When did the injury occur?
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Where did the injury occur?
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Was this location the injured person's
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If "Workplace," did the injury occur as a result of employment activities?
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If "Other," was this a road accident?
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If no, did the injury occur on another's property?
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If yes, who owns the property?
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How did the injury happen?
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What were the surrounding circumstances (weather, lighting, slipperiness, other)?
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Were there witnesses to the injury?
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If yes, what are their names/contact information?
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Were others involved or injured at the same time?
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If yes, what are their names/contact information?
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Was there a police report?
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Did the injured person receive medical treatment?
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If yes, provide dates, locations, provider names, and details:
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Is the injured person still receiving treatment?
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Was the injured person killed as a result of the accident?
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If yes, what was the date of his or her death?
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Describe lifestyle changes experienced by the injured person and his or her family as a result of the accident:
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Describe other losses resulting from the injury (lost wages, damaged property, other):
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Where did you hear about this website?
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indicate required information.
