Medical response form

A short simple form to establish a basic file on people who have experienced health problems that may have been caused by exposure to polluted waters.

These files and their contents will not be published without the persons permission. We may use a summary of cases but would not use peoples actual names without permission. We may approach you if we feel that your case would be useful in furthering SAS’ aims and objectives. Please fill in the form below...

Details of health problem
Did you visit a doctor?
Do medical records exist?

What were you doing?

Did you have time off work due to the illness?
Would you work with the media if necessary?
Are you an SAS member?