without prejudice. If a plaintiff fails to timely
respond to Merck’s Motion to Compel as required by this paragraph, absent agreement by the
Parties, any request to dismiss will be deemed uncontested and the plaintiff’s case will be
dismissed without prejudice.
3. Notice to the Court
All pending motions to dismiss and any PFS deficiency issues that remain outstanding for
more than sixty (60) days after the PFS was originally due pursuant Section II.B.1 – II.B.2, shall
be identified for the Court in the Parties’ Joint Status Report – due one week before the MDL
conference.
4. Procedure Relating to Orders of Dismissal
If the Court enters an Order of Dismissal Without Prejudice due to a non-compliant fact
sheet or authorizations, any motion to vacate the Order of Dismissal Without Prejudice must be
filed within thirty (30) days. Where a plaintiff files a motion to vacate for good cause, Merck may
file its opposition, if any, within fourteen (14) days, and the plaintiff’s reply, if any, is due within
seven (7) days of Merck’s opposition.
Case 3:22-md-03036-KDB Document 78 Filed 03/10/23 Page 11 of 42

12
If a plaintiff fails to move to vacate the dismissal within thirty (30) days, the Order will be
converted into an Order of Dismissal with Prejudice.
E. Failure to File Claim(s) in Vaccine Court
If a plaintiff’s response to Section II of his/her/their PFS – Part I and/or Merck’s attempted
collection of his/her/their Vaccine Court file indicates that he/she/they never filed a claim in
Vaccine Court related to his/her/their alleged Gardasil injuries claimed in their federal lawsuit,
Merck may move to dismiss that plaintiff’s claim. This provision does not waive Merck’s right to
later challenge whether a plaintiff timely filed a claim in Vaccine Court, whether a plaintiff
properly exhausted a claim in Vaccine Court, and/or other aspects of a plaintiff’s compliance with
the National Childhood Vaccine Injury Act, 42 U.S.C. §§ 300a-1 – 300aa-34.
F. Cost Sharing and Availability of Records Collected Pursuant to Authorizations
Merck shall ensure that its outside medical records collection vendor, LMI, makes
available to the plaintiff’s counsel via a secure web portal maintained by the vendor any and all
records collected by or on behalf of Merck pursuant to any authorization provided in accordance
with this PFSO. LMI will charge an individual plaintiff’s counsel a one-time fee of $30 per
provider for any records that the individual plaintiff’s counsel wishes to view and/or download.
LMI shall have the right to contact Health Care Providers and/or records custodian(s), but
only as necessary to follow up on medical record collection, copying, or production.
G. Documents Obtained Designated As Confidential.
Any records obtained pursuant to an authorization provided by any plaintiff pursuant to
this PFSO shall be deemed confidential under the terms of the Stipulated Protective Order (Doc.
No. 70) entered in this MDL.
Case 3:22-md-03036-KDB Document 78 Filed 03/10/23 Page 12 of 42

SO ORDERED.

Signed: March 9, 2023

atk} Coeef

% anh

Robert J. Conrad, Jr.
United States District Judge

13
Case 3:22-md-03036-KDB Document 78 _ Filed 03/10/23 Page 13 of 42

14
EXHIBIT A – PLAINTIFF FACT SHEETS ORDER
UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF NORTH CAROLINA
CHARLOTTE DIVISION
3:22-md-03036-RJC
IN RE: GARDASIL PRODUCTS LIABILITY
LITIGATION
)
)
)
)
)
)
)
MDL No. 3036
THIS DOCUMENT RELATES TO
ALL CASES
)
)
PLAINTIFF FACT SHEET
Each plaintiff who alleges personal injury as a result of receiving a Gardasil vaccination
and who has filed a lawsuit in the above-captioned matter (this “litigation”) must complete a
Plaintiff Fact Sheet (“PFS”), consisting of four (4) parts. Parts I, II, and III are to be completed by
or on behalf of all Plaintiffs. Part IV is to be completed in those cases selected for individual case
work up or which have been selected as part of the bellwether process.
If the PFS is completed by someone serving in a representative capacity, the representative
should answer the PFS as completely as possible. Those questions using the term “Plaintiff” or
“you” refer to the person who received Gardasil. If the individual is deceased, the representative
should respond as of the time immediately before his/her/their death, unless a different time period
is specified.
Each question below must be answered truthfully and completely to the best of Plaintiff’s
knowledge, information, and belief. Plaintiff has an obligation to provide information that is
available to Plaintiff or under the Plaintiff’s control (including medical records collected on
Plaintiff’s behalf) and cannot limit the answers simply to what is within the Plaintiff’s own
knowledge.
In completing this PFS, please use the following definitions: (1) The term “Gardasil”
includes Gardasil® and Gardasil®9; (2) “you” refers to the person who received Gardasil, unless
otherwise specified; (3) “Health Care Provider” means any hospital, clinic, medical center,
physician’s office, urgent care center, infirmary, laboratory, or other facility that provides medical
care, with the exception of mental health care, and any pharmacy, physical therapist, rehabilitation
specialist, physician, osteopath, homeopath, chiropractor, nurse or nurse practitioner, or any other
Case 3:22-md-03036-KDB Document 78 Filed 03/10/23 Page 14 of 42

