Survey

All fields are required, unless specified.

Injury Information

1. Which body part(s) did you injure? Select all that apply		2. Select the severity of the injury: Adjust all that apply. 1 is minor, 5 is serious.
	Foot, hand, or eye
	Arm, leg (including shoulder, elbow, knee)
	Hearing
	Thumb
	Fingers or toes
	Back, groin, neck, face or head
	Hypertension, heart disease, stroke or occupational disease