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Please select the injury(ies) that you received for each part of the body, by selecting that type of injury from the drop down boxes below. If you have more than one type of injury for a particular part of the body, you can select additional injuries by holding the "Ctrl" button (for PC users) or the "Apple" button (for Mac users). If you suffered an injury to an arm, hand, leg, or foot, please click the appropriate side (left or right). If you make a mistake, just click on the pull down menu again and click on the correct response or "Not applicable" as appropriate. (NOTE FOR BURNS: We have categorized blistering burns as "second-degree burns" and charring as "third-degree burns." We do not consider first-degree burns (redness) to be a serious bodily injury in most cases.)

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*	Please fill in at least one injury

Head ---------Not Applicable--------- Impaired vision Loss of sight Impaired hearing Loss of hearing Amputation of ear Second-Third degree burns Brain injury
Left Arm/Shoulder -----------Not Applicable----------- Cuts and bruises Sprain Dislocation Second-Third degree burns Broken bone(s) Paralysis-loss of function Amputation		Right Arm/Shoulder -----------Not Applicable----------- Cuts and bruises Sprain Dislocation Second-Third degree burns Broken bone(s) Paralysis-loss of function Amputation
Left Hand -----------Not Applicable----------- Cuts and bruises Sprain Dislocation Second-Third degree burns Broken bone(s) Paralysis-loss of function Loss of 1 or more fingers Amputation		Right Hand -----------Not Applicable----------- Cuts and bruises Sprain Dislocation Second-Third degree burns Broken bone(s) Paralysis-loss of function Loss of 1 or more fingers Amputation
Torso -----------Not Applicable----------- Back Injury Second-Third degree burns Broken bone(s) Loss of internal organ Loss of organ function Paralysis-loss of function Repair to internal organ		Reproductive System -----------Not Applicable----------- Pregnancy complications Loss of pregnancy Inability to have children Injury to testicle(s) Loss of testicle(s)
Left Leg -----------Not Applicable----------- Cuts and bruises Sprain Dislocation Second-Third degree burns Broken bone(s) Paralysis-loss of function Amputation		Right Leg -----------Not Applicable----------- Cuts and bruises Sprain Dislocation Second-Third degree burns Broken bone(s) Paralysis-loss of function Amputation

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