Class Action Lawsuit

If you received a Hepatitis A Vaccination after eating at Genki Sushi or any of the other restaurants/airlines implicated in the recent Hepatitis A outbreak, please complete this questionnaire so that we can evaluate your claim. It is important that you read and answer each question carefully. Do not answer a question if you do not know the answer.

A SEPARATE QUESTIONNAIRE MUST BE COMPLETED FOR EACH PERSON MAKING A CLAIM.

indicates a required field.

CLAIMANT INFORMATION

Full Name:

Address:

City:

State:

ZIP:

County:

Date of Birth (MM/DD/YYYY):

Social Security Number:

Contact information for claimant (or parent/guardian if claimant is less than 18 years old):

Home Telephone:

Work Telephone:

Mobile Telephone:

Email:

If Claimant is less than 18 years old:

Parent/Guardian Name:

Address (if different from above):

City:

State:

ZIP:

EXPOSURE INFORMATION

In addition to the Genki Sushi location on Oahu and Kauai, the Hawaii Department of Health has implicated the following locations as sources of exposure to the Hepatitis A virus:

Baskin-Robbins, Oahu, Waikele Center, June 17, 18, 19, 21, 22, 25, 27, 30, and July 1 and 3, 2016
Chili's, Oahu, Kapolei (590 Farrington Highway), July 10, 12, 14, 15, 17, 18, 20-23, 25-27, 2016
Costco Bakery, Oahu, Hawaii Kai, June 16-20, 2016
Hawaiian Airlines:
- July 1, 2016 - Flight 48 from Honolulu, HI (HNL) to Oakland, California
- July 2, 2016 - Flight 67 from Oakland, California to Lihue, Kauai
- July 2, 2016 - Flight 394 from Lihue, Kauai to Honolulu, HI
- July 3, 2016 - Flight 228 from Honolulu, HI to Kona, HI
- July 3, 2016 - Flight 227 from Kona, HI to Honolulu, HI
- July 3, 2016 - Flight 216 from Honolulu, HI to Kahului, Maui
- July 3, 2016 - Flight 505 from Kahului, Maui to Honolulu, HI
- July 3, 2016 - Flight 278 from Honolulu, HI to Kona, HI
- July 3, 2016 - Flight 279 from Kona, HI to Honolulu, HI
- July 4, 2016 - Flight 148 from Honolulu, HI to Kona, HI
- July 4, 2016 - Flight 66 from Kona, HI to Oakland, California
- July 6, 2016 - Flight 23 from Oakland, California to Kahului, Maui
- July 6, 2016 - Flight 199 from Kahului, Maui to Honolulu, HI
- July 8, 2016 - Flight 8 from Honolulu, HI to Las Vegas, Nevada
- July 10, 2016 - Flight 7 from Las Vegas, Nevada to Honolulu, HI
- July 11, 2016 - Flight 202 from Honolulu, HI to Hilo, HI
- July 11, 2016 - Flight 201 from Hilo, HI to Honolulu, HI
- July 11, 2016 - Flight 509 from Honolulu, HI to Lihue, Kauai
- July 11, 2016 - Flight 514 from Lihue, Kauai to Honolulu, HI
- July 11, 2016 - Flight 343 from Honolulu, HI to Lihue, Kauai
- July 11, 2016 - Flight 394 from Lihue, Kauai to Honolulu, HI
- July 16, 2016 - Flight 451 from Honolulu, HI to Sydney, Australia
- July 18, 2016 - Flight 452 from Sydney, Australia to Honolulu, HI
- July 24, 2016 - Flight 118 from Honolulu, HI to Kona, HI
- July 24, 2016 - Flight 117 from Kona, HI to Honolulu, HI
- July 24, 2016 - Flight 382 from Honolulu, HI to Hilo, HI
- July 24, 2016 - Flight 383 from Hilo, HI to Honolulu, HI
- July 24, 2016 - Flight 396 from Honolulu, HI to Kahului, Maui
- July 24, 2016 - Flight 365 from Kahului, Maui to Honolulu, HI
- July 25, 2016 - Flight 273 from Honolulu, HI to Lihue, Kauai
- July 25, 2016 - Flight 68 from Lihue, Kauai to Oakland, California
- July 26, 2016 - Flight 65 from Oakland, California to Kona, HI
- July 26, 2016 - Flight 147 from Kona, HI to Honolulu, HI
- July 31, 2016 - Flight 22 from Honolulu, HI to Seattle, Washington
- July 31, 2016 - Flight HA22 from Honolulu, HI (HNL) to Seattle, WA (SEA)
- August 1, 2016 - Flight HA21 from Seattle, WA (SEA) to Honolulu, HI (HNL)
- August 10, 2016 - Flight HA18 from Honolulu, HI (HNL) to Las Vegas, NV (LAS)
- August 12, 2016 - Flight HA17 from Las Vegas, NV (LAS) to Honolulu, HI (HNL)
New Lin Fong Bakery, Oahu, Chinatown (1132 Maunakea Street), July 20, 22-23, 25, 27, 29-30, and Aug. 1, 3, and 5-6, 2016
Zippy’s Restaurant, Oahu, Kapolei (950 Kamokila Boulevard), August 14, 18-19, 21, 23 and 25-26, 2016
Harbor Restaurant at Pier 38, Oahu, Honolulu (1133 North Nimitz Highway), August 26 through September 12, 2016
Benjamin Parker Elementary School, August 28 through August 30, 2016
Ohana Seafood at Sam’s Club, Oahu, Pearl City (1000 Kamehameha Highway), August 29 through September 11, 2016
Chart House Restaurant, located at 1765 Ala Moana Boulevard in Honolulu on September 1-4, and 8-11, 2016
Hokkaido Ramen Santouka, Oahu, Honolulu (801 Kaheka Street), July 21-23, 26-30, and August 2-6, 9-11, 2016
Sushi Shiono, Hawaii, Waikoloa Beach Resort, Queen's Market Place (69-201 Waikoloa Beach Drive), July 5-8, 11-15, and 18-21, 2016
Taco Bell, Oahu, Waipio (94-790 Ukee Street), June 16, 17, 20, 21, 24, 25, 28-30, and July 1, 3, 4, 6, 7, and 11, 2016
Tamashiro Market, Oahu, Kalihi (802 N. King Street), July 2, 4, 6-8, 11-13, 15-19, and 23, 2016
Papa John's Waipahu, Oahu, Waipahu (94-1021 Waipahu Street), July 23-24, and Aug. 2, 2016

