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SUPERIOR COURT OF THE STATE OF CALIFORNIA
FOR THE COUNTY OF LOS ANGELES
IN RE: SOCIAL MEDIA CASES JCCP No. 5255
[Consolidated with JCCP No. 5256]
Case No. 22STCV21355
This Document Relates to:
[PROPOSED] PLAINTIFF FACT
Case Caption and Civil Action No.: SHEET
Full Name of Plaintiff (First, Middle, and
Last):
PLAINTIFF FACT SHEET
Please provide the following information for each plaintiff who claims that use of
Defendants’ platforms (Facebook, Instagram, Snapchat, TikTok, and YouTube) caused them (or
a person who died) injury as alleged in the above-captioned litigation. In completing this
Plaintiff Fact Sheet, you are under oath and must provide information that is true and correct to
the best of your knowledge. If you cannot recall all of the details requested, provide as much
information as you can (including approximate times and dates), including by review of
documents or materials in your or your attorneys’ custody or possession. This Plaintiff Fact
Sheet is an electronic version that expands to accommodate as much information as is necessary
to fully answer any of these questions, including by adding rows or columns to tables. You must
fill out the applicable appendix for each entity you have named as a Defendant. Please do not
leave any questions unanswered or blank.
You may and should consult with your attorney if you have any questions regarding the
completion of this form.
This Plaintiff Fact Sheet constitutes discovery responses subject to California Code of
Civil Procedure. This Plaintiff Fact Sheet and the information provided herein will be used only
for this litigation and is designated Confidential under the Protective Order. Plaintiffs do not
concede the relevance or admissibility of any of the information herein.
I. CASE INFORMATION
A. Name of the court in which the complaint was initially filed:
B. Case number in court in which complaint was originally filed:
C. Are you alleging in this case that you began using Facebook, Instagram,
Snapchat, TikTok, or YouTube when you were under thirteen years old?
[Click here to select your answer.]
**IMPORTANT**
DEFINITION OF “RELEVANT TIME PERIOD”
If your answer to question I.C. is “YES,” then the phrase
“Relevant Time Period” throughout this Plaintiff Fact Sheet
means from the time you turned SEVEN (7) years old to today.
If your answer to question I.C. is “NO,” then the phrase
“Relevant Time Period” throughout this Plaintiff Fact Sheet
means from the time you turned TEN (10) years old to today.
II. REPRESENTATIVE CAPACITY
If you are completing this Plaintiff Fact Sheet in a representative capacity (meaning on
behalf of a minor, someone who died, or a person who lacks capacity to complete it on
their own), respond on your own behalf only to the questions in this section. For the
remainder of the questions in this Fact Sheet, respond on behalf of the person who used
and was allegedly harmed by Defendants’ platforms, and assume that “you” refers to that
person. Please complete the following:
A. Name of individual completing this Fact Sheet:
B. Your current address:
C. What is your relationship to the person upon whose behalf you are completing
this Fact Sheet (e.g., parent, guardian, Estate Administrator)?
D. If you represent the estate of someone who died or serve as a successor-in-
interest, do you contend that use of Defendants’ platforms caused or contributed
to that person’s death?
[Click here to select your answer.]
E. Have you ever used any Defendant’s reporting features to report a negative
experience on that platform by the person on whose behalf you are completing
this Fact Sheet?
[Click here to select your answer.]
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1. If yes, please provide the following information:
Platform Involved (select one) How Many Times Did You Report
☐ Facebook
☐ Instagram
☐ Snapchat
☐ TikTok
☐ YouTube
III. PERSONAL INFORMATION
If you are completing this questionnaire in a representative capacity, the remainder of this
Fact Sheet should be completed on behalf of the represented individual who used
Defendants’ platforms. For representatives who are completing this Fact Sheet for
someone else, assume that “you” means the person who used and was allegedly harmed
by Defendants’ platforms.
A. Legal name:
B. Other names by which you have been known (including maiden names, if any):
C. Gender:
D. Social Security Number:
E. Date of birth: [Click or tap to enter a date.]
F. List all addresses where you lived for the last six (6) years. Include addresses
where you lived while at school, to the extent that you lived away from home for
school (e.g., boarding school or college). For each address, provide the
approximate periods you resided at each location:
Address Date Range of Residence
G. Household Information. Provide the name of any adult who has resided in the
same household as you for all the addresses you listed above in III.F.
Name Relationship to You Date Range the Individual Resided with You
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H. Educational History.
Provide the following information about your education for the Relevant Time
Period:
1. Primary and Secondary Schools Attended.
Name of School or Educational Grade(s)
City and State Dates of Attendance
Institution Completed
2. Post-Secondary Schools (e.g., Colleges, Trade Schools), or Other
Educational Institutions, Attended.
Name of School or Degree Major or
City and State Dates of Attendance Awarded
Educational Institution Primary Field
3. During the Relevant Time Period, have you ever been subject to
disciplinary action by any school or other educational institution?
[Click here to select your answer.]
(a) If yes, provide the following information:
Name of School
Dates of Type of Disciplinary Action
or Educational Grounds for Disciplinary Action
Disciplinary Action (select all that apply)
Institution
☐ Detention
☐ In-School Suspension
☐ Out-of-School Suspension
☐ Expulsion
I. Previous Interactions with Law Enforcement and the Legal System.
1. Have you ever been convicted of a crime as an adult?felony?
[Click here to select your answer.]
(a) If yes, please answer all of the following questions that apply to
you for each instance:
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Charge(s)
Court Where Action Was/Is Pending
Date of Conviction [Click or tap to enter a date.]
2. Have you ever been determined to have committed an offense in a juvenile
delinquency proceeding? Note: You are only required to answer this
question with “Yes” if any records from a conviction or a juvenile
delinquency proceeding involving you remain unsealed.
[Click here to select your answer.]
3. To the best of your knowledge, has any individual who regularly cared for
you ever been convicted of a crime related to your care or been the subject
of an investigation by any Department of Child and Family Services
related to your care?
IV. [Click here to select your answer.]ABUSE / VIOLENCE / DISCRIMINATION
A. Have you ever been the victim of discrimination or harassment on the basis of
race/ethnicity, national origin, sex, sexual orientation, gender identity, transgender
status, or disability?
[Click here to select your answer.]
1. If yes, please select one of the following options to indicate when the
discrimination or harassment occurred:
[Click here to select your answer.]
B. Have you ever been the victim of bullying, cyberbullying, verbal abuse, or
emotional neglect?
[Click here to select your answer.]
1. If yes, please select one of the following options to indicate when the
bullying, cyberbullying, verbal abuse, or emotional neglect occurred:
[Click here to select your answer.]
C. Have you ever been the victim of physical abuse, physical assault, or physical
neglect?
[Click here to select your answer.]
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1. If yes, please select one of the following options to indicate when the
physical abuse, physical assault, or physical neglect occurred:
[Click here to select your answer.]
D. Have you ever been the victim of rape, sexual abuse, or sexual assault?
[Click here to select your answer.]
1. If yes, please select one of the following options to indicate when the rape,
sexual abuse, or sexual assault occurred:
[Click here to select your answer.]
E. Have you ever experienced violence or threats of violence (e.g., a shooting, a
threatened shooting, or a bombing) in a school, place of worship, or other public
place?
