Archibald Form

Thank you for taking the time to provide the information requested below. We are gathering this information to assist us in working with Rockefeller University Hospital and its insurance companies to try to resolve your claim, but please do not guess or feel compelled to provide answers to questions if you do not know the answer. For example, some of the questions ask about dates because certain insurance policies apply to certain date ranges. If for some reason you can recall those dates, the questions allow you to share that information with us. However, please do not be alarmed if you cannot recall the dates as we will likely have other ways to obtain the dates, such as your medical records.

We are providing this online form because some people find it easier to provide the information in this fashion. Please let us know if you would rather provide this information over the phone.

Please know that the information you provide to us will be kept confidential and will not be shared with anyone else other than Rockefeller University Hospital and its insurance companies. They have agreed to keep the information confidential as we try to explore an informal resolution of your claim.

Finally, we understand that you will likely recall more information as time goes on, so please only provide the best information that you can today. You are always welcome to share more information with us, and we will be clear to Rockefeller University Hospital and its insurance companies that we will likely provide more information down the road.
Name*
Prefix First Middle Last

Date of Birth
Current Marital Status
- Married
- Single - Never Married
- Single - Divorced
- Single - Spouse Deceased
Years Married
Do you have any children, including biological, adopted, or step-children?
- Yes
- No
How many children?
What is your highest level of education?
Please describe your post-graduate degree(s):
Please describe your highest level of education:
Are You Employed?
- Yes
- No
Current Employer
First
Address of Current Employer
Street Address Address Line 2 City State ZIP Code
Start Date
Previous Employer
First
Address of Previous Employer
Street Address Address Line 2 City State ZIP Code
Approximately what year did you start working there?
Approximately what year did you stop working there?
Please provide a brief description of your work history, including the position listed above:

Some people interacted with Dr. Archibald at multiple places, but the abuse occurred at one location. For example, some people met Dr. Archibald through the Madison Square Boys Club, but he did not abuse them at the Boys Club. Instead, he used the Boys Club as a way to ask them to come to his office at Rockefeller University Hospital, where he then abused them. Please select *each* location where you had any interaction with Dr. Archibald, regardless of whether any abuse occurred at the location.
- Select All
- Rockefeller University Hospital
- Madison Square Boys Club
- Other
Where else did interaction occur?
This question is more narrow than the last question. Please select *each* location where Dr. Archibald had any inappropriate contact with you:
- Select All
- Rockefeller University Hospital
- Madison Square Boys Club
- Other
Where else did the inappropriate contact occur?
To the best of your ability, please describe what you recall about each location you identified above. We are asking this question because some people have reported meeting with Dr. Archibald in an examination room and others have reported meeting him in more of an office-type setting. Please do not guess and only describe what you can remember.

Do you believe you know the approximate first date, month, or year that you believe you first visited Dr. Archibald, regardless of what happened during the visit? We know this may be difficult to remember, so please do not guess. We are just trying to find out what you may remember because it could help us locate insurance coverage for your claim. If you cannot approximate the first visit, please pick “I am not sure.” Please do not be alarmed if you are not able to give an approximation. There are other ways for us to determine the approximate date.
Date
Month
Year
Year
Please explain how you are approximating the date that you believe he first acted inappropriately with you. Again, this is only to help us try to determine relevant dates for insurance coverage and we have other ways to determine these dates.
How many times do you believe Dr. Archibald acted inappropriately with you? We realize this may be difficult to remember, or to know with certainty, so please just answer to the best of your memory.
Do you believe you know the approximate date, month, or year that you believe Dr. Archibald last did anything inappropriate with you? Again, we know this may be difficult to remember, so please do not guess. We are just trying to find out what you may remember because it could help us locate insurance coverage for your claim. If you cannot approximate the last time you believe he may have done something inappropriate with you, please pick “I am not sure.” Please do not be alarmed if you are not able to give an approximation. There are other ways for us to determine the approximate date.
Date
Month
Year
Year
Please explain how you are approximating the date that you believe he last acted inappropriately with you. Again, this is only to help us try to determine relevant dates for insurance coverage and we have other ways to determine these dates.

In your own words, please describe what you recall about your visit(s) with Dr. Archibald, including anything that he did inappropriately during your visits:
How and why did the inappropriate conduct by Dr. Archibald come to an end?
Please describe how you believe the abuse by Dr. Archibald may have affected you when you were a child:
Please describe how you believe the abuse by Dr. Archibald may have affected you as an adult:

We know that most children do not ever tell anyone about sexual abuse, but when you were a child did you ever tell anyone that you did not like Dr. Archibald or that he had done something inappropriate to you?
- Yes
- No
Name of person you told Approximate year you told them What you told them
Aside from what he did during your visits, can you think of any evidence that Rockefeller University Hospital knew or should have known that he was acting inappropriately with you or any of his other patients?
- Yes
- No
What evidence can you think of that Rockefeller University Hospital knew or should have known that Dr. Archibald may have been acting inappropriately with you or any of his other patients?

Have you ever sought counseling which you now believe was directly or indirectly related to your experience with Dr. Archibald?
- Yes
- No
Please explain why you believe the counseling was related to your experience with Dr. Archibald:
Approximately what year did you first receive counseling?
Approximately how long did you participate in counseling?
Over the course of your life have you had any out-of-pocket expenses for the inappropriate conduct by Dr. Archibald? For example, have you paid for counseling or medication?
- Yes
- No
How Much Out of Pocket?
Out-of-pocket expense: Your best estimate of the cost:

Thank you very much for taking the time to complete this questionnaire. Is there anything else that you would like us to know about your answers or about any other issue?

Name of person you told	Approximate year you told them	What you told them

Out-of-pocket expense:	Your best estimate of the cost:

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