List each date that claimant ate Hepatitis A tainted scallops at Genki Sushi or ate at one of the restaurants or airline noted above. Indicate if a receipt or proof of purchase is available for that date and provide a copy of the receipt or proof of purchase:

Upload proof of purchase (images and PDFs only, max size 2 MB):

IMMUNE GLOBULIN ("IG")/VACCINE

Did claimant receive Immune Globulin (IG) or the Hepatitis A Vaccine because he/she ate hepatitis A tainted scallops or ate at one of the restaurants or airline implicated by the Hawaii Department of Health?

YES

IF YES, Date(s) IG or vaccine were given:

Who provided the Immune Globulin or vaccine?

Health Department

Healthcare Provider

Health Department/Provider Name:

Address:

City:

State:

ZIP:

Telephone:

ADDITIONAL MEDICAL CARE

Did claimant seek additional medical care or advice because of exposure to the Hepatitis A virus?

YES

IF YES, Date(s) of contact:

Provider/Facility Name:

Address:

City:

State:

ZIP:

Telephone:

HEALTH DEPARTMENT CONTACT

Did claimant speak with anyone at a local, state, or federal health department or other agency about eating Hepatitis A tainted scallops or after eating at one of the restaurants or airline implicated by the Hawaii Department of Health?

YES

DON'T KNOW

IF YES, which health department or agency?

Identify health department or agency staff you/claimant spoke with and describe the nature of the conversation:

NAME OF PERSON COMPLETING QUESTIONNAIRE:

RELATIONSHIP TO CLAIMANT:

DATE COMPLETE:

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