[Click here to select your answer.]
1. If yes, please select one of the following options to indicate when the
violence or threats of violence occurred:
[Click here to select your answer.]
F. Have you ever been the victim of a crime against your person not listed above?
[Click here to select your answer.]
V. EMPLOYMENT AND MILITARY HISTORY
A. Complete the chart below detailing your current employment and all prior
employment from when you were fourteen years old through today. Please
include any part-time jobs.
Date Range of Was Your Reason for
Leaving Related to Medical,
Employment Occupation/
Employer City and State Physical, Psychiatric,
(Month/Year to Position/Title Psychological, or Emotional
Month/Year) Reasons?
B. Have you ever served in any branch of the military?
[Click here to select your answer.]
1. If yes, provide the following information:
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(a) Branch of service: __________________________
(b) Rank upon discharge: __________________________
(c) Type of discharge: __________________________
VI. MEDICAL BACKGROUND
A. You must complete and execute the attached authorization to release your
medical records and answer the following questions.
B. Identify each of the health care providers (including all doctors, psychiatrists,
dieticians, nutritionists, neuropsychologists, psychologists, therapists, licensed
clinical social workers, nurse practitioners, and physician assistants) whom you
saw on an out-patient basis about any chronic physical, mental, or
neurodevelopmental condition (defined as any condition that lasted for more than
three months) during the Relevant Time Period. If you saw multiple health care
providers within the same medical practice, you are not required to list each
doctor, nurse practitioner, or physician assistant you may have seen as part of
that group; rather, include the name of the health care provider you primarily
saw at the medical practice, and identify the medical specialties of all healthcare
providers you saw.
Name of Provider’s Address,
Dates as Condition/Reason
Medical Practice Specialty Phone Number, and
Patient for Consultation
or Provider Email
C. Identify every hospital, clinic, or facility where you were admitted as an in-
patient or presented for an emergency room visit for any physical, mental, or
neurodevelopmental condition or treatment/surgery during the Relevant Time
Period.
Dates of ER Visit or Name and Address Reason for
Hospital Admission of Facility Admission Treatment Received
and Discharge
D. List all prescription anti-depressants, anti-anxiety medications, anti-psychotic
medications, and other medications for the treatment of any mental health
problem that you took for three (3) months or more during the Relevant Time
Period:
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Prescribing Physician or
Pharmacy Used
Healthcare Provider
Medication Dates of Use (Name, Address, and Phone
(Name, Address, and Phone
Number)
Number)
[Click here to select or write
in a medication.]
E. Except for those pharmacies identified in your response to question VI.D, identify
every pharmacy that has dispensed medication to you during the Relevant Time
Period:
Address and
Name of Medication(s) Date Range You Used
Name of Pharmacy Phone
Dispensed Pharmacy
Number
VII. ALLEGED INJURIES, ILLNESSES, AND CONDITIONS
A. Identify the below-listedall physical and mental injuries, illnesses, or conditions
that you believe you have ever sufferedallege were caused or worsened by
Defendant’s social medial platforms.
Platform(s) to which you Deleted Cells
Injury, Illness, or If Not Ongoing, Date
Date Injury, Illness, attribute this injury, illness,
Condition (check all Injury, Illness, or
or Condition Began or condition, in part or in
that apply) Condition Ended
full (select all that apply)
☐ “Social media [Click or tap to [Click or tap to ☐ Facebook
addiction” enter a date.] enter a date.] ☐ Instagram
☐ Snapchat
☐ TikTok
☐ YouTube
☐ None
☐ Anxiety [Click or tap to [Click or tap to ☐ Facebook
enter a date.] enter a date.] ☐ Instagram
☐ Snapchat
☐ TikTok
☐ YouTube
☐ None
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☐ Depression [Click or tap to [Click or tap to ☐ Facebook
enter a date.] enter a date.] ☐ Instagram
☐ Snapchat
☐ TikTok
☐ YouTube
☐ None
☐ Body [Click or tap to [Click or tap to ☐ Facebook
dysmorphia enter a date.] enter a date.] ☐ Instagram
☐ Snapchat
☐ TikTok
☐ YouTube
☐ None
☐ Anorexia [Click or tap to [Click or tap to ☐ Facebook
enter a date.] enter a date.] ☐ Instagram
☐ Snapchat
☐ TikTok
☐ YouTube
☐ None
☐ Bulimia [Click or tap to [Click or tap to ☐ Facebook
enter a date.] enter a date.] ☐ Instagram
☐ Snapchat
☐ TikTok
☐ YouTube
☐ None
☐ Binge Eating [Click or tap to [Click or tap to ☐ Facebook
Disorder enter a date.] enter a date.] ☐ Instagram
☐ Snapchat
☐ TikTok
☐ YouTube
☐ None
☐ Other feeding [Click or tap to [Click or tap to ☐ Facebook
or eating disorder enter a date.] enter a date.] ☐ Instagram
(specify):
☐ Snapchat
☐ TikTok
☐ YouTube
☐ None
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☐ Sleep [Click or tap to [Click or tap to ☐ Facebook
disorder(s) enter a date.] enter a date.] ☐ Instagram
☐ Snapchat
☐ TikTok
☐ YouTube
☐ None
☐ Self-harm [Click or tap to [Click or tap to ☐ Facebook
enter a date.] enter a date.] ☐ Instagram
☐ Snapchat
☐ TikTok
☐ YouTube
☐ None
☐ Suicidal [Click or tap to [Click or tap to ☐ Facebook
thoughts enter a date.] enter a date.] ☐ Instagram
☐ Snapchat
☐ TikTok
☐ YouTube
☐ None
☐ Suicide [Click or tap to [Click or tap to ☐ Facebook
Attempt(s) enter a date.] enter a date.] ☐ Instagram
☐ Snapchat
☐ TikTok
☐ YouTube
☐ None
☐ Death by [Click or tap to [Click or tap to ☐ Facebook
suicide enter a date.] enter a date.] ☐ Instagram
☐ Snapchat
☐ TikTok
☐ YouTube
☐ None
☐ Other Injury [Click or tap to [Click or tap to ☐ Facebook
You Attribute to enter a date.] enter a date.] ☐ Instagram
Conduct of a ☐ Snapchat
Defendant
☐ TikTok
(specify):
☐ YouTube
B. Diagnosis of Alleged Injuries, Illnesses, or Conditions
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1. Have you been diagnosed by a healthcare professional for any injury(ies),
illness(es), or condition(s) identified in VII.A?
[Click here to select your answer.]
(a) If yes, please provide the following information:
Injury, Illness, or Condition Name of Diagnosing Provider/ Address of
Diagnosed (list all that apply) Facility/Counselor Provider/Facility/Counselor
C. Treatment of Alleged Injuries, Illnesses, or Conditions
1. Have you sought medical treatment for any of the injury(ies), illness(es),
or condition(s) identified in VII.A? Medical treatment includes
counseling or therapy sought for psychological, psychiatric, mood, or
behavioral disorders or conditions, as well as social, emotional, or other
related services at a community health center, school, or other educational
institution you attended.
[Click here to select your answer.]
