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.

Before you complete this, please make sure you have listened to the podcast that explains:

how the Workers Compensation scheme works;
Medical Discharge;
claiming TPD;
section 66 & 67 lump sum benefits;
Income Protection payments;
continuing benefits once Income Protection finishes;
what happens to your benefits if you plan to sue your Employer in negligence.

Let’s start with a thumbnail sketch of you:

Name

Age

Years as a Police Officer

Last day at work

Rank & station/unit as at last day at work

Relationship status

Current ages of any kids under 21 who are financially dependent on you:

Name of any GP (and their practice) you have seen in the last 15 years

Name of your treating psychiatrist:

Name of your treating psychologist:

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)?

Yes

No

If you have been diagnosed with PTSD, who made the diagnosis?

GP?

Psychologist?

Psychiatrist?

Circumstances of developing PTSD

I don't have PTSD

Exposure to violent, traumatic and stressful events in the course of my duties

Bullying, harassment, targeting, false complaints, intimidation or assault by Police colleagues

A bit of both

Which of these circumstances apply to you? Tick as many as are relevant.

TPD claim

I don't need any help with my claim for TPD

I have not lodged my claim for TPD

I have lodged my claim for TPD and it has been approved

I have lodged my claim for TPD and it has been declined

I would like some help/advice with my TPD

My TPD is with TAL/Aware

My TPD is with SASS

Have you had legal advice before?

No

Yes

Which Firm / Solicitor?

Have you done your s.66 lump sum claims for PTSD?

No

Yes

Which Firm / Solicitor?

What was the result (insert % WPI)?

Have you done your s.66 lump sum claims for physical injuries?

No

Yes

Which Firm / Solicitor?

What was the result - (insert % WPI and body part)?

Have you had legal advice about suing the Police?

No

Yes

Which Firm / Solicitor?

Where is the claim up to now?

When you first went totally off work, were you:

I'm still at work

Doing full unrestricted duties and full hours up to the day I couldn’t face it any more

Doing restricted duties due to a physical injury

Doing restricted duties due to the early signs of PTSD

Working in another role (e.g. Licensing or HWP because you thought it would be a break from working on the truck?)

Relieving in a higher rank?

Working somewhere other than your normal duties because you were starting to struggle?

Please complete this section if you are suffering PTSD

I’m being treated solely by my GP

I’m seeing my GP and I’m also seeing a psychologist

I have had at least one appointment with a psychiatrist

I am waiting for my first appointment with a psychiatrist

I don’t yet have a referral to a psychiatrist

I need a recommendation for a good psychiatrist

I am taking prescribed medication

I am not currently taking any medication

I have previously been admitted to a Hospital or Rehabilitation Centre for PTSD treatment

GP’s name?

Have you lodged a claim for PTSD?

I don't have PTSD

I have a WorkCover Certificate from my GP giving me time off work and recommending medical treatment

I have lodged a claim form with the workers compensation insurer and the claim has been accepted

I have lodged a claim form with the workers compensation insurer and the claim has been declined

I am still at work but I am struggling and I need help to work out what to do and what my options are

I lodged a claim years ago and have been getting weekly benefits and medical expenses ever since

I lodged a claim years ago and have been getting weekly benefits and medical expenses ever since but I think I am entitled to other benefits or higher benefits

Are you getting Weekly Benefits and medical expenses?

I'm still at work and not getting any weekly benefits

I’m still in the first 9 months, and getting my full Award pay

I’m past the first 9 months and I’m getting the 75% Income Protection top-up

I haven’t lodged a claim yet

I think I’m entitled to some more pay than I’m getting

All my medical expenses are being paid

Some or all of my medical expenses have been declined

Police Hurt on Duty Questionaire

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