15
persons or entities involved in the, care and/or treatment of you; (4) “Mental Health Care
Provider” means any professional (including physicians, therapists, social workers, and
counselors) whose practice primarily involves the diagnosis of mental health conditions and/or the
treatment of mental health conditions; (5) “Mental Health Records” means the records of any
Mental Health Care Provider, (6) “social media” should include but not be limited to Facebook,
Myspace, Twitter, Tumblr, Pinterest, Instagram, LinkedIn, YouTube, Flickr, Snapchat, TikTok,
Google, and BeReal; and (7) “document” means any writing or record of any type in your
possession or the possession of your attorney, including, but not limited to, written documents,
electronic documents, e-mails, text message, social media posts, cassettes, videotapes, DVDs,
photographs, medical records, charts, health or activity data or information tracked by a device,
application, or phone, computer discs, tapes, or COs, x-rays, drawings, graphs, non-identical
copies, and other data from which information can be obtained and translated, if necessary, through
electronic devices into a reasonably usable form. Plaintiff may attach as many sheets of paper
as necessary to fully answer the questions in this PFS. When attaching additional sheets,
clearly label what question the answer pertains to.
If a response provided in this Plaintiff Fact Sheet is discovered to be incomplete or
inaccurate, the response must be updated promptly.
Information provided will only be used for purposes related to this litigation and may be
disclosed only as permitted by the Protective Order in this litigation. This Fact Sheet is completed
pursuant to the Federal Rules of Civil Procedure governing discovery.
Case 3:22-md-03036-KDB Document 78 Filed 03/10/23 Page 15 of 42

16
UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF NORTH CAROLINA
CHARLOTTE DIVISION
3:22-md-03036-RJC
IN RE: GARDASIL PRODUCTS LIABILITY
LITIGATION
)
)
)
)
)
)
)
MDL No. 3036
THIS DOCUMENT RELATES TO
ALL CASES
)
)
PLAINTIFF FACT SHEET – PART I
I. CASE INFORMATION
A. State the following for the civil action that you have filed against Merck:
1. Case name/caption:
2. Docket/case number:
3. Court in which the case was originally filed:
B. Provide the indicated information for the attorney/firm representing you:
1. Name of principal attorney:
2. Firm Name:
3. Firm Address:
4. Firm Telephone:
5. E-mail address:
C. If you are completing this questionnaire on behalf of someone else (e g., a minor,
deceased, or an incapacitated person), complete the following:
1. Your name:
2 Your current address:
3. Relationship to the person:
4. If you were appointed by a court, state the Court and Date of Appointment:
5. If you represent a decedent’s estate, state the place and date of the decedent’s death:
Case 3:22-md-03036-KDB Document 78 Filed 03/10/23 Page 16 of 42

17
II. VACCINE COURT CASE INFORMATION
1. Have you filed a petition in Vaccine Court related to your Gardasil vaccination?
❏ Yes ❏ No
2. Please provide the following information regarding that petition:
a. Case name/caption:
b. Docket/case number:
c. Date Vaccine Court petition filed:
d. Date you filed an Election under Section 21 of the Vaccine Act:
III. SELECT REQUESTS FOR PRODUCTION OF DOCUMENTS
These initial document requests are made pursuant to Federal Rule of Civil Procedure 34.
Please check “Yes” or “No” as appropriate below to indicate whether any of the documents
described below are in your possession, custody, or control. If, “yes,” produce a copy of all the
documents in the manner set forth in ESI Order that is entered in this litigation.
Ref. No. Category/Description Yes No
1. Plaintiff’s medical records (including Mental Health Records)
obtained from any source. This request does not seek Plaintiff’s
Mental Health Records, unless (a) mental health records were
submitted in Plaintiff’s Vaccine Court proceeding, (b) Plaintiff is
making, or made in Vaccine Court, a claim for mental or psychological
injury (excluding a claim solely based on pain and suffering, emotional
distress, and/or mental anguish), (c) Plaintiff is claiming, or claimed in
Vaccine Court, that she/he/they have POTS, orthostatic intolerance,
brain fog, chronic fatigue syndrome, hypotension, hallucinations,
severe insomnia, excessive sleep (more than 15 hours per day), non-
epileptic seizures, movement disorder, or functional neurologic
disorder (FND), (d) Counsel for Plaintiff and Counsel for Merck agree
that the Mental Health Records of the Plaintiff are discoverable or (e)
the Court so orders.
❏ ❏
2. Prescription records for any medication taken by Plaintiff obtained
from any source ❏ ❏
3. Any documents or filings made on your behalf in Vaccine Court,
except that attorney billing records submitted to the Vaccine Court
may be excluded. Plaintiff identifies the following Vaccine Court
docket entries as containing attorney billing records:
 [Docket No. and name of filing]

If, pursuant to The Third Pretrial Order (Docket #58), Plaintiff asserts
that the “Vaccine Court file contains expert reports, opinions, or other
❏ ❏
Case 3:22-md-03036-KDB Document 78 Filed 03/10/23 Page 17 of 42

18
Ref. No. Category/Description Yes No
documentation from experts that Plaintiffs will retain ‘in anticipation
of litigation or to prepare for trial and who [are] not expected to be
called as [] witness[es]’ pursuant to Federal Rule of Civil Procedure
26(b)(4)(D),” identify by Vaccine Court docket number the specific
expert reports, opinions, or other documentation over which Plaintiff
makes such an assertion:
 [Docket No. and name of filing]

