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1.What is the injury? (death, pelvic fracture, cardiac arrest, etc)

2. How did the injury happen? (brief description)

3. When did the injury occur? (month/year)

4.Who or what do you think was at fault in contributing to the injury? (name of the person, company, or product)

5. If the injury is to someone else, please provide the following:
His / Her name
Your relationship
 
Your name
Your address
Your city
Your phone
Your email

6. Is there anything else you wish to add?


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