Title
—Please choose an option—MisterMissusMiss

First Name*

Middle Name

Last Name*

Personal email address*

Best phone number*

What is your preferred means of contact?
—Please choose an option—EmailPhone

Who was hurt?

Self?

First Name*

Middle Name*

Last Name*

Relationship*
—Please choose an option—I am the person injuredSpouseParentStep-ParentChildStep-ChildSiblingStep SiblingTrusteeFriendFormer CollegueOther

When was the person injured/killed? (If unsure, please approximate)*

What organization did the person serve in?*
—Please choose an option—US ArmyUS Marine CorpsUS NavyUS Air ForceUS Coast GuardUS Department of Stateother US Government Agency (for example, Department of Justice)US Agency for International Development CapitalUS Government ContractorPrivate US CompanyOther

If other, please, explain

Is the person an American citizen?
—Please choose an option—YesNo

If yes, in what state do they reside?
—Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

If no, are this person's family members American citizens?
—Please choose an option—YesNo

Where was the person injured or killed?
—Please choose an option—Anbar GovernorateMuthanna GovernorateQadisiyyah GovernorateBabil GovernorateBaghdad GovernorateBasra GovernorateDhi Qar GovernorateDiyala GovernorateKarbala GovernorateKirkuk GovernorateMaysan GovernorateNajaf GovernorateNineveh GovernorateSaladin GovernorateWasit GovernorateKurdistan RegionUnsure

How was the person injured?
—Please choose an option—Roadside Bomb (IED or EFP)Small Arms FireRocketMortarComplex Attack (Ambush)SniperOther

Any other terrorism cases you are involved in?
—Please choose an option—YesNo

If the person was injured but survived, did he or she complete a disability-related legal proceeding with DOD, DOS, or any other public or private disability determination process?
—Please choose an option—YesNo

You understand that we will evaluate your information but there is no attorney-client relationship and the fact that we have received your information does not create one.*
I agree