Those docket entries will be sequestered from the production by LMI
and not made available to Merck unless the Court denies Plaintiff’s
motion made pursuant to and under the terms of Third Pretrial Order,
Section 7.
IV. SELECT AUTHORIZATIONS
Please complete and execute the select authorizations identified below. Please note that
some authorizations must be notarized. The authorizations are attached hereto as exhibits.
1. Exhibit 1 is an authorization for the release of Plaintiff’s Vaccine Court file. Plaintiff must
also attach to this authorization copy of a government-issued ID (e.g., a driver’s license or
U.S. passport). Any docket entries specifically identified in the above table related to
Category/Description No. 3 will be screened from any production of the Vaccine Court file
prior to Merck receiving a copy.
2. Exhibit 2 contains proprietary authorizations required by certain providers. Please
complete and execute any of those authorizations that pertain to Plaintiff. A listing of the
authorizations is included on the cover page of Exhibit 2 and may be updated as the parties
learn of additional providers who require a proprietary authorization and/or an existing
authorization is updated by the provider.
3. Exhibit 3 is a blank HIPAA-compliant authorization. Please provide a signed
authorization for each Health Care Provider, Mental Health Care Provider (if applicable),
pharmacy, hospital, or other facility referenced in Plaintiff’s PFS or in Plaintiff’s Vaccine
Court file. With Part I, authorizations should be provided for each Health Care Provider,
Mental Health Care Provider (if applicable), pharmacy, hospital, or other facility identified
in Vaccine Court or otherwise known to Plaintiff. If additional Health Care Providers,
Mental Health Care Providers (if applicable), pharmacies, hospitals or other facilities are
identified as Plaintiff completes or supplements Part II, authorizations for those
persons/entities should be provided when Part II is submitted and/or supplemented. Each
separate authorization provided by Plaintiff’s Counsel must be specific to the Health Care
Provider, Mental Health Care Provider (if applicable), pharmacy, hospital, or other facility.
The date range for records collection shall be from five years prior to the date Plaintiff
received Plaintiff’s first dose of Gardasil through the present. Do not check the box on the
Case 3:22-md-03036-KDB Document 78 Filed 03/10/23 Page 18 of 42

19
first page of the authorization regarding mental health or other psychiatric records if (a)
mental health records were submitted in Plaintiff’s Vaccine Court proceeding, (b) Plaintiff
is making, or made in Vaccine Court, a claim for mental or psychological injury (excluding
a claim solely based on pain and suffering), (c) Plaintiff is claiming, or claimed in Vaccine
Court, that she/he/they have POTS, orthostatic intolerance, brain fog, chronic fatigue
syndrome, hypotension, hallucinations, severe insomnia, excessive sleep (more than 15
hours per day), non-epileptic seizures, movement disorder, or functional neurologic
disorder (FND), (d) Counsel for Plaintiff and Counsel for Merck agree that the Mental
Health Records of the Plaintiff are discoverable or (e) the Court so orders.
Case 3:22-md-03036-KDB Document 78 Filed 03/10/23 Page 19 of 42

20
Submitted by:
[Plaintiff’s Counsel’s Signature Block]
Case 3:22-md-03036-KDB Document 78 Filed 03/10/23 Page 20 of 42

21
UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF NORTH CAROLINA
CHARLOTTE DIVISION
3:22-md-03036-RJC
IN RE: GARDASIL PRODUCTS LIABILITY
LITIGATION
)
)
)
)
)
)
)
MDL No. 3036
THIS DOCUMENT RELATES TO
ALL CASES
)
)
PLAINTIFF FACT SHEET – PART II
Case name/caption:
Docket/case number:
I. CLAIM INFORMATION FOR INDIVIDUAL WHO RECEIVED GARDASIL
A. Background Information
1. Name:
2. Have you ever used any other names, and, if so, what and when?
3. Last four digits of your Social Security Number:
4. Date and Place of Birth:
5. Sex: ❏ Male ❏ Female ❏______________
6. Medicare Number, if applicable:
7. Are you or have you ever been married? ❏Yes ❏ No
If “yes,” please provide the following information for your current and any former
spouses:
Name Date of
Marriage and
Issuing State
Date Range of
Any Periods of
Separation
Date Marriage
Was
Reason for
Termination
(e.g., Death,
Case 3:22-md-03036-KDB Document 78 Filed 03/10/23 Page 21 of 42

22
Terminated, if
Applicable
Divorce), if
Applicable
8. Do you have children? ❏Yes ❏ No
If “yes” and you claim that Gardasil affected your gynecological health or your fertility,
please state the number of children you have and the year of his/her/their birth(s):
B. Gardasil Vaccination(s)
1. Please provide the information in the following chart:
Date of
Each
Gardasil
Vaccination
Lot
Number
Name and Address of
Health Care Provider
Who Recommended the
Gardasil Vaccination
Name and Address
of the Person who
Administered the
Vaccination
Location of
the
Vaccination
(e.g., left
arm)
2. Did anyone attend any medical appointments with you where you were counseled about
Gardasil? ❏ Yes ❏ No ❏ Don’t Recall
If “yes,” please identify the individual(s) who attended any appointments with you
when you were counseled about Gardasil, which appointment(s) he/she/they attended,
and his/her/their relationship to you:
3. Did anyone attend any medical appointments with you when you received Gardasil?
❏ Yes ❏ No ❏ Don’t Recall
If “yes,” please identify the individual(s) who attended any appointments with you
when you received Gardasil, which appointment(s) he/she/they attended, and
his/her/their relationship to you:
Case 3:22-md-03036-KDB Document 78 Filed 03/10/23 Page 22 of 42

23
4. Did you or anyone on your behalf ever decline a vaccination with Gardasil that was
recommended by a Heath Care Provider?
❏ Yes ❏ No ❏ Don’t Recall
If “yes,” please state who declined the vaccination, when they declined the vaccination
(an approximate or relative date is acceptable if the date is unknown), and the reasons
it was declined to your knowledge:
C. Information Regarding Gardasil
1. Excluding advertisements, did you receive any information about Gardasil, including
but not limited to its risks, side effects, and effectiveness from your Health Care
Provider? ❏ Yes ❏ No ❏ Don’t Recall
If “yes,”
a. Identify the Health Care Provider who provided the information about Gardasil
with
you:
b. Please briefly describe the information
provided:
2. Excluding advertisements, did you have any discussions about Gardasil, including but
not limited to its risks, side effects, and effectiveness with your Health Care Provider?
❏ Yes ❏ No ❏ Don’t Recall
If “yes,”
a. Identify the Health Care Provider who discussed Gardasil with
you:
b. Please briefly describe the information provided or the discussion you
had:
Case 3:22-md-03036-KDB Document 78 Filed 03/10/23 Page 23 of 42

