Conn. Practice Book Form 220

The undersigned, on behalf of the Plaintiff(s), hereby propounds the following Interrogatories to be

answered by the Defendant, _____________________________(Defendant Health Care Provider’s

Name), under oath, within sixty (60) days of the filing hereof in compliance with Practice Book Section

13-2.

Definition: ‘‘Y ou’’ or ‘‘your’’ shall mean the Defendant to whom these interrogatories are directed,

except that if that Defendant has been sued as the representative of the estate of a decedent, ward,

or incapable person, ‘‘you’’ or ‘‘your’’ shall also refer to the Defendant’s decedent, ward or incapable

person unless the context of an interrogatory clearly indicates otherwise.

In answering these interrogatories, the Defendant(s) is (are) required to provide all information within

their knowledge, possession or power. If an interrogatory has subparts, answer each subpart separately

and in full and do not limit the answer to the interrogatory as a whole. If any interrogatories cannot be

answered in full, answer to the extent possible.

(1) State the following:

(a) Y our full name and any other name(s) by which you have been known;

(b) Y our date of birth; and

(c) Y our business address.

(2) If the Defendant is deceased, state the date and place of death, whether an estate has been

created, and the name and address of the Administrator or Executor thereof.

Unless the information requested is provided in your curriculum vitae, respond to Interrogatories #3

through #11:

(3) State the name of each college and graduate school you attended, the date of graduation, and

each degree obtained, or provide your curriculum vitae including such information.

(4) State the name and address of each medical institution where you underwent postgraduate

training (e.g., internship, residency, fellowship, or similar training), and the dates of attendance, or

provide your curriculum vitae including such information.

(5) If you have been trained in a medical or surgical specialty, identify the specialty, the dates you

practiced the specialty, and the name and address of each institution where you were trained, or

provide your curriculum vitae including such information.

(6) If you have ever specialized in or limited your practice to a particular field or branch of medicine

or surgery, for each specialized or limited practice, state the field or branch of medicine or surgery,

No. CV- : SUPERIOR COURT

(Plaintiff): JUDICIAL DISTRICT OF

VS. : AT

(Defendant): (Date)

the inclusive dates you so practiced, and each location where you so practiced in the past ten years,

or provide your curriculum vitae including such information.

(7) If you have held any teaching positions, for each institution, state:

(a) The name and address of the institution;

(b) The inclusive dates of your association; and

(c) The title held in each position.

(8) State the name and location of any hospital or medical facility at which you have or have had

appointments and/or clinical privileges in the past ten years, and the dates you had such appointments

or privileges.

(9) Identify each medical book, paper, article, or other document that you have published, written,

or contributed, and for each, state the title, whether you were an author, co-author, or contributor.

(10) State the name of every jurisdiction in which you are or have been licensed as a health

care provider.

(11) State whether you are, or have ever been, a member of any medical or other health care

provider association, society or organization, and if so, as to each such membership, state:

(a) The name and address of the medical or other health care provider association, society, or organization;

(b) The inclusive dates of your membership; and

(c) Whether you have ever held any office and, if so, the title of the office and the dates you held

such office.

(12) With respect to any medical specialty board or other specialty board, for each board state,

whether you were refused or granted certification, the reasons therefor, and, if granted certification,

your title or rank (e.g., diplomate, fellow, member), and whether you still hold such certification, title,

or rank.

(13) During the past ten years have you ever had your privileges or application for privileges denied,

revoked, restricted, suspended, or limited in any way at any hospital or medical facility?

(14) Unless agency or another vicarious liability relationship is admitted to such codefendant, state

whether at the time of the negligence alleged in the Complaint to the present you were an officer,

shareholder, employee, member, partner, or otherwise affiliated with any entity or person involved in

the care and treatment of the Plaintiff. If the answer is yes, describe the nature and time period of

the affiliation.

(15) During the ten years prior to the negligence alleged in the Complaint, have you ever had your

application for a license denied, revoked, restricted, suspended, or limited in any way in any jurisdiction?

(16) State the time period(s) of the physician-patient relationship, if any, you had with the Plaintiff.

(17) With respect to the negligence alleged in the Complaint, did you ever consult with any physician

or other health care provider regarding your diagnosis, care, or treatment of the Plaintiff that is not

documented in the medical record? If so, identify the person consulted, his or her specialty, and the

reason for the consultation.

(18) Are you aware of any nonprivileged documents concerning consultations, care or treatment of

the Plaintiff regarding the negligence alleged in the Complaint that are not contained in the medical

records or hospital chart? If so, identify each document.

(19) If you are covered by an insurance policy under which an insurer may be liable to satisfy part

or all of a judgment or reimburse you for payments to satisfy part or all of a judgment relating to the

negligence alleged in the Complaint, state the following:

(a) The name(s) and address(es) of the insured(s);

(b) The amount of coverage under each insurance policy; and

(c) The name(s) and address(es) of said insurer(s).

