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How severe is your injury?
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What kind of injury
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Cause of the injury
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How severe is your injury?
Light injury (recovery expected within 3 months, not disabled)
Medium injury (3 to 6 months recovery period, temporarily disabled)
Serious injury (> 6 months recovery period and/or permanent disability)
What injury did you suffer?
Arm/hand injury
Leg/foot injury
Impaired speech/mouth injury
Hip injury
Shoulder/chest/spine
Damaged internal organs
Head, brain and nerve injury
Loss of smell/taste/nose injury
Psychological damage
Headache/concentration disorders
Scars
Eye injury
Ear injury
Back injuries
Whiplash
Paraplegia
Death
What is the cause of the injury?
Traffic accident
Work accident
Medical error
Other
Gender
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Age
Date of accident
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Are you permanently or temporarily disabled?
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Yes, permanently
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