24
3. Prior to any vaccination with Gardasil, did you do any research about Gardasil?
❏ Yes ❏ No ❏ Don’t Recall
If “yes,” please describe what research you did and, to the best of your recollection,
what you found:
4. Prior to receiving any vaccination with Gardasil, did you see any advertising materials
relating to Gardasil, including but not limited to any televised or internet-based
advertising or materials? ❏ Yes ❏ No ❏ Don’t Recall
If “yes,” please describe and state when, approximately, you saw the
advertisement:
D. Injuries and Claims Related to Gardasil
1. Have you been diagnosed with or have you experienced any injury or illness as a result
of receiving the Gardasil vaccination? ❏ Yes ❏ No
If “yes,” identify the diagnosis or medical conditions(s) which you claim resulted from
receiving the Gardasil vaccine and complete the information requested in the following
chart. This question does NOT request information about claimed mental health
injuries, which is requested in a separate chart below.
Diagnosis or
Medical Condition
Experienced
Date of Onset
of First
Symptom(s)
or Approx.
Date, if Date
is Unknown
Symptoms
Experienced
Date of
Diagnosis,
if any (and
approx.
date if
date is
unknown)
Have Your
Symptoms
Resolved?
Information About
Health Care Provider(s)
Who Made Diagnosis
or Identified Medical
Condition
❏ Yes
❏ No
❏ Unknown
Name:
Address:
❏ Yes
❏ No
Name:
Case 3:22-md-03036-KDB Document 78 Filed 03/10/23 Page 24 of 42

25
Diagnosis or
Medical Condition
Experienced
Date of Onset
of First
Symptom(s)
or Approx.
Date, if Date
is Unknown
Symptoms
Experienced
Date of
Diagnosis,
if any (and
approx.
date if
date is
unknown)
Have Your
Symptoms
Resolved?
Information About
Health Care Provider(s)
Who Made Diagnosis
or Identified Medical
Condition
❏ Unknown Address:
❏ Yes
❏ No
❏ Unknown
Name:
Address:
❏ Yes
❏ No
❏ Unknown
Name:
Address:
2. Identify the symptoms which you claim are related to any of the above diagnoses and/or
conditions or that have resulted from receiving the Gardasil vaccine and complete the
information requested in the following chart. This question does NOT request
information about claimed mental health injuries, which is requested in a separate chart
below.
Symptom
Experienced
Date of Onset of
First Symptom(s)
or Approx. Date, if
Date is Unknown
Frequency and
Severity of
Symptom
Have Your
Symptoms
Resolved?
Information About
Health Care
Provider(s) Who
Treated Symptom
❏ Yes
❏ No
❏ Unknown
Name:
Address:
❏ Yes
❏ No
❏ Unknown
Name:
Address:
❏ Yes
❏ No
❏ Unknown
Name:
Address:
3. To the best of your knowledge, have any of your biological parents, siblings, children,
or grandparents been diagnosed with any of the conditions you have identified in
Section I.D.1.? ❏ Yes ❏ No ❏ Unknown ❏ Don’t Recall
If “yes,” for each condition, please identify the condition, the name of the family
member, his/her/their relationship to you, and the approximate dates during which the
Case 3:22-md-03036-KDB Document 78 Filed 03/10/23 Page 25 of 42

26
individual had the condition:
4. Identify the following information for the Health Care Provider(s) who has/have
examined or treated you in connection with the injuries and/or illnesses from Sections
I.D.1:
Health Care
Provider, Specialty
and Facility Name
Address and
Telephone Number
Date Range of
Treatment
(Approx.)
Alleged Medical
Condition Treated/
Examined
5. Has any Health Care Provider ever told you that any of your alleged injuries or medical
conditions related to or caused by Gardasil?
❏ Yes ❏ No ❏ Do Not Recall
If “yes,” please identify the Health Care Provider and state which of your alleged
injuries or medical conditions the provider told you were related to or caused by
Gardasil:
6. Do you allege that your vaccination with Gardasil caused you to be diagnosed with a
psychiatric and/or psychological condition(s) (other than pain and suffering, emotional
distress, and/or mental anguish) for which treatment was sought from a Health Care
Provider or Mental Health Care Provider? ❏ Yes ❏ No
If “yes,” complete the information requested in the chart below:
Diagnosis or
Psychiatric or
Psychological
Condition
Experienced
Date of Onset
of First
Symptom(s)
or Approx.
Date, if Date
is Unknown
Symptoms
Experienced
Date of
Diagnosis,
if any (and
approx.
date if
date is
unknown)
Have Your
Symptoms
Resolved?
Information About
Health Care Provider(s)
Who Made Diagnosis
or Identified Condition
❏ Yes
❏ No
Name:
Case 3:22-md-03036-KDB Document 78 Filed 03/10/23 Page 26 of 42

