How did you become injured?	== Please Select == Accident at work Accident in a shop Accident on somebody else's property Pavement tripping accident Harmful substance Defective product Holiday accident Road traffic accident Other
Who was mainly to blame?	== Please Select == Employers Fellow employee Main contractors Sub contractors Owner of premises Local council Seller of product Tour operator Car driver Other
Why do you blame the above? *
What are your main injuries?	== Please Select == Head injury Psychiatric injury Eye injury Injury to internal organs Neck injury Back injury Injury to arm Hand injury Injury to leg Injury to knee Foot injury Facial injury Dermatitis Other
Do you have continuing symptoms?	== Please Select == Full medical recovery Continuing mild symptoms Continuing severe symptoms
What date were you injured?	== Year == 2006 2007 2008 2009 2010 2011 == Month == January February March April May June July August September October November December == Day == 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
Do you have any witnesses?	== Please Select == Yes No
Are your witnesses happy to help?	== Please Select == Yes No Not sure Not applicable
Was there an official investigation?	== Please Select == Yes No Not sure
Has anybody been prosecuted?	== Please Select == Yes No Not sure
Has anybody admitted blame?	== Please Select == Yes No Not sure
Have you been off work, or "out of action"?	== Please Select == Yes No
If so, for how long?	== Please Select == Up to a week Up to a fortnight Up to a month Up to 6 months Over 6 months Permanently off work Unemployed Retired No time off work
Have you lost earnings?	== Please Select == Yes No
If you live in the UK, then where?	== Please Select == London South East South West East Midlands West Midlands Wales North East North West Scotland
If you are outside the UK, then where?	== Please Select == Poland Elsewhere in Europe The Americas Oceania Africa Asia
Should I call you at home or at work?	== Please Select == At home At work
Which day of the week is best?	== Please Select == Monday Tuesday Wednesday Thursday Friday Saturday Any day As soon as possible
What time of day is best?	== Please Select == Early morning Late morning Lunchtime Early afternoon Late afternoon Early evening Saturday morning Any time
What is your telephone number?*
What is your e-mail address?*
What is your name?*

Please click the 'submit' button to send me the details, which will be treated in the strictest confidence. I will then contact you at the time you requested. Any advice 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.