THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) MEDICAL MALPRACTICE SCREENING PANEL WITNESS LIST Witness List submitted by (Name of party) To: Dr. Attorney cc: Medical Malpractice Screening Panel Coordinator The individuals identified below are witnesses who may testify at the panel hearing, or have been identified as experts whose opinions may be presented to you at the hearing. We need to be certain at the earliest possible time that no panel member has any association with any of the witnesses that would prevent the panel member from fairly serving on this case. Please check off the appropriate line next to each name and return the completed form within 10 days of receipt to: Superior Court Center, 45 Chenell Drive, Suite 1, Concord, NH 03301 NOTE: The Panel Coordinator will forward this screening panel to the Panel Chair for review. Witness name, address and practice affiliation 1. No conflict Possible Conflict 2. 3. 4. NHJB-2698-S (10/01/2013) American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: MEDICAL MALPRACTICE WITNESS LIST Witness name, address and practice affiliation 5. No conflict Possible Conflict 6. 7. 8. 9. 10. Date Panel Member's Name (please print) Panel Member's Signature NHJB-2698-S (10/01/2013) American LegalNet, Inc. www.FormsWorkFlow.com