27
Diagnosis or
Psychiatric or
Psychological
Condition
Experienced
Date of Onset
of First
Symptom(s)
or Approx.
Date, if Date
is Unknown
Symptoms
Experienced
Date of
Diagnosis,
if any (and
approx.
date if
date is
unknown)
Have Your
Symptoms
Resolved?
Information About
Health Care Provider(s)
Who Made Diagnosis
or Identified Condition
❏ Unknown Address:
❏ Yes
❏ No
❏ Unknown
Name:
Address:
7. If you are responding “yes” to question I.D.6 above, has any Health Care Provider or
Mental Health Care Provider ever told you that any of your alleged injuries or medical
conditions related to or caused by Gardasil? ❏ Yes ❏ No ❏ Do Not Recall
If “yes,” please identify the Health Care Provider or Mental Health Care Provider and
state which of your alleged injuries or medical conditions the provider told you were
related to or caused by
Gardasil:
8. Has any Health Care Provider or Mental Health Care Provider ever told you that any
of your alleged injuries or medical conditions are not related to or caused by Gardasil
or that any of these injuries or medical conditions are related to or caused by something
other than Gardasil? ❏ Yes ❏ No ❏ Do Not Recall
If “yes,” please identify the Health Care Provider or Mental Health Care Provider,
describe what was said, and state which of your alleged injuries or medical conditions
the provider told you were not related to or caused by Gardasil or were related to or
caused by something other than
Gardasil:
9. Have you ever communicated with any Merck employee or agent relating to Gardasil?
❏ Yes ❏ No ❏ Do Not Recall
If “yes,” please state the form, date, and content of the communication(s)and provide
the name of the Merck employee(s) or agent(s) with whom you communicated:
Case 3:22-md-03036-KDB Document 78 Filed 03/10/23 Page 27 of 42

28
10. Are you making a claim for lost wages? ❏ Yes ❏ No
If “yes,” for what time period are you claiming lost wages:
11. Are you making a claim for lost earning capacity? ❏ Yes ❏ No
12. Provide the following information with respect to your employment history, for the
period beginning five (5) years prior to your first vaccination with Gardasil to the two
years after your claimed injuries resolved. If you are making a claim for lost wages or
earning capacity, you are required to provide salary/wage information:
Employer and
Employer’s
Address
Name of
Supervisor
Job Title/ Duties
Add Salary/Wage
information, if
required
Dates of
Employment
(Approx.)
Reason for
Leaving
13. Have you taken a medical leave(s) of absence from any job or educational institution?
❏ Yes ❏ No
If “yes,” identify each employer or educational institution you took leave from, and
state when and why you took leave:
14. Are you making a claim for medical expenses or other out-of-pocket expenses?
❏ Yes ❏ No
If “yes, please provide a description of the type of medical expenses or other out-of-
pocket expenses you are claiming and the date range during which the expenses were
incurred:
Case 3:22-md-03036-KDB Document 78 Filed 03/10/23 Page 28 of 42

29
E. Other Health Information
1. Have you experienced any allergic reaction, adverse reaction, or side effect that you
ever attributed to any vaccine (other than Gardasil) or any medications?
❏ Yes ❏ No ❏ Do Not Recall
If “yes,” please answer the following:
Product and
Date of
Vaccination or
Use of
Medication
Reaction or
Side Effect
Experienced
Date of Side
Effect
Treatment
Received
Health Care
Provider
Consulted
2. Have you ever declined to receive a vaccine for which you are eligible (other than
Gardasil, if applicable)? ❏ Yes ❏ No ❏ Do Not Recall
If “yes,” what vaccine, when, why, and, if applicable, identify the Health Care
Provider(s) recommended the vaccine:
3. For the period three (3) years prior to your vaccination with Gardasil to the present, in
response to Plaintiff’s alleged injuries and/or symptoms identified in I.D.1 and 2, have
you intentionally used a fitness or health device or application to track any information
related to your health, weight, heart rate, fitness, steps, or diet (e.g., Fitbit, Apple
Health, Google Fit, Oura Ring, Samsung Galaxy Watch, Garmin, Peloton, Nike
Training Club, Sworkit, FitON, Orange Theory Fitness, MyFitnessPal, Strava, Map My
Run)? ❏ Yes ❏ No
If “yes,” please answer the following:
Name of Device,
Application, or
Method of Tracking
Type of Data That is
Tracked (e.g., type
of exercise, calories
burned, steps taken)
Date of Purchase or
Download of Device
or Application
Date Range of Data
Presently Available
Case 3:22-md-03036-KDB Document 78 Filed 03/10/23 Page 29 of 42

30
4. Do you contend that injuries or illnesses you attribute to Gardasil have prevented you
from engaging in any activity or limited your ability to engage in any activity?
❏ Yes ❏ No
If “yes,” please describe and provide the timeframe during which your participation in
the activity was limited:
F. Additional Information
1. Identify each address at which you have resided, beginning five (5) years prior to your
first vaccination with Gardasil to the present, and list the approximate dates when you
started and stopped living at each one:
Address Approx. Date of Residence
From To
2. Provide the following information with respect to your educational history, beginning
with elementary school and continuing to include colleges, universities, graduate
schools, or vocational programs:
School/Institutional
Program and
Address
Degree or Certificate
Pursued or Awarded
Clubs and Activities
in Which You
Participated
Dates of Attendance
(Approx.)
Case 3:22-md-03036-KDB Document 78 Filed 03/10/23 Page 30 of 42

31
3. For the period three (3) years prior to your vaccination with Gardasil to two (2) year
after your claimed injury(ies) resolved, have you used any social media platforms,
internet “chat rooms,” social media groups, or other online media to post pictures,
content, text, comments, or any other information about Gardasil or your health,
vacations, exercise, sports, or recreational activities.
❏ Yes ❏ No ❏ Unknown/Don’t Remember
If “yes,” please answer the following for each such social media platform, internet “chat
room,” social media group, or other online media:
Name of Platform, Group, etc. Date Joined & End Date (if
applicable)
Username(s)
4. Beginning five (5) years prior to your first vaccination with Gardasil to the present,
have you been convicted of any felony or a crime involving dishonesty or false
statement? ❏ Yes ❏ No
If “yes,” please set forth the charge, the date of conviction or plea, the court and the
outcome:
5. Beginning five (5) years prior to your first vaccination with Gardasil to the present,
have you filed for bankruptcy? ❏ Yes ❏ No
If “yes,” please identify the court in which the bankruptcy proceeding was filed, the
case number, and the disposition:
6. Beginning five (5) years prior to your first vaccination with Gardasil to the present,
have you filed a lawsuit, other than in the present suit? ❏ Yes ❏ No
If “yes,” please provide the following for each lawsuit or claim:
a. Party you sued or made a claim against:
Case 3:22-md-03036-KDB Document 78 Filed 03/10/23 Page 31 of 42