(20) If you are covered by an excess or umbrella insurance policy, or any other insurance policy

relating to the negligence alleged in the Complaint, state:

(a) The name(s) and address(es) of the named insured(s);

(b) The amount of effective coverage; and

(c) The name(s) and address(es) of the insurer(s).

(21) As to each insurance policy identified in response to the preceding two interrogatories, state

whether:

(a) Any disclaimer or reservation of rights letter has been issued; and

(b) It is an eroding policy.

(22) Pursuant to General Statutes § 19a-17b, were your staff privileges terminated or restricted by

a medical review committee conducting a peer review with respect to the negligence alleged in the

Complaint? If so, please disclose the specific restriction imposed, if any.

(23) Have you or any entity or person been sued for medical negligence arising out of your conduct

as a health care provider? If so, state the caption, venue and docket number of the lawsuit(s).

(24) Have you made any statements, as defined in Practice Book Section 13-1, to any person

regarding any of the allegations in the Complaint?

COMMENT:

Interrogatory #24 is intended to include party statements made to a representative of an insurance company prior to involvement

of defense counsel.

(25) If the answer to the previous interrogatory is affirmative, state:

(a) The name(s) and address(es) of the person or persons to whom such statements were made;

(b) The date on which such statements were made;

(c) The form of the statement (i.e., whether written, made by recording device or recorded by a

stenographer, etc.); and

(d) The name and address of each person having custody or a copy of each statement.

(26) Other than those individuals referenced in the medical record, state the names and addresses

of all persons known to you who were present at the time of the negligence alleged in the Complaint

or who observed or witnessed all or part of the negligence alleged in the Complaint.

(27) As to each individual named in response to the previous interrogatory, state whether, to your

knowledge or the knowledge of your attorney, the individual(s) has given any statement or statements,

as defined in Practice Book Section 13-1, concerning the subject matter of the Complaint. If your

answer to this interrogatory is affirmative, state:

(a) The date on which the statement(s) were taken;

(b) The name(s) and address(es) of the person(s) who took the statement(s);

(c) The name(s) and address(es) of any person(s) present when the statement(s) were taken;

(d) Whether the statement(s) were written, made by recording device or taken by a court reporter

or stenographer;

(e) The name(s) and address(es) of any person(s) that have custody or copies of the statement(s).

(28) State whether the Plaintiff was referred to you, and if so, identify the person or entity that made

the referral and the date thereof.

(29) Did you create, use, or maintain any ‘‘electronic protected health information’’ (hereinafter ‘‘health

information’’), as defined in 45 C.F .R. § 160.103, during your treatment of the Plaintiff?

(30) If the answer to the previous interrogatory is in the affirmative, list the names of any and all

electronic ‘‘information system(s)’’ (hereinafter ‘‘EMR system(s)’’), as defined in 45 C.F .R. § 164.304,

that contain or previously contained the health information of the Plaintiff.

(31) Identify surveillance material discoverable under Practice Book Section 13-3 (c), by stating the

name and address of any person who obtained or prepared any and all recordings, by film, photograph,

video, audio or any other digital or electronic means, of any party concerning this lawsuit or its subject

matter, including any transcripts which are in your possession or control or in the possession or control

of your attorney, and state the date on which each recording(s) was obtained and the person or persons

of whom each such recording was made.

PLAINTIFF,

BY____________________________

I, _______, hereby certify that I have reviewed the above interrogatories and responses thereto and

that they are true and accurate to the best of my knowledge and belief.

______________________________

(Defendant)

Subscribed and sworn to before me this _____________ day of ___________, 20____.

______________________________

Notary Public/

Commissioner of the Superior Court

CERTIFICATION

I certify that a copy of this document was or will immediately be mailed or delivered electronically or

non-electronically on (date) ________ to all attorneys and self-represented parties of record and that

written consent for electronic delivery was received from all attorneys exempt from e-filing and self-represented parties of record who received or will immediately be receiving electronic delivery.

Name and address of each party and attorney that copy was or will immediately be mailed or

delivered to*

*If necessary, attach additional sheet or sheets with the name and address which the copy was or

will immediately be mailed or delivered to.

_________________________________________________________________________________

Signed (Signature of filer) Print or type name of person signing Date Signed

_________________________________________________________________________________

Mailing address (Number, street, town, state and zip code) or Email address, if applicable Telephone number

HISTORY—2026: In the first sentence of the certification, “exempt from e-filing” was added after “from all attorneys.”

COMMENTARY—2026: The changes to this form are consistent with the changes to the proof of service language in Section

10-14 (a).