(a) If yes, please provide the following information:
Injury, Illness,
Address of
or Condition Name of Provider/ Date Range of
Provider/Facility/ Treatment Received
Treated (list Facility/Counselor Counselor Treatment
all that apply)
2. Have you been hospitalized or received in-patient treatment for any of the
injury(ies), illness(es), or condition(s) identified in VII.A?
[Click here to select your answer.]
(a) If yes, please provide the following information:
Injury, Illness,
or Condition Type of Name and Date of Date of
Address Treatment Received
Treated (list Facility Admission Discharge
all that apply)
[Choose [Click or tap to [Click or tap
an item.] enter a date.] to enter a
date.]
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3. Has any physician or other healthcare provider told you that your
injury(ies), illness(es), or condition(s) identified in VII.A are related to
your use of any of Defendants’ platforms? You do not need to list any
retained expert witnesses.
[Click here to select your answer.]
(a) If yes, provide the physician’s or healthcare provider’s name and
address and the approximate date of that discussion:
Healthcare Provider’s Name Address Approximate Date of Discussion
[Click or tap to enter a date.]
VIII. INSURANCE
A. Provide the following information for each private or public health insurance
program with whom you had health insurance coverage during the Relevant Time
Period. Include all private insurance and public assistance, if applicable:
Name and Address of
Approx. Dates of
Insurance Company or Policy Number Name of Policy Holder
Coverage
Public Assistance
IX. ALCOHOL, TOBACCO, AND DRUG USE
A. Have you consumed alcohol while under age 21?regularly (i.e., once or more per
week) during the Relevant Time Period?
[Click here to select your answer.]
1. If yes, please provide the following information:
(a) When did you first begin consuming alcohol?
[Click here to select your answer.]
(b) What was/is the average frequency of your alcohol consumption
while under age 21?
[Click here to select your answer.]
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B. If you are currently age 21 or over: Have you consumed alcohol while age 21 or
over?
[Click here to select your answer.]
1. If yes, how frequently do you consume alcohol?
[Click here to select your answer.]
(a) Have you ever sought, received, or been given a professional
recommendation or referral for treatment for alcohol addiction?
[Click here to select your answer.]
C.B. Have you used tobacco (including cigarettes, cigars, pipes, chewing
tobacco/snuff, vaping devices, dissolving tobacco, hookah, and/or electronic
cigarettes) while under age 18?regularly (i.e., once or more per week) during the
Relevant Time Period?
[Click here to select your answer.]
1. If yes, please provide the following information:
(a) When did you first begin using tobacco?
[Click here to select your answer.]
(b) What was/is the average frequency of your tobacco use while
under age 18?
[Click here to select your answer.]
D. If you are currently age 18 or over: Have you used tobacco (including cigarettes,
cigars, pipes, chewing tobacco/snuff, vaping devices, dissolving tobacco, hookah,
and/or electronic cigarettes) while age 18 or over?
[Click here to select your answer.]
1. If yes, how frequently do you use tobacco?
[Click here to select your answer.]
(a) Have you ever sought, received, or been given a professional
recommendation or referral for treatment for tobacco addiction?
[Click here to select your answer.]
13
E. Have you consumed or ingested (in any manner, including swallowing, smoking,
snorting, injecting, or using suppositories) recreational drugs (i.e., legal or illegal
drugs used without medical supervision) during the Relevant Time Period?
[Click here to select your answer.]
1. If yes, please provide the following information:
(a) When did you first begin consuming or ingesting recreational
drugs?
[Click here to select your answer.]
(b) How frequently do you consume or ingest recreational drugs?
[Click here to select your answer.]
(c) Have you sought, received, or been given a professional
recommendation or referral for treatment for drug addiction?
[Click here to select your answer.]
F. Have you played video games during the Relevant Time Period?
[Click here to select your answer.]
1. If yes, please provide the following information:
(a) When did you first begin playing video games?
[Click here to select your answer.]
(b) How frequently do you play video games?
[Click here to select your answer.]
(c) Have you sought, received, or been given a professional
recommendation or referral for treatment for gaming addiction?
[Click here to select your answer.]
G.C. Have you engaged in gambling (e.g., casino games, online gambling, or sports
bettingregularly (i.e., once or more per week) during the Relevant Time Period?
[Click here to select your answer.]
1. If yes, please provide the following information:
(a) When did you first begin engaging in gambling?
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[Click here to select your answer.]
(b) How frequently do you engage in gambling?
(c)(a) [Click here to select your answer.]Have you sought, received, or
been given a professional recommendation or referral for treatment
for gamblingdrug addiction?
[Click here to select your answer.]
H.D. Have you ever received treatment for any other addiction?
[Click here to select your answer.]
1. If yes, please indicate the addiction(s) for which you received treatment:
X. DAMAGES
A. Are you claiming any lost wages or earning capacity?
[Click here to select your answer.]
If yes, please provide the following information:
1. Provide your annual income for each year during the period beginning at
age fourteen (14) through today:
Year Gross Annual Income
2. From when you were fourteen (14) years old through today, has any
doctor or other healthcare provider told you that you cannot work?
[Click here to select your answer.]
(a) If yes, state the name(s) and address(es) of such health care
provider(s):
3. From when you were fourteen (14) years old through today, have you quit
or taken a medical leave(s) of absence from any job as a result of the
injury(ies) you allege in this case?
[Click here to select your answer.]
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(a) If yes, identify each employer from which you quit or took leave
and when:
B. Do you claim medical expenses (including for mental health, psychiatric,
psychological, or other treatment) as a result of the injury(ies) you allege in this
case?
[Click here to select your answer.]
1. If yes, please approximate the total amount of medical expenses you are
claiming:
C. Are you claiming injuries as a result of or in the form of educational disruption,
i.e., disciplinary issues, impact on grades, impact on attendance, etc.?
[Click here to select your answer.]
1. If yes, answer the following:
(a) During the Relevant Time Period, have you ever received
additional or supplemental academic, social, or emotional services
at a community center, school, or other educational institution you
attended?
[Click here to select your answer.]
(i) If yes, provide the following information:
Name of Community Center,
Dates of Services Description of Services Provided
School, or Educational Institution
[Click here to make your selection.]
D. Is anyone claiming loss of consortium and/or loss of services as a result of your
use of Defendants’ platforms?
1. If yes, please identify all persons claiming loss of consortium and/or loss
of services, to the best of your knowledge, and your relationship to each
person (e.g., spouse, child):
Name Address Relationship
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XI. ELECTRONICS USAGE
A. At what age did you first have regular access to a mobile phone, tablet, or
computer (i.e. once per week or more)?
XII. SOCIAL MEDIA USE
A. Identify whether you used the following platforms (fill in all that apply), the age
at first use, the approximate dates of use, and your best estimate of the average
frequency of use:
Average Frequency of Use
Have You Used This Age at Date Range of
Platform When You Used This
Platform? First Use Use
Platform
Facebook [Click here to select [Click here to select your
your answer.] answer.]
Instagram [Click here to select [Click here to select your
your answer.] answer.]
Snapchat [Click here to select [Click here to select your
your answer.] answer.]
TikTok [Click here to select [Click here to select your
your answer.] answer.]
YouTube [Click here to select [Click here to select your
your answer.] answer.]