32
b. Court in which suit was filed and case number:
c. Nature of the
suit:
d. Name, address, and firm representing
you:
7. Beginning five (5) years prior to your first vaccination with Gardasil to the present,
have you ever filed for worker’s compensation, social security, and/or state or federal
disability benefits or support services? ❏ Yes ❏ No
If “yes,” then as to each application, separately state:
a. Date (or year) of application:
b. Nature and time period of the claimed injury/disability:
c. The agency to which you submitted your application:
d. Resolution of claim (e.g., denied, granted):
8. Have you ever served in any branch of the U.S. Military? ❏ Yes ❏ No
If “yes,” please identify, please state the branch, dates of service, and type and
manner of discharge:
II. MEDICAL HISTORY
1. Other than any Health Care Providers identified above, identify each Health Care
Provider (including, but not limited to, primary care, pediatrics, emergency rooms,
hospitals, and diagnostic centers) from whom you have received inpatient or outpatient
care in the five (5) years preceding your first vaccination with Gardasil to the present,
with the exception of mental health care.
Name of Health
Care Provider/
Facility, and
Specialty
Address Date or Date Range
of Care/Treatment
(Approx.)
Reason for
Care/Treatment
Case 3:22-md-03036-KDB Document 78 Filed 03/10/23 Page 32 of 42

33
Name of Health
Care Provider/
Facility, and
Specialty
Address Date or Date Range
of Care/Treatment
(Approx.)
Reason for
Care/Treatment
2. If (a) mental health records were submitted in your Vaccine Court proceeding, (b) you
are making, or made in Vaccine Court, a claim for mental or psychological injury
(excluding a claim solely based on pain and suffering, emotional distress, and/or mental
anguish), or (c) you are claiming, or claimed in Vaccine Court, that you have POTS,
orthostatic intolerance, brain fog, chronic fatigue syndrome, hypotension,
hallucinations, severe insomnia, excessive sleep (more than 15 hours per day), non-
epileptic seizures, movement disorder, or functional neurologic disorder (FND), then
answer the following questions:
a. Did you receive treatment for any mental health condition prior to your first
vaccination with Gardasil? ❏ Yes ❏ No ❏ Do Not Recall
If “no,” did any Health Care Provider recommend evaluation for a mental health
condition or recommend treatment for a mental health condition prior to your first
vaccination with Gardasil? ❏ Yes ❏ No ❏ Do Not Recall
If “yes” is checked in response to either question above, please identify the Health
Care Provider:
b. Have received treatment for any mental health condition after receiving your first
vaccination with Gardasil? ❏ Yes ❏ No ❏ Do Not Recall
If “no,” did any Health Care Provider recommend evaluation for a mental health
condition or recommend treatment for a mental health condition after your first
vaccination with Gardasil? ❏ Yes ❏ No ❏ Do Not Recall
If “yes” is checked in response to either question above, please identify the Health
Care
Provider:
3. Identify the following for each pharmacy, drugstore, and/or other supplier (including
mail order and internet pharmacies) from which you obtained any prescription
medication in the five (5) years preceding your first vaccination with Gardasil to the
present:
Case 3:22-md-03036-KDB Document 78 Filed 03/10/23 Page 33 of 42

34
Name of
Pharmacy/Drugstore/
Supplier
Address of
Pharmacy/Drugstore/
Supplier
Approximate Dates of Use
4. Have you ever smoked, vaped, or used smokeless tobacco? ❏ Yes ❏ No
If “yes,” provide the following information:
a. Type(s) of product:
b. Years of use:
c. Amount consumed per day, on average:
5. Have you ever used illegal drugs? ❏Yes ❏ No
If “yes,” please provide the following:
a. Type(s) of product:
b. Years of use:
c. Amount consumed per day, on average:
6. Have you ever used CBD or marijuana? ❏Yes ❏ No
If “yes,” please provide the following:
a. Type(s) of product:
b. Years of use:
c. Amount consumed per day, on average:
7. Have you experienced or been diagnosed with any of the following?
❏Yes ❏ No ❏ Unknown/Don’t Remember
If “yes,” check the condition you have experienced and provide the requested details.
❏ Joint Hypermobility
Date of diagnosis:
Diagnosing and Treating Health Care Provider(s):
Treatment received:
Do any family members carry this diagnosis? ❏Yes ❏ No ❏Unsure
Case 3:22-md-03036-KDB Document 78 Filed 03/10/23 Page 34 of 42

