The following items are blank or not valid and must be updated:
First Name
*
Last Name
*
Phone
*
e.g. 555-555-5555
Email
*
Were you injured as the result of an attack while serving in Iraq or Afghanistan?
*
Iraq
Afghanistan
No
Did the attack occur after 2003?
*
Yes
No
When did the attack where you were injured occur (if you are unsure of the exact date, please put the best approximation)
*
Was anyone killed in the attack where you were injured?
*
Yes
No
Unsure
What was the nature of the attack where you were injured?
*
-- Select --
EFP
IED
Small Arms
RPG
Mine
Mortar
Rocket
Grenades
Other
Describe the injury you sustained:
*
When would be a good time to call you?
--Select--
8am-10am
10am-12pm
12pm-2pm
2pm-4pm
4pm-6pm
Anytime
Central Time
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