B. For each Defendant’s platform, have you ever created an account(s) with an
incorrect date of birth or age?
1. Facebook [Click here to select your answer.]
2. Instagram [Click here to select your answer.]
3. Snapchat [Click here to select your answer.]
4. TikTok [Click here to select your answer.]
5. YouTube [Click here to select your answer.]
C. Have you used any other social media platforms?
[Click here to select your answer.]
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1. If yes, identify the platform, the username(s) you used, the email
address(es) you used, the approximate dates of use, your age at first use,
and your best estimate of your average frequency of use:
Average Frequency of Use
Email Approximate Dates Age at Time
Platform Username(s) When You Used This
Address(es) of Use of First Use
Platform
[Click here to select your
answer.]
D. If you have ever tried to delete or deactivate your Facebook, Instagram, Snapchat,
TikTok, or YouTube account, provide the following information:
Platform Delete or Deactivate? Date of Attempt Did You Succeed?
[Click [Click or tap to [Click here to select your answer.]
here to enter a date.]
select
your
answer.]
E. If you have ever used any of Defendants’ platforms through another person’s
account, provide the following information regarding those accounts:
Email Address
Accountholder
Account Associated Accountholder’s Date Range of Your
Platform ’s Relationship
Username with Account Name Use of the Account
to You
(if known)
[Click
here to
select
your
answer.]
F. Have you ever used any app or electronic mechanism to keep content on a device
private, such as Calculator+, Hide it Pro (HIP), Vault, AppLock, Secret
Calculator?
[Click here to select your answer.]
1. If yes, identify the following information:
App or Mechanism
Approximate Date App Was Downloaded Apps/Content Hidden in App
Used
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G. Have you ever been paid by a Defendant in connection with your use of their
platform?
If yes, identify the platform(s):
H. Do you claim injury or damages as a consequence of your participation in a
“challenge” on any of Defendants’ platforms? [Click here to select your answer.]
1. If yes, identify the following information:
Platform(s) on Which
Approximate Date You
Name of You Observed and/or Injury or Damage Caused by
First Saw the Challenge
Challenge Participated in the the Challenge
Attempted
Challenge
[Click or tap to enter a ☐ Facebook
date.] ☐ Instagram
☐ Snapchat
☐ TikTok
☐ YouTube
I. Do you claim that any party facilitated the spread of sexually explicit media
depicting or relating to you?
[Click here to select your answer.]
1. If yes, identify the platform(s) on which this occurred:
Platform(s) Involved (select all that apply)
☐ Facebook
☐ Instagram
☐ Snapchat
☐ TikTok
☐ YouTube
XIII. DEFENDANTS’ PLATFORMS
A. Accessing Defendants’ Platforms.
1. What devices have you used on a routine basis to access Defendants’
platforms?
☐ Personal phone ☐ Parent or guardian’s phone ☐ School tablet or computer
☐ Personal tablet ☐ Friend or sibling’s phone ☐ Other:
☐ Personal computer ☐ Family tablet or computer
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2. Have you or anyone else placed or attempted to place restrictions on your
access to Defendants’ platforms on the devices listed above (e.g., through
Screen Time, internet network, physical removal, etc.)?
[Click here to select your answer.]
B. Reporting on Defendants’ Platforms. If you have ever used any Defendant’s
reporting features to report a negative experience on that platform, provide the
following information:
Platform Involved (select one) How Many Times Did You Report
☐ Facebook
☐ Instagram
☐ Snapchat
☐ TikTok
☐ YouTube
XIV. FACT WITNESSES
A. Please identify the five individuals (including, but not limited to, family members,
friends, educators, and employers) other than your attorney(s) and healthcare
providers who you believe possess the most significant information concerning:
(1) your use of social media and (2) your claimed injuries, illnesses, and/or
conditions:
Information You
Name Address Relationship to You
Believe They Possess
XV. AUTHORIZATIONS
For all authorizations listed herein, the starting date for the records release is the
beginning of the Relevant Time Period to today.
A. Authorizations for Release of Health Information Pursuant to HIPAA
Please provide a signed (but undated) Limited Authorization to Disclose Health
Information Pursuant to HIPAA, attached as Exhibit “A-1.” And a signed (but
undated) Limited Authorization to Disclose Psychological, Psychiatric and Other
Mental Health Information, attached as Exhibit A-2.
B. If you are claiming lost wages or earning capacity:
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1. For each year you have filed a tax return, please provide signed (but
undated) IRS Forms 4506 and 4506-T, attached as Exhibits “B-1” and
“B-2.”
2.1. Please provide a signed (but undated) Authorization to Disclose
Employment Records, attached as Exhibit “C.”
3.2. Please provide a signed (but undated) Authorization for Release of
Workers’ Compensation Records, attached as Exhibit “D.”
4.C. Please provide a signed (but undated) Authorization for Release of Disability Formatted: Level 2, Don't keep lines together
Claims Records, attached as Exhibit “E.”
C.D. Authorization for Release of Educational Records
Please provide a signed (but undated) Authorization for Release of Educational
Records, attached as Exhibit “F.”
D.E. Authorization for Release of Insurance Records
Please provide a signed (but undated) Authorization for to Disclose Insurance
Information, attached as Exhibit “G.”
E.F. Authorization for Release of Medicare and Medicaid Records.
Please provide a signed (but undated) Authorization for Release of Medicaid
Information, attached as Exhibit “H,” and a signed (but undated) Medicare
Authorization to Disclose Personal Health Information Form attached as Exhibit
I.
XVI. DOCUMENTS IN YOUR POSSESSION, CUSTODY, OR CONTROL
For each of the following questions, indicate whether you have any of the specified
materials in your possession, custody, or control, and attach a copy of each document in
your possession, custody, or control to this Plaintiff Fact Sheet:
A. All non-privileged documents you reviewed that assisted you in the preparation of
your answers to the Short-Form Complaint or this Plaintiff Fact Sheet.
[Click here to select your answer.]
B. All educational records pertaining to you that are related to disciplinary actions or
the symptoms, side effects, or injuries (including mental, psychological, or
psychiatric injuries, if any) you are claiming during the Relevant Time Period.
[Click here to select your answer.]
21
C. All police reports pertaining to any crime committed by, or crime or attempted
crime committed against, you, to the extent these records are unsealed and their
dissemination is not prohibited by law.
[Click here to select your answer.]
D. All juvenile justice, criminal justice, or family court records pertaining to you, to
the extent these records are unsealed and their dissemination is not prohibited by
law.
E.C. [Click here to select your answer.]All medical, billing, insurance (including but
not limited to your Explanation of Benefits), or other records and/or other
documents relating to your use of Defendants’ platforms, or the symptoms, side
effects, or injuries (including mental, psychological, or psychiatric injuries, if any)
you are claiming.
[Click here to select your answer.]
F.D. All records of expenditures that you contend are attributable to your alleged
injury.
[Click here to select your answer.]
G.E. All documents or materials in your possession relating to your physical or mental
condition, or the symptoms, side effects, or injuries (including mental,
psychological, or psychiatric injuries, if any) you are claiming.
[Click here to select your answer.]
