Step 1: Locate the area near where you were hit

Please enter the state, city and street intersection nearest to where you were hit and click Search. The map will then zoom to that location. When you can see hte location where you were hit, press "Next".

Step 2: Locate the spot of collision

Use the mouse to place the pin at the place where you were hit by a vehicle. You can edit the spot as many times as you want. Press "Next" when finishing.

Step 3: Use the cross-hairs tool to draw the route you walked

Move the cross hair to the street intersection you crossed immediately before you were hit and click the mouse. Then move the mouse to the intersection before that one and click the mouse and so on. Doing this will draw your walking route on the map.
You can delete the last section of the route by pressing "remove last intersection".

Step 4: Time the accident occured

Tell us the Month/Year in which you were injured. Press "Next" to continue.

Step 5: Collision Information

Please press "Next" after answering the questions below.

1. Were you hit by a:

2. Were you hit during the:

3. Was a police report filed at the scene of the collision?

4. Were you provided medical evaluation or care at the scene of the collision?

5. Were you taken from the scene of the collision to an emergency room or hospital?

6. If you did not visit an emergency room or hospital on the day of the collision, did you later seek medical care for injuries occurring from the collision?

Step 6: A little bit about youserlf

Please answer them and then press "Done".

this is a submitting form
this is a submitting form for uncomplete datasets