35
❏ Scoliosis
Date of diagnosis:
Diagnosing and Treating Health Care Provider(s):
Treatment received:
Do any family members carry this diagnosis? ❏Yes ❏ No ❏Unsure
❏ Ehlers Danlos Syndrome
Date of diagnosis:
Diagnosing and Treating Health Care Provider(s):
Treatment received:
Do any family members carry this diagnosis? ❏Yes ❏ No ❏Unsure
❏ Celiac Disease
Date of diagnosis:
Diagnosing and Treating Health Care Provider(s):
Treatment received:
Do any family members carry this diagnosis? ❏Yes ❏ No ❏Unsure
❏ Crohn’s Disease or Ulcerative Colitis
Date of diagnosis:
Diagnosing and Treating Health Care Provider(s):
Treatment received:
Do any family members carry this diagnosis? ❏Yes ❏ No ❏Unsure
❏ Traumatic Injury (i.e., injury from a car accident, head injury, concussion, fall,
etc.)
Date of injury:
Diagnosing and Treating Health Care Provider(s):
Treatment received:
❏ Post-Traumatic Stress Disorder
Date of injury:
Diagnosing and Treating Health Care Provider(s):
Treatment received:
❏ Viruses (e.g., COVID-19, Epstein-Barr, Mononucleosis)
Date of diagnosis:
Diagnosing and Treating Health Care Provider(s):
Treatment received:
8. Have you ever been diagnosed with cancer?
❏Yes ❏ No ❏Unsure
If “yes,” please provide the following:
Type of cancer:
Case 3:22-md-03036-KDB Document 78 Filed 03/10/23 Page 35 of 42

36
Date of diagnosis:
Diagnosing and Treating Health Care Provider(s):
9. Provide the following information regarding each insurer or other entity (including
Medicaid or any similar federal or state program) that has provided you with health
care coverage or other benefits in the five (5) years preceding your Gardasil vaccination
to the present:
Insurer Name and
Address
Policy Number Dates of Coverage
(Approx.)
Policy Holder
III. FACT WITNESSES
Other than your Health Care providers, please identify all persons who you believe
possess information concerning your alleged injury(ies) and/or other facts related to
your claims.
Name Address Relationship to You Subject Matter of
the Person’s
Information
IV. DECLARATION
Pursuant to 28 U.S.C. § 1746, I declare under penalty of perjury that all of the information
provided in Sections I – III of this Plaintiff Fact Sheet – Part II is true and correct to the best of my
knowledge, information, and belief.
Date: Signature:
Case 3:22-md-03036-KDB Document 78 Filed 03/10/23 Page 36 of 42

37
V. ADDITIONAL AUTHORIZATIONS
Please complete and execute the authorizations identified below. Please note that some
authorizations must be notarized. The authorizations are attached hereto as exhibits.
1. Exhibit A is an authorization for the release of educational records. Each separate
authorization provided by Plaintiff’s Counsel must be specific to the educational institution
identified in Plaintiff’s PFS. Please provide a signed authorization for each educational
institution identified in Plaintiff’s PFS.
2. Exhibit B is an authorization for the release of employment records. Each separate
authorization provided by Plaintiff’s Counsel must be specific to the employer identified
in Plaintiff’s PFS. Please provide a signed authorization for each employer identified in
Plaintiff’s PFS.
3. Exhibit C is an authorization for the release of insurance records. Each separate
authorization provided by Plaintiff’s Counsel must be specific to the insurance carrier
identified in Plaintiff’s PFS. Please provide a signed authorization for each insurer
identified in Plaintiff’s PFS.
Case 3:22-md-03036-KDB Document 78 Filed 03/10/23 Page 37 of 42

38
UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF NORTH CAROLINA
CHARLOTTE DIVISION
3:22-md-03036-RJC
IN RE: GARDASIL PRODUCTS LIABILITY
LITIGATION
)
)
)
)
)
)
)
MDL No. 3036
THIS DOCUMENT RELATES TO
ALL CASES
)
)
PLAINTIFF FACT SHEET – PART III
Case name/caption:
Docket/case number:
REQUESTS FOR PRODUCTION OF DOCUMENTS
These document requests are made pursuant to Federal Rule of Civil Procedure 34. Please
check “Yes” or “No” as appropriate below to indicate whether any of the documents described
below are in Plaintiff’s possession, custody, or control. If, “yes,” produce a copy of all the
documents in the manner set forth in ESI Order (____).
In accordance with Rule 34, if any documents are withheld by claiming that it is privileged
or otherwise protected, please make any such claim expressly and describe the nature of the
information or documents withheld in a manner that enables other parties to assess the applicability
of the claimed privilege or protection.
Ref. No. Category/Description Yes No
1. Communications to, from, or with any Health Care Provider,
pertaining to Gardasil, your health, or any injuries caused by
Gardasil.
❏ ❏
2. Any instructions or information about Gardasil that you received
before you received any vaccination with Gardasil. This includes
product warnings, package inserts, Vaccine Information Statement,
handouts, or other materials provided or made available to Plaintiff
concerning Gardasil.
❏ ❏
Case 3:22-md-03036-KDB Document 78 Filed 03/10/23 Page 38 of 42

39
Ref. No. Category/Description Yes No
3. Advertising material Plaintiff saw prior to receiving any vaccination
with Gardasil. ❏ ❏
4. Communications sent to or received from Merck, any Merck
employee, or any Merck agent relating to Plaintiff or Gardasil. ❏ ❏
5. Any other documents Plaintiff obtained from Merck related to
Gardasil, Plaintiff’s claims, or Plaintiff’s alleged injuries. ❏ ❏
6. Any documents evidencing, discussing, or related to any medical
leave of absence Plaintiff has taken from any job or educational
institution.
7. If Plaintiff is making a claim for medical expenses or lost out-of-
pocket expenses, copies of all bills from any Health Care Provider,
pharmacy, vendor, or other source for which Plaintiff is seeking
compensation.
❏ ❏
8. Documents Plaintiff has used to track or record any information
about Plaintiff’s health, weight, heart rate, fitness, steps, or diet for
the period three (3) years prior to Plaintiff’s vaccination with
Gardasil to the present.
❏ ❏
9. All data, information, or entries identified in response to I.E.3 of
the PFS – Part II that stores information about Plaintiff’s health,
weight, heart rate, fitness, steps, or diet in Plaintiff’s possession,
custody, or control.
❏ ❏
10. If Plaintiff was in school at the time of any Gardasil vaccination and
claims that Gardasil impacted his/her/their ability to attend school,
or impacted his/her/their achievement in school, Plaintiff’s records
from any school or educational institution Plaintiff has attended,
including but not limited to report cards, transcripts, educational
plans/accommodations, medical leave, enrollments, attendance
reports, and withdrawals for the period of five (5) years prior to
Plaintiff’s first vaccination with Gardasil to two (2) years after
Plaintiff’s symptoms resolved.
❏ ❏
11. If Plaintiff was in school at the time of any Gardasil vaccination and
claims that Gardasil impacted his/her/their ability to attend school,
or impacted his/her/their achievement in school, any
communications with any teacher, school employee,
school/educational institution (or any office therein) or testing
organizations (e.g., College Board) relating to Plaintiff during the
time frame indicated in question 10, including any educational
accommodations sought or granted, any absences from school,
Plaintiff’s performance in school, and Plaintiff’s ability to attend
school.
❏ ❏
Case 3:22-md-03036-KDB Document 78 Filed 03/10/23 Page 39 of 42

