Questionnaire for Injured Passengers

This questionnaire contains three parts, (1) the client details (if applicable), (2) the passengers details and (3) the passenger's injries.

Client Details

This section is devoted to details about the Client – where the client IS NOT the passenger due to the passenger either being (A) Deceased or (B) Incapacitated and/or unable to represent their own interests – as in the case of a minor.

In the event that the passenger is able to represent the interests of his or herself – proceed to the next section by clicking the NEXT button at the end of the form.

Client's Name

First Last

Client's Date of Birth

Age of Client

Client's Gender

Client's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Client's Phone

Client's Email

Relationship to Passenger

Passengers Details

This section is devoted to details about the Passenger. In the event that the passenger is unable to represent the interests of his or herself – please return to the previous section by clicking the PREVIOUS button at the end of the form.

Passenger's name?*

First Name Last Name

Passenger's Date of Birth*

Age of Passenger*

Passenger's Gender*

Passenger's Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Passenger's Phone*

Passenger's Email*

Passenger's School Level*

Passenger's Occupation*

What was your round-trip destination?*

Was the ticket one-way, return or something else?*

If other, please explain*

Where was the ticket purchased from?*

Travel agent? Directly online with the airline etc?

What country was the ticket purchased in?*

What country were you in when you purchased the ticket?

Passenger's Injuries

Please list in detail each and every injury (both physical and psychological) that has resulted from the passenger being on the flight.

Please note: no injury is too small, provide as much details as possible and describe your injuries as best as you can.

Injury Details

Did the passenger receive medical treatment for their injuries?*

Yes

No

Was the injured passenger hospitalised?*

Yes

No

Which hospital/s did the injuried passenger receive treatment at?*

What seat number was the passenger in on the plane?*

Please include any other information / comments you would like us to know.*

Email

This field is for validation purposes and should be left unchanged.