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Personal Details

Full name:

Current address :

Your address(es) when you were exposed to asbestos dust.:
Telephone
Fax

Email
Date of birth

Marital/civil partnership status

Medical History

What is your medical diagnosis?
When were you diagnosed?
Were you employed or self-employed when exposed to asbestos dust? (If self-employed were you working under a 714/715 tax certificate and/or did you receive SC60s?)
During which years of employment/self-employment were you exposed to asbestos dust?
Names and addresses of all employers throughout your career indicating those which exposed you to asbestos dust? Any changes of company name?
Have you kept any contract of employment or wage slips? Can you supply us with a copy?
 yes no
Can you describe the types of occupation within your working environment giving rise to inhalation of airborne asbestos dust/fibres? Examples: stripping asbestos lagging, mixing up an asbestos paste, cutting asbestos products, working near others carrying out these processes and similar.
What was the nature of your exposure to e.g. airborne asbestos dust? How exposed? When? For how long? By which employer?
Have there been any significant breaks in your employment/working history?
Can you describe any training or instructions given by your employer/contractor?
Were any preventative or protective methods or equipment used by the employer to prevent the escape of airborne asbestos dust?
Were you provided with a face-mask/respiratory equipment/ breathing apparatus? If so, do you remember the type?
Were you trained in how to use it? When was it supplied?
Were you provided with any protective clothing? If so, can you give details?
Were any facilities provided for the cleaning and storage of protective clothing/equipment?
Was any exhaust ventilation equipment provided?
Was any vacuum cleaning equipment used?
What was the system of working when you were exposed to airborne dust (or other exposure):
What hours did you work per day/week?
Can you estimate your periods of exposure to airborne asbestos dust (or other exposure) per day/month/year?
Can you describe the conditions you worked in?
Do you know any fellow workers details [e.g. names, addresses, telephone numbers] who may be able to supply confirmatory evidence or who may also be suffering from an asbestos-related condition?
Were you exposed to airborne asbestos fibres in any activity apart from your work/employment?
 yes no
When did you first notice symptoms e.g. breathlessness?
When were they first reported to your employer or your doctor?
What is the name of your GP and the name of the hospital you have attended?
Can you describe your current symptoms?
Have you ever smoked? If so can you say how many per day and state over what period of time?
If you have given up smoking, when was that?
Are you covered by any insurance policies (building, contents, motor, credit cards or standalone) which provide for your legal expenses to be paid? If so can you supply details?
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