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Case Review Form

*Name:

*Address:

*City:

*State:

*Zip:

*E-mail address:

*Home Phone:

Who was injured?

If "Other," please describe:

When did the injury occur?

Where did the injury occur?

Was this location the injured person's

If "Workplace," did the injury occur as a result of employment activities?
Yes  No 

If "Other," was this a road accident?
Yes  No 

If no, did the injury occur on another's property?
Yes  No 

If yes, who owns the property?

How did the injury happen?

What were the surrounding circumstances (weather, lighting, slipperiness, other)?

Were there witnesses to the injury?
Yes  No 

Were others involved or injured at the same time?
Yes  No 

Was there a police report?
Yes  No 

Did the injured person receive medical treatment?
Yes  No 

Is the injured person still receiving treatment?
Yes  No 

Was the injured person killed as a result of the accident?
Yes  No 

 

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