40
Ref. No. Category/Description Yes No
12. Documents relating to any claim for lost wages or reduced earning
capacity, including but not limited to W-2s, paychecks and pay
stubs for the five (5) years prior to Plaintiff’s first vaccination with
Gardasil to the present.
❏ ❏
13. For the period three (3) years prior to Plaintiff’s vaccination with
Gardasil to two (2) year after Plaintiff’s claimed injury(ies)
resolved, all pictures, content, text, comments, or any other
information about Gardasil or Plaintiff’s health, vacations, exercise,
sports, or recreational activities posted on any social media
platforms, internet “chat rooms”, social media groups, or other
online media.
❏ ❏
14. For the period from the date of Plaintiff’s vaccination with Gardasil
to two (2) years after Plaintiff’s claimed injury(ies) resolved, all
photographs or videos of Plaintiff (with or without other people)
that relate to Gardasil or Plaintiff’s health, vacations, exercise,
sports, or recreational activities.
❏ ❏
15. If the individual who was vaccinated with Gardasil is deceased, a
copy of the death certificate ❏ ❏
Submitted by:
[Plaintiff’s Counsel’s Signature Block]
Case 3:22-md-03036-KDB Document 78 Filed 03/10/23 Page 40 of 42

41
UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF NORTH CAROLINA
CHARLOTTE DIVISION
3:22-md-03036-RJC
IN RE: GARDASIL PRODUCTS LIABILITY
LITIGATION
)
)
)
)
)
)
)
MDL No. 3036
THIS DOCUMENT RELATES TO
ALL CASES
)
)
PLAINTIFF FACT SHEET – PART IV
Part IV only needs to be completed once the case is selected as a bellwether or
otherwise selected for case work up.
Case name/caption:
Docket/case number:
REQUESTS FOR PRODUCTION OF DOCUMENTS
These document requests are made pursuant to Federal Rule of Civil Procedure 34. Please
check “Yes” or “No” as appropriate below to indicate whether any of the documents described
below are in Plaintiff’s possession, custody, or control. If, “yes,” produce a copy of all the
documents in the manner set forth in ESI Order (____).
In accordance with Rule 34, if any documents are withheld by claiming that it is privileged
or otherwise protected, please make any such claim expressly and describe the nature of the
information or documents withheld in a manner that enables other parties to assess the applicability
of the claimed privilege or protection.
Ref. No. Category/Description Yes No
1. Any materials Plaintiff found, saw, or posted on to any website
(including any chat room or social media site) that Plaintiff visited at
any time seeking information regarding Gardasil or alleged injuries
attributed to Gardasil, including any chats, posts, or content Plaintiff
can access.
❏ ❏
Case 3:22-md-03036-KDB Document 78 Filed 03/10/23 Page 41 of 42

42
Ref. No. Category/Description Yes No
2. Any documents explaining any denial of life insurance benefits for
health-related reasons relating to Plaintiff. ❏ ❏
3. Not including the documents already produced, any documents or
records from or relating to any employer identified in response to
I.D.12 of the PFS – Part II, including but not limited to employment
applications, performance reviews, communications regarding any
employment accommodations sought or granted, any absences/sick
days, and any leave sought or taken by Plaintiff.
❏ ❏
4. Text messages and emails Plaintiff has sent or received about Gardasil,
the injuries Plaintiff claims are associated or caused by Gardasil, or
Plaintiff’s health.
❏ ❏
5. Diaries, calendars, or other writings or recordings made by Plaintiff
describing, discussing, explaining or referring to the injuries or
damages alleged by Plaintiff’s in this lawsuit or in Vaccine Court.
❏ ❏
6. Documents that Plaintiff reviewed, accessed, or possessed at any time
relating to Gardasil, including but not limited to product literature,
articles, emails, material from internet sites, video recordings, and
audio recording (including podcasts).
❏ ❏
7. All applications for health insurance, social security, worker’s
compensation, and/or any state or federal disability benefits or support
services that Plaintiff has made or that have been made on Plaintiff’s
behalf and all documents, records, and correspondence related to the
same.
❏ ❏
8. Any sworn or verified statements by Plaintiff, or Plaintiff’s parent, or
in Plaintiff’s possession, custody, or control, written or otherwise
recorded, concerning Gardasil, Plaintiff’s alleged injuries or Plaintiff’s
alleged damages.
❏ ❏
9. Any video or audio recordings where Plaintiff or a family member
discussed Gardasil or Plaintiff’s alleged injuries. ❏ ❏
Submitted by:
[Plaintiff’s Counsel’s Signature Block]
Case 3:22-md-03036-KDB Document 78 Filed 03/10/23 Page 42 of 42