Kratom Information Gathering

Thank you for placing your trust in us. Please answer each question as fully and accurately as you can. If you do not have complete information, please add what you can and submit the form. You can add additional information later. Please know that all information will be held completely confidential.

Name(Required)

Prefix First Last

Address

Street Address City State ZIP Code

Phone Number

Email Address(Required)

Your Experience With Kratom

Are you submiting this form for yourself or someone else?

Your date of birth

First Name of the Person Impacted by Kratom

Last Name of the Person impacted by Kratom

Their Date of Birth

What is your relationship to the person you are completing this form for?

What sympoms have you experienced from using kratom?

What sympoms has the person experienced from using kratom?

What was the date of death?

What was the official cause of death?

Has an estate already been setup?

Who is the administrator of the estate?

Their Phone Number

Please describe any adverse health issues experienced due to kratom

Approximately when did you first start taking kratom products?

Approximately when did they first start taking kratom products?

Approximately when was the last time you used a kratom product?

Approximately when was the last time they used a kratom product?

Do you currently consider yourself addicted to kratom?

Do you currently consider the person addicted to kratom?

What types and quantities do you currently take on a daily/weekly basis?

Did you use any of the following brands of kratom?

O.P.M.S - Optimized Plan Mediated Soutions

Chief Kratom

King Kratom

Whole Herbs

Kratom Kaps

Remarkeable Herbs

Did the person use any of the following brands of kratom?

O.P.M.S - Optimized Plan Mediated Soutions

Chief Kratom

King Kratom

Whole Herbs

Kratom Kaps

Remarkeable Herbs

Please describe all forms of kratom that you have used.

(Please give us all information you have, including the name brand, how much, and anything else you can think of that may be helpful to our investigation)

Please describe all forms of kratom that the person used.

(Please give us all information you have, including the name brand, how much, and anything else you can think of that may be helpful to our investigation)

Do you currently have unused kratom products?

Do you have any photos of the kratom products consumed?

Prior to learning about this lawsuit, had you heard of the American Kratom Association?

Prior to learning about this lawsuit, had you ever been to the American Kratom Association website?

Are you open to share portions of your story with legislators and/or reporters?

This field is for validation purposes and should be left unchanged.

Your Experience With Kratom

Submitting Your Completed Form