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DePuy/J&J ASR –Compensation
Application FORM
To,
The Chairman
Central Expert Committee,
CDSCO, Head Quarter, FDA Bhawan, Kotla Road, New Delhi, 110002
Patient Details
Name
Gender
Contact Number
Email ID
Address
Address for correspondence
Date of Birth
Occupation
ASR Hip (DePuy/J&J ASR Metal-on- Left ☐
Metal) implanted
Right ☐
(please tick the appropriate box) Bilateral ☐
First/Initial Surgery Details
Date of First Surgery
Type of Surgery ASR Hip Resurfacing(DePuy/J&J ASR ☐
Metal-on-Metal)
(please tick the appropriate box)
ASR XL Total Hip Replacement(DePuy/J&J ☐
ASR Metal-on-Metal)
Identification Number of the ASR Hip
implanted(DePuy/J&J ASR Metal-
on-Metal)
Hospital Name, address and contact
number
Surgeon Name, address and contact
number*Revision Surgery Details
Date of Revision Surgery
Hospital Name, address and contact
number
Surgeon Name, address and contact
number
* In case of multiple revision surgeries, provide above details for each such surgery in separate columns.
Previous medical management Details
Has the patient received any medical
management by the M/s DePuy International
Limited, U.K. (now M/s Johnson & Johnson
Pvt. Ltd), if yes, please give the details, If Not
received any reimbursement, write No.
Has the patient received any compensation,
other than the reimbursement paid for the
revision surgery or any other medical
management? if yes, please give the details, If
Not received, write No.
What are the medical symptoms caused due to
use of faulty ASR implant with documentary
evidences?
Whether the patient has suffered with any
temporary disability or is suffering with any
permanent disability, if any, please give details
along with the disability certificate issued by a
competent authority.
Please attach the recent and relevant clinical
test lab report, or any other medical
laboratory report (s), or any other document
in support of the claim made, if any.
Whether the patient has lost its
occupation/job/source of income due to the
adverse medical condition which is caused due
to faulty ASR implant, if any, please give
details.
(please enclose a separate sheet having details
of loss of wages or income due to such adverse
condition, if any. It is advised to attach the
evidences in support of such claim)
Discharge slip from the hospital where the
patient was implanted ASR (DePuy/Johnson
& Johnson Metal-on-Metal Hip Implant) have
been operated uponAny documentary proof proving the purchase
and use of ASR (DePuy/Johnson & Johnson
Metal-on-Metal Hip Implant)
Copy of Disability Certificate issued by
competent authorities (as guided by Ministry
of Social justice and Empowerment)
Any other relevant information / document (if
any)
Declaration
I, _____________________________ [Patient Name] hereby submit my application to the Chairman, Central
Expert Committee for grant of compensation from M/s DePuy International Limited, U.K.(M/s Depuy India),
now M/s Johnson & Johnson Pvt. Ltd.
I do hereby declare that the information given in this application form and the documents enclosed herewith are
true and correct to the best of my knowledge and belief.
Signed ___________________
Patient’s Name &Signature
Date ____________________
Address ____________________
Email and Mobile Number ________________
List of Enclosures:
1. Proof of Identity (Document issued by the Government such as Driving Licence, Aadhaar Card, Passport,
etc.) (Mandatory)
2. List of documents attached