H. All diaries; journals; notebooks; posts on social media platforms (including
tweets) other than Facebook, Instagram, Snapchat, TikTok, or YouTube; or posts
on chat rooms, blogs, message boards, and online support groups in which you
have discussed the injuries you are claiming.
I. If you are making a claim for lost wages or lost earning capacity, your federal tax
returns and W-2s from the time you were fourteen through today, for each year
you have filed a tax return.
[Click here to select your answer.]
J. If you have been the claimant or subject of any Social Security or other disability
proceeding, all documents in your possession relating to such proceeding.
K.F. [Click here to select your answer.]For deceased plaintiffs, the death certificate of
the person who died and any certificate or letters of administration that establish
the authority of the Representative bringing this lawsuit on behalf of the person
who died.
Preview
SUPERIOR COURT OF THE STATE OF CALIFORNIA FOR THE COUNTY OF LOS ANGELES IN RE: SOCIAL MEDIA CASES JCCP No. 5255 [Consolidated with JCCP No. 5256] Case No. 22STCV21355 This Document Relates to: [PROPOSED] PLAINTIFF FACT Case Caption and Civil Action No.: SHEET Full Name of Plaintiff (First, Middle, and Last): PLAINTIFF FACT SHEET Please provide the following information for each plaintiff who claims that use of Defendants’ platforms (Facebook, Instagram, Snapchat, TikTok, and YouTube) caused them (or a person who died) injury as alleged in the above-captioned litigation. In completing this Plaintiff Fact Sheet, you are under oath and must provide information that is true and correct to the best of your knowledge. If you cannot recall all of the details requested, provide as much information as you can (including approximate times and dates), including by review of documents or materials in your or your attorneys’ custody or possession. This Plaintiff Fact Sheet is an electronic version that expands to accommodate as much information as is necessary to fully answer any of these questions, including by adding rows or columns to tables. You must fill out the applicable appendix for each entity you have named as a Defendant. Please do not leave any questions unanswered or blank. You may and should consult with your attorney if you have any questions regarding the completion of this form. This Plaintiff Fact Sheet constitutes discovery responses subject to California Code of Civil Procedure. This Plaintiff Fact Sheet and the information provided herein will be used only for this litigation and is designated Confidential under the Protective Order. Plaintiffs do not concede the relevance or admissibility of any of the information herein. I. CASE INFORMATION A. Name of the court in which the complaint was initially filed: B. Case number in court in which complaint was originally filed: C. Are you alleging in this case that you began using Facebook, Instagram, Snapchat, TikTok, or YouTube when you were under thirteen years old? [Click here to select your answer.] **IMPORTANT** DEFINITION OF “RELEVANT TIME PERIOD” If your answer to question I.C. is “YES,” then the phrase “Relevant Time Period” throughout this Plaintiff Fact Sheet means from the time you turned SEVEN (7) years old to today. If your answer to question I.C. is “NO,” then the phrase “Relevant Time Period” throughout this Plaintiff Fact Sheet means from the time you turned TEN (10) years old to today. II. REPRESENTATIVE CAPACITY If you are completing this Plaintiff Fact Sheet in a representative capacity (meaning on behalf of a minor, someone who died, or a person who lacks capacity to complete it on their own), respond on your own behalf only to the questions in this section. For the remainder of the questions in this Fact Sheet, respond on behalf of the person who used and was allegedly harmed by Defendants’ platforms, and assume that “you” refers to that person. Please complete the following: A. Name of individual completing this Fact Sheet: B. Your current address: C. What is your relationship to the person upon whose behalf you are completing this Fact Sheet (e.g., parent, guardian, Estate Administrator)? D. If you represent the estate of someone who died or serve as a successor-in- interest, do you contend that use of Defendants’ platforms caused or contributed to that person’s death? [Click here to select your answer.] E. Have you ever used any Defendant’s reporting features to report a negative experience on that platform by the person on whose behalf you are completing this Fact Sheet? [Click here to select your answer.] 2 1. If yes, please provide the following information: Platform Involved (select one) How Many Times Did You Report ☐ Facebook ☐ Instagram ☐ Snapchat ☐ TikTok ☐ YouTube III. PERSONAL INFORMATION If you are completing this questionnaire in a representative capacity, the remainder of this Fact Sheet should be completed on behalf of the represented individual who used Defendants’ platforms. For representatives who are completing this Fact Sheet for someone else, assume that “you” means the person who used and was allegedly harmed by Defendants’ platforms. A. Legal name: B. Other names by which you have been known (including maiden names, if any): C. Gender: D. Social Security Number: E. Date of birth: [Click or tap to enter a date.] F. List all addresses where you lived for the last six (6) years. Include addresses where you lived while at school, to the extent that you lived away from home for school (e.g., boarding school or college). For each address, provide the approximate periods you resided at each location: Address Date Range of Residence G. Household Information. Provide the name of any adult who has resided in the same household as you for all the addresses you listed above in III.F. Name Relationship to You Date Range the Individual Resided with You 3 H. Educational History. Provide the following information about your education for the Relevant Time Period: 1. Primary and Secondary Schools Attended. Name of School or Educational Grade(s) City and State Dates of Attendance Institution Completed 2. Post-Secondary Schools (e.g., Colleges, Trade Schools), or Other Educational Institutions, Attended. Name of School or Degree Major or City and State Dates of Attendance Awarded Educational Institution Primary Field 3. During the Relevant Time Period, have you ever been subject to disciplinary action by any school or other educational institution? [Click here to select your answer.] (a) If yes, provide the following information: Name of School Dates of Type of Disciplinary Action or Educational Grounds for Disciplinary Action Disciplinary Action (select all that apply) Institution ☐ Detention ☐ In-School Suspension ☐ Out-of-School Suspension ☐ Expulsion I. Previous Interactions with Law Enforcement and the Legal System. 1. Have you ever been convicted of a crime as an adult?felony? [Click here to select your answer.] (a) If yes, please answer all of the following questions that apply to you for each instance: 4 Charge(s) Court Where Action Was/Is Pending Date of Conviction [Click or tap to enter a date.] 2. Have you ever been determined to have committed an offense in a juvenile delinquency proceeding? Note: You are only required to answer this question with “Yes” if any records from a conviction or a juvenile delinquency proceeding involving you remain unsealed. [Click here to select your answer.] 3. To the best of your knowledge, has any individual who regularly cared for you ever been convicted of a crime related to your care or been the subject of an investigation by any Department of Child and Family Services related to your care? IV. [Click here to select your answer.]ABUSE / VIOLENCE / DISCRIMINATION A. Have you ever been the victim of discrimination or harassment on the basis of race/ethnicity, national origin, sex, sexual orientation, gender identity, transgender status, or disability? [Click here to select your answer.] 1. If yes, please select one of the following options to indicate when the discrimination or harassment occurred: [Click here to select your answer.] B. Have you ever been the victim of bullying, cyberbullying, verbal abuse, or emotional neglect? [Click here to select your answer.] 