Industrial injury questionnaire

If you would like a free initial assessment of your potential industrial injury 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.

What injury have you suffered?
Select -> Foot injury Leg injury Pelvis injury Back injury Hand injury Arm injury Shoulder injury Neck injury Head injury Eye injury Internal injury Skin injury Psychiatric injury Other

How long have you been off work as a result of your accident?
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

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

What date did your accident happen?
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

Who do you blame for your industrial injury?
Employer
Fellow employee
Contractor
Other

Why do you blame the above?*


In the light of your injuries, have your employers made any changes to how the work is organised? Yes
No
Not sure

Have your employers admitted fault?
Yes
No
Not sure

If your claim concerns a back injury, did you ever have any pre-existing back pain?
Yes
No
Other

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 injuries?
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

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:


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.