RSI questionnaire

If you would like a free initial assessment of your potential RSI claim by e-mail or telephone, kindly complete this short questionnaire.

Please note that the boxes marked with an asterisk * must be filled in fully, so as to allow the completed online form to be submitted to us.

Thank you.

Where is most of your RSI pain located?
Fingers
Wrist
Forearm
Upper arm
Shoulder
Neck
Other

Who advised that you have RSI?
GP
Treating Consultant
Other

Do you have visible symptoms (eg redness, swelling etc)?
Yes
No

Have you made a full recovery, or do you have continuing symptoms?
Full recovery
Continuing mild symptoms
Continuing severe symptoms

How long have you been off work as a result of your RSI symptoms?
Select -> A few days Over a week Over a fortnight Over a month Over 2 months Over 3 months Over 4 months Over 5 months Over 6 months Permanently off work No time off work

When did your RSI symptoms first become noticeable?
Select -> 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Other Select -> January March April May June July August September October November December Select -> 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

In which type of work did your RSI symptoms occur?
Data Inputter
Typist
Production Line
Other

Did you receive any training when you first started the job?
Yes
No

Did your employer provide any warnings about the dangers of RSI?
Yes
No
Not sure

Following the onset of your RSI symptoms, did your employers make any changes to how the work was organised?
Yes
No
Not sure

Was there a system of “payment by results”?
Yes
No

Were regular breaks allowed?
Yes
No

Were the breaks adequate?
Yes
No

Was there a system of measuring your productivity by electronic means?
Yes
No

Was there a system of supervisors measuring your productivity?
Yes
No

Was there a system of publicly rewarding fast workers?
Yes
No

Was there a system of job rotation?
Yes
No

Were there penalties if your productivity fell below a certain level?
Yes
No

Was there a “No Talking” rule?
Yes
No

Are there any witnesses who might be able to support your claim?
Yes
No
Not sure

Has anybody else doing the same work also suffered similar symptoms?
Yes
No
Not sure

If so, has anybody else also made a compensation claim?
Yes
No
Not sure

Did you, or anybody else previously complain about the work?
I complained
A few of us complained
Nobody complained
I did not complain, but others did

Do you have any hobbies or play any sports that might have contributed to your RSI symptoms?
Yes
No
Not sure

Where do you live in the UK?
Select -> South East South West London Wales East Anglia West Midlands East Midlands North East North West Scotland Other

Would you prefer a telephone call at home or at work?
At home
At work

Which day of the week would you prefer to be contacted?
Select -> Any day Sunday Monday Tuesday Wednesday Thursday Friday Saturday

When is the most convenient time to speak?
Select -> Early morning Late morning Lunchtime Early afternoon Late afternoon Early evening

Please give a convenient telephone number where we can reach you*:

Please state your name*

Please give a convenient e-mail address where we can reach you

In your opinion, why did your RSI symptoms start when they did? For example, was there a change in the system at work?*

Please state any further relevant facts that we might need to know about:

Kindly state how you heard about us, or which search engine you used:
Select -> Law Society Other solicitors Citizens Advice Bureau Personal Recommendation Yellow Pages Infoseek Northern Light Lycos Open Directory Ask Jeeves Fast Search Lycos Alta Vista Yahoo! MSN Hotbot AOL Excite Anzwers Google Other search engine Other referral source

Please click the submit button to send us the details, which will be treated in the strictest confidence, and not released to any third parties.

We will then contact you as close as possible to the time you specified. Any advice given regarding your potential claim will be on a free, no obligations basis, and does not constitute the acceptance of formal legal instructions.

Thank you for completing this questionnaire. Your interest is much appreciated and we look forward to hearing from you.