1. If yes, please select one of the following options to indicate when the bullying, cyberbullying, verbal abuse, or emotional neglect occurred: [Click here to select your answer.] C. Have you ever been the victim of physical abuse, physical assault, or physical neglect? [Click here to select your answer.] 5 1. If yes, please select one of the following options to indicate when the physical abuse, physical assault, or physical neglect occurred: [Click here to select your answer.] D. Have you ever been the victim of rape, sexual abuse, or sexual assault? [Click here to select your answer.] 1. If yes, please select one of the following options to indicate when the rape, sexual abuse, or sexual assault occurred: [Click here to select your answer.] E. Have you ever experienced violence or threats of violence (e.g., a shooting, a threatened shooting, or a bombing) in a school, place of worship, or other public place? [Click here to select your answer.] 1. If yes, please select one of the following options to indicate when the violence or threats of violence occurred: [Click here to select your answer.] F. Have you ever been the victim of a crime against your person not listed above? [Click here to select your answer.] V. EMPLOYMENT AND MILITARY HISTORY A. Complete the chart below detailing your current employment and all prior employment from when you were fourteen years old through today. Please include any part-time jobs. Date Range of Was Your Reason for Leaving Related to Medical, Employment Occupation/ Employer City and State Physical, Psychiatric, (Month/Year to Position/Title Psychological, or Emotional Month/Year) Reasons? B. Have you ever served in any branch of the military? [Click here to select your answer.] 1. If yes, provide the following information: 6 (a) Branch of service: __________________________ (b) Rank upon discharge: __________________________ (c) Type of discharge: __________________________ VI. MEDICAL BACKGROUND A. You must complete and execute the attached authorization to release your medical records and answer the following questions. B. Identify each of the health care providers (including all doctors, psychiatrists, dieticians, nutritionists, neuropsychologists, psychologists, therapists, licensed clinical social workers, nurse practitioners, and physician assistants) whom you saw on an out-patient basis about any chronic physical, mental, or neurodevelopmental condition (defined as any condition that lasted for more than three months) during the Relevant Time Period. If you saw multiple health care providers within the same medical practice, you are not required to list each doctor, nurse practitioner, or physician assistant you may have seen as part of that group; rather, include the name of the health care provider you primarily saw at the medical practice, and identify the medical specialties of all healthcare providers you saw. Name of Provider’s Address, Dates as Condition/Reason Medical Practice Specialty Phone Number, and Patient for Consultation or Provider Email C. Identify every hospital, clinic, or facility where you were admitted as an in- patient or presented for an emergency room visit for any physical, mental, or neurodevelopmental condition or treatment/surgery during the Relevant Time Period. Dates of ER Visit or Name and Address Reason for Hospital Admission of Facility Admission Treatment Received and Discharge D. List all prescription anti-depressants, anti-anxiety medications, anti-psychotic medications, and other medications for the treatment of any mental health problem that you took for three (3) months or more during the Relevant Time Period: 7 Prescribing Physician or Pharmacy Used Healthcare Provider Medication Dates of Use (Name, Address, and Phone (Name, Address, and Phone Number) Number) [Click here to select or write in a medication.] E. Except for those pharmacies identified in your response to question VI.D, identify every pharmacy that has dispensed medication to you during the Relevant Time Period: Address and Name of Medication(s) Date Range You Used Name of Pharmacy Phone Dispensed Pharmacy Number VII. ALLEGED INJURIES, ILLNESSES, AND CONDITIONS A. Identify the below-listedall physical and mental injuries, illnesses, or conditions that you believe you have ever sufferedallege were caused or worsened by Defendant’s social medial platforms. Platform(s) to which you Deleted Cells Injury, Illness, or If Not Ongoing, Date Date Injury, Illness, attribute this injury, illness, Condition (check all Injury, Illness, or or Condition Began or condition, in part or in that apply) Condition Ended full (select all that apply) ☐ “Social media [Click or tap to [Click or tap to ☐ Facebook addiction” enter a date.] enter a date.] ☐ Instagram ☐ Snapchat ☐ TikTok ☐ YouTube ☐ None ☐ Anxiety [Click or tap to [Click or tap to ☐ Facebook enter a date.] enter a date.] ☐ Instagram ☐ Snapchat ☐ TikTok ☐ YouTube ☐ None 8 ☐ Depression [Click or tap to [Click or tap to ☐ Facebook enter a date.] enter a date.] ☐ Instagram ☐ Snapchat ☐ TikTok ☐ YouTube ☐ None ☐ Body [Click or tap to [Click or tap to ☐ Facebook dysmorphia enter a date.] enter a date.] ☐ Instagram ☐ Snapchat ☐ TikTok ☐ YouTube ☐ None ☐ Anorexia [Click or tap to [Click or tap to ☐ Facebook enter a date.] enter a date.] ☐ Instagram ☐ Snapchat ☐ TikTok ☐ YouTube ☐ None ☐ Bulimia [Click or tap to [Click or tap to ☐ Facebook enter a date.] enter a date.] ☐ Instagram ☐ Snapchat ☐ TikTok ☐ YouTube ☐ None ☐ Binge Eating [Click or tap to [Click or tap to ☐ Facebook Disorder enter a date.] enter a date.] ☐ Instagram ☐ Snapchat ☐ TikTok ☐ YouTube ☐ None ☐ Other feeding [Click or tap to [Click or tap to ☐ Facebook or eating disorder enter a date.] enter a date.] ☐ Instagram (specify): ☐ Snapchat ☐ TikTok ☐ YouTube ☐ None 9 ☐ Sleep [Click or tap to [Click or tap to ☐ Facebook disorder(s) enter a date.] enter a date.] ☐ Instagram ☐ Snapchat ☐ TikTok ☐ YouTube ☐ None ☐ Self-harm [Click or tap to [Click or tap to ☐ Facebook enter a date.] enter a date.] ☐ Instagram ☐ Snapchat ☐ TikTok ☐ YouTube ☐ None ☐ Suicidal [Click or tap to [Click or tap to ☐ Facebook thoughts enter a date.] enter a date.] ☐ Instagram ☐ Snapchat ☐ TikTok ☐ YouTube ☐ None ☐ Suicide [Click or tap to [Click or tap to ☐ Facebook Attempt(s) enter a date.] enter a date.] ☐ Instagram ☐ Snapchat ☐ TikTok ☐ YouTube ☐ None ☐ Death by [Click or tap to [Click or tap to ☐ Facebook suicide enter a date.] enter a date.] ☐ Instagram ☐ Snapchat ☐ TikTok ☐ YouTube ☐ None ☐ Other Injury [Click or tap to [Click or tap to ☐ Facebook You Attribute to enter a date.] enter a date.] ☐ Instagram Conduct of a ☐ Snapchat Defendant ☐ TikTok (specify): ☐ YouTube B. Diagnosis of Alleged Injuries, Illnesses, or Conditions 10 1. Have you been diagnosed by a healthcare professional for any injury(ies), illness(es), or condition(s) identified in VII.A? [Click here to select your answer.] (a) If yes, please provide the following information: Injury, Illness, or Condition Name of Diagnosing Provider/ Address of Diagnosed (list all that apply) Facility/Counselor Provider/Facility/Counselor C. Treatment of Alleged Injuries, Illnesses, or Conditions 1. Have you sought medical treatment for any of the injury(ies), illness(es), or condition(s) identified in VII.A? Medical treatment includes counseling or therapy sought for psychological, psychiatric, mood, or behavioral disorders or conditions, as well as social, emotional, or other related services at a community health center, school, or other educational institution you attended. [Click here to select your answer.] (a) If yes, please provide the following information: Injury, Illness, Address of or Condition Name of Provider/ Date Range of Provider/Facility/ Treatment Received Treated (list Facility/Counselor Counselor Treatment all that apply) 2. Have you been hospitalized or received in-patient treatment for any of the injury(ies), illness(es), or condition(s) identified in VII.A? [Click here to select your answer.] (a) If yes, please provide the following information: Injury, Illness, or Condition Type of Name and Date of Date of Address Treatment Received Treated (list Facility Admission Discharge all that apply) [Choose [Click or tap to [Click or tap an item.] enter a date.] to enter a date.] 11 3. Has any physician or other healthcare provider told you that your injury(ies), illness(es), or condition(s) identified in VII.A are related to your use of any of Defendants’ platforms? You do not need to list any retained expert witnesses. [Click here to select your answer.] (a) If yes, provide the physician’s or healthcare provider’s name and address and the approximate date of that discussion: Healthcare Provider’s Name Address Approximate Date of Discussion [Click or tap to enter a date.] VIII. INSURANCE A. Provide the following information for each private or public health insurance program with whom you had health insurance coverage during the Relevant Time Period. Include all private insurance and public assistance, if applicable: Name and Address of Approx. Dates of Insurance Company or Policy Number Name of Policy Holder Coverage Public Assistance IX. ALCOHOL, TOBACCO, AND DRUG USE A. Have you consumed alcohol while under age 21?regularly (i.e., once or more per week) during the Relevant Time Period? [Click here to select your answer.] 