Police Hurt on Duty Questionnaire

Have you suffered an injury or illness while working for the NSW Police Force? You may be entitled to a compensation claim.

Private Police Hurt on Duty Form
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Completing this questionnaire will give us a lot more information about you and your circumstances. Your information is not publicly available, and won’t be provided to anyone. It comes to us as an entirely confidential email.

Once we receive your completed questionnaire, we will contact you by telephone to discuss what happens next. We will also send you a link to a podcast that explains:

  1. how the Workers Compensation scheme works;
  2. Medical Discharge;
  3. claiming TPD;
  4. section 66 & 67 lump sum benefits;
  5. Income Protection payments;
  6. continuing benefits once Income Protection finishes;
  7. what happens to your benefits if you plan to sue your Employer in negligence.
Let’s start with a thumbnail sketch of you:
Referral Source
Was the position permanent or were you acting in that position?
Relationship status

Now, onto the reason you are contacting us:

Have you been diagnosed with PTSD or do you think you might have PTSD (or other psychological injury)?
If you have been diagnosed with PTSD, who made the diagnosis?
Circumstances of developing PTSD
Which of these circumstances apply to you? Tick as many as are relevant.
Have you ever had time off work before this, for PTSD or any other psychological injury?
TPD claim
Have you had legal advice before?
Have you done your s.66 lump sum claims for PTSD?
Have you done your s.66 lump sum claims for physical injuries?
Have you had legal advice about suing the Police?
If you have sought advice about suing the Police, where is the claim up to now? Tick as many as are relevant.
When you first went totally off work, were you:
Please complete this section if you are suffering PTSD
Have you lodged a claim for PTSD or any other psychological injury?
Are you getting Weekly Benefits and medical expenses?