Have you suffered an injury or illness in the course of your employment in a NSW Coal Mine? *

Yes

Have you suffered a different type of injury? *

An injury at another type of workplace

An injury involving a car, truck, or motorcycle

An injury in a public place (like a supermarket or park)

An illness or injury that has permanently stopped you from working

In which Australian State or Territory did the accident occur? *

Choose a state from the dropdown

Are you employed by a NSW employer? *

Yes

How have you been affected? *

Physical injury

Psychological impacts

None of the above

Did you sustain injuries to any of the below as a result of a work-related incident? *

Neck or back

Hip, knee or ankle

Shoulder, elbow or wrist

Lung or stomach condition from exposure to a harmful substance (e.g. asbestos or silica)

Another injury not listed above

Have you received medical treatment? *

No, I haven’t needed it

I need treatment but have not had it yet

I have been to the doctor, had therapy or physio treatment

I have an Illness, disease or virus

I have been admitted to hospital and had or need surgery

Do you need surgery for any of these injuries? *

Yes

Was your psychological condition caused by any of the following? *

Bullying or harrassment at work

Workplace stress

Witnessing a traumatic accident, incident or event

None of the above

How has your work been impacted because of your psychological condition? *

I have lost income

I am working modified duties

I have lodged a claim (for my lost income) that has been rejected

None of the above

What is your email address? *

Please enter your email address and click "verify email" and enter the verification code.

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Phone *

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What is your first name (so we speak with the right person)? *

What is your last name? *

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