1. If yes, please provide the following information: (a) When did you first begin consuming alcohol? [Click here to select your answer.] (b) What was/is the average frequency of your alcohol consumption while under age 21? [Click here to select your answer.] 12 B. If you are currently age 21 or over: Have you consumed alcohol while age 21 or over? [Click here to select your answer.] 1. If yes, how frequently do you consume alcohol? [Click here to select your answer.] (a) Have you ever sought, received, or been given a professional recommendation or referral for treatment for alcohol addiction? [Click here to select your answer.] C.B. Have you used tobacco (including cigarettes, cigars, pipes, chewing tobacco/snuff, vaping devices, dissolving tobacco, hookah, and/or electronic cigarettes) while under age 18?regularly (i.e., once or more per week) during the Relevant Time Period? [Click here to select your answer.] 1. If yes, please provide the following information: (a) When did you first begin using tobacco? [Click here to select your answer.] (b) What was/is the average frequency of your tobacco use while under age 18? [Click here to select your answer.] D. If you are currently age 18 or over: Have you used tobacco (including cigarettes, cigars, pipes, chewing tobacco/snuff, vaping devices, dissolving tobacco, hookah, and/or electronic cigarettes) while age 18 or over? [Click here to select your answer.] 1. If yes, how frequently do you use tobacco? [Click here to select your answer.] (a) Have you ever sought, received, or been given a professional recommendation or referral for treatment for tobacco addiction? [Click here to select your answer.] 13 E. Have you consumed or ingested (in any manner, including swallowing, smoking, snorting, injecting, or using suppositories) recreational drugs (i.e., legal or illegal drugs used without medical supervision) during the Relevant Time Period? [Click here to select your answer.] 1. If yes, please provide the following information: (a) When did you first begin consuming or ingesting recreational drugs? [Click here to select your answer.] (b) How frequently do you consume or ingest recreational drugs? [Click here to select your answer.] (c) Have you sought, received, or been given a professional recommendation or referral for treatment for drug addiction? [Click here to select your answer.] F. Have you played video games during the Relevant Time Period? [Click here to select your answer.] 1. If yes, please provide the following information: (a) When did you first begin playing video games? [Click here to select your answer.] (b) How frequently do you play video games? [Click here to select your answer.] (c) Have you sought, received, or been given a professional recommendation or referral for treatment for gaming addiction? [Click here to select your answer.] G.C. Have you engaged in gambling (e.g., casino games, online gambling, or sports bettingregularly (i.e., once or more per week) during the Relevant Time Period? [Click here to select your answer.] 1. If yes, please provide the following information: (a) When did you first begin engaging in gambling? 14 [Click here to select your answer.] (b) How frequently do you engage in gambling? (c)(a) [Click here to select your answer.]Have you sought, received, or been given a professional recommendation or referral for treatment for gamblingdrug addiction? [Click here to select your answer.] H.D. Have you ever received treatment for any other addiction? [Click here to select your answer.] 1. If yes, please indicate the addiction(s) for which you received treatment: X. DAMAGES A. Are you claiming any lost wages or earning capacity? [Click here to select your answer.] If yes, please provide the following information: 1. Provide your annual income for each year during the period beginning at age fourteen (14) through today: Year Gross Annual Income 2. From when you were fourteen (14) years old through today, has any doctor or other healthcare provider told you that you cannot work? [Click here to select your answer.] (a) If yes, state the name(s) and address(es) of such health care provider(s): 3. From when you were fourteen (14) years old through today, have you quit or taken a medical leave(s) of absence from any job as a result of the injury(ies) you allege in this case? [Click here to select your answer.] 15 (a) If yes, identify each employer from which you quit or took leave and when: B. Do you claim medical expenses (including for mental health, psychiatric, psychological, or other treatment) as a result of the injury(ies) you allege in this case? [Click here to select your answer.] 1. If yes, please approximate the total amount of medical expenses you are claiming: C. Are you claiming injuries as a result of or in the form of educational disruption, i.e., disciplinary issues, impact on grades, impact on attendance, etc.? [Click here to select your answer.] 1. If yes, answer the following: (a) During the Relevant Time Period, have you ever received additional or supplemental academic, social, or emotional services at a community center, school, or other educational institution you attended? [Click here to select your answer.] (i) If yes, provide the following information: Name of Community Center, Dates of Services Description of Services Provided School, or Educational Institution [Click here to make your selection.] D. Is anyone claiming loss of consortium and/or loss of services as a result of your use of Defendants’ platforms? 1. If yes, please identify all persons claiming loss of consortium and/or loss of services, to the best of your knowledge, and your relationship to each person (e.g., spouse, child): Name Address Relationship 16 XI. ELECTRONICS USAGE A. At what age did you first have regular access to a mobile phone, tablet, or computer (i.e. once per week or more)? XII. SOCIAL MEDIA USE A. Identify whether you used the following platforms (fill in all that apply), the age at first use, the approximate dates of use, and your best estimate of the average frequency of use: Average Frequency of Use Have You Used This Age at Date Range of Platform When You Used This Platform? First Use Use Platform Facebook [Click here to select [Click here to select your your answer.] answer.] Instagram [Click here to select [Click here to select your your answer.] answer.] Snapchat [Click here to select [Click here to select your your answer.] answer.] TikTok [Click here to select [Click here to select your your answer.] answer.] YouTube [Click here to select [Click here to select your your answer.] answer.] B. For each Defendant’s platform, have you ever created an account(s) with an incorrect date of birth or age? 1. Facebook [Click here to select your answer.] 2. Instagram [Click here to select your answer.] 3. Snapchat [Click here to select your answer.] 4. TikTok [Click here to select your answer.] 5. YouTube [Click here to select your answer.] C. Have you used any other social media platforms? [Click here to select your answer.] 