UPRR Form 52032 Rev. 01/04

Personal Injury Form Guide

Section V

1) DESCRIBE INJURY OR ILLNES:

List all body parts injured, no matter how minor it seems at the moment.

2) WHAT ARE YOUR SYMPTOMS?

Back hurting, neck hurting, shoulder hurting; for all body parts listed in previous question.

3) WHEN DID YOU FIRST NOTICE SYMPTOMS? (GIVE DATE)

When switch hung up.

4) WHEN WERE YOU FIRST TREATED OR DIAGNOSED?

Date you were seen by EMS technician, doctor or other medical professional.

5) PARTS OF BODY AFFECTED

Same listed as in question 1 and any body functions having issues account of injury.

6) thru 9)

Fill out appropriately if you know the information, otherwise state you do not know.