17 1. If yes, identify the platform, the username(s) you used, the email address(es) you used, the approximate dates of use, your age at first use, and your best estimate of your average frequency of use: Average Frequency of Use Email Approximate Dates Age at Time Platform Username(s) When You Used This Address(es) of Use of First Use Platform [Click here to select your answer.] D. If you have ever tried to delete or deactivate your Facebook, Instagram, Snapchat, TikTok, or YouTube account, provide the following information: Platform Delete or Deactivate? Date of Attempt Did You Succeed? [Click [Click or tap to [Click here to select your answer.] here to enter a date.] select your answer.] E. If you have ever used any of Defendants’ platforms through another person’s account, provide the following information regarding those accounts: Email Address Accountholder Account Associated Accountholder’s Date Range of Your Platform ’s Relationship Username with Account Name Use of the Account to You (if known) [Click here to select your answer.] F. Have you ever used any app or electronic mechanism to keep content on a device private, such as Calculator+, Hide it Pro (HIP), Vault, AppLock, Secret Calculator? [Click here to select your answer.] 1. If yes, identify the following information: App or Mechanism Approximate Date App Was Downloaded Apps/Content Hidden in App Used 18 G. Have you ever been paid by a Defendant in connection with your use of their platform? If yes, identify the platform(s): H. Do you claim injury or damages as a consequence of your participation in a “challenge” on any of Defendants’ platforms? [Click here to select your answer.] 1. If yes, identify the following information: Platform(s) on Which Approximate Date You Name of You Observed and/or Injury or Damage Caused by First Saw the Challenge Challenge Participated in the the Challenge Attempted Challenge [Click or tap to enter a ☐ Facebook date.] ☐ Instagram ☐ Snapchat ☐ TikTok ☐ YouTube I. Do you claim that any party facilitated the spread of sexually explicit media depicting or relating to you? [Click here to select your answer.] 1. If yes, identify the platform(s) on which this occurred: Platform(s) Involved (select all that apply) ☐ Facebook ☐ Instagram ☐ Snapchat ☐ TikTok ☐ YouTube XIII. DEFENDANTS’ PLATFORMS A. Accessing Defendants’ Platforms. 1. What devices have you used on a routine basis to access Defendants’ platforms? ☐ Personal phone ☐ Parent or guardian’s phone ☐ School tablet or computer ☐ Personal tablet ☐ Friend or sibling’s phone ☐ Other: ☐ Personal computer ☐ Family tablet or computer 19 2. Have you or anyone else placed or attempted to place restrictions on your access to Defendants’ platforms on the devices listed above (e.g., through Screen Time, internet network, physical removal, etc.)? [Click here to select your answer.] B. Reporting on Defendants’ Platforms. If you have ever used any Defendant’s reporting features to report a negative experience on that platform, provide the following information: Platform Involved (select one) How Many Times Did You Report ☐ Facebook ☐ Instagram ☐ Snapchat ☐ TikTok ☐ YouTube XIV. FACT WITNESSES A. Please identify the five individuals (including, but not limited to, family members, friends, educators, and employers) other than your attorney(s) and healthcare providers who you believe possess the most significant information concerning: (1) your use of social media and (2) your claimed injuries, illnesses, and/or conditions: Information You Name Address Relationship to You Believe They Possess XV. AUTHORIZATIONS For all authorizations listed herein, the starting date for the records release is the beginning of the Relevant Time Period to today. A. Authorizations for Release of Health Information Pursuant to HIPAA Please provide a signed (but undated) Limited Authorization to Disclose Health Information Pursuant to HIPAA, attached as Exhibit “A-1.” And a signed (but undated) Limited Authorization to Disclose Psychological, Psychiatric and Other Mental Health Information, attached as Exhibit A-2. B. If you are claiming lost wages or earning capacity: 20 1. For each year you have filed a tax return, please provide signed (but undated) IRS Forms 4506 and 4506-T, attached as Exhibits “B-1” and “B-2.” 2.1. Please provide a signed (but undated) Authorization to Disclose Employment Records, attached as Exhibit “C.” 3.2. Please provide a signed (but undated) Authorization for Release of Workers’ Compensation Records, attached as Exhibit “D.” 4.C. Please provide a signed (but undated) Authorization for Release of Disability Formatted: Level 2, Don't keep lines together Claims Records, attached as Exhibit “E.” C.D. Authorization for Release of Educational Records Please provide a signed (but undated) Authorization for Release of Educational Records, attached as Exhibit “F.” D.E. Authorization for Release of Insurance Records Please provide a signed (but undated) Authorization for to Disclose Insurance Information, attached as Exhibit “G.” E.F. Authorization for Release of Medicare and Medicaid Records. Please provide a signed (but undated) Authorization for Release of Medicaid Information, attached as Exhibit “H,” and a signed (but undated) Medicare Authorization to Disclose Personal Health Information Form attached as Exhibit I. XVI. DOCUMENTS IN YOUR POSSESSION, CUSTODY, OR CONTROL For each of the following questions, indicate whether you have any of the specified materials in your possession, custody, or control, and attach a copy of each document in your possession, custody, or control to this Plaintiff Fact Sheet: A. All non-privileged documents you reviewed that assisted you in the preparation of your answers to the Short-Form Complaint or this Plaintiff Fact Sheet. [Click here to select your answer.] B. All educational records pertaining to you that are related to disciplinary actions or the symptoms, side effects, or injuries (including mental, psychological, or psychiatric injuries, if any) you are claiming during the Relevant Time Period. [Click here to select your answer.] 21 C. All police reports pertaining to any crime committed by, or crime or attempted crime committed against, you, to the extent these records are unsealed and their dissemination is not prohibited by law. [Click here to select your answer.] D. All juvenile justice, criminal justice, or family court records pertaining to you, to the extent these records are unsealed and their dissemination is not prohibited by law. E.C. [Click here to select your answer.]All medical, billing, insurance (including but not limited to your Explanation of Benefits), or other records and/or other documents relating to your use of Defendants’ platforms, or the symptoms, side effects, or injuries (including mental, psychological, or psychiatric injuries, if any) you are claiming. [Click here to select your answer.] F.D. All records of expenditures that you contend are attributable to your alleged injury. [Click here to select your answer.] G.E. All documents or materials in your possession relating to your physical or mental condition, or the symptoms, side effects, or injuries (including mental, psychological, or psychiatric injuries, if any) you are claiming. [Click here to select your answer.] H. All diaries; journals; notebooks; posts on social media platforms (including tweets) other than Facebook, Instagram, Snapchat, TikTok, or YouTube; or posts on chat rooms, blogs, message boards, and online support groups in which you have discussed the injuries you are claiming. I. If you are making a claim for lost wages or lost earning capacity, your federal tax returns and W-2s from the time you were fourteen through today, for each year you have filed a tax return. [Click here to select your answer.] J. If you have been the claimant or subject of any Social Security or other disability proceeding, all documents in your possession relating to such proceeding. K.F. [Click here to select your answer.]For deceased plaintiffs, the death certificate of the person who died and any certificate or letters of administration that establish the authority of the Representative bringing this lawsuit on behalf of the person who died.