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This questionnaire is available in

here.
Download it, print it, fill it in and send it to the address at the bottom of the form.

ASBESTOS DATABASE QUESTIONNAIRE:

This is Form is sent direct to NOT via the FBU

Questions in BOLD are required to be answered

Full Name
Address
Date of Birth	dd mm yy
Home Phone
Work Phone
Mobile Phone

Period of time in Fire Service Years
Brigade(s)
Station(s) / Places(s) of work and dates
Names and addresses of colleagues who can confirm asbestos exposure:

Have you ever been told that you may be suffering from any asbestos related disease? Yes No
If yes, have you been told which of the following you are suffering from?		Mesothelioma Pleural Plaques Pleural Thickening Asbestosis Lung Cancer
When were you diagnosed?
Have you ever applied for social security benefits for asbestos related disease? Yes No
If yes, when did you claim and at which social security office?
Have you ever previously obtained legal advice in connection with your asbestos exposure? Yes No
If yes, please give the name and address of the solicitors.

FIREFIGHTERS Please give specific details of any incidents you can recall where asbestos may have been involved. Names of premises and approximate dates would be useful.
In what way do you think you were exposed to asbestos?
Please identify any personal protective equipment that may have contained asbestos, e.g. hoods, gloves. Was this equipment ever in poor condition resulting in asbestos dust?

CONTROL AND NON-RIDER PERSONNEL Please specify the premises where you were exposed, the dates and details of information confirming there was asbestos in the workplace or otherwise exposure to asbestos.
In what way do you think you were exposed to asbestos?

By clicking 'SUBMIT', I confirm that I consent to this information being stored on a database and shared with others, including other law firms instructed by the Union and it belongs to FBU for the benefit of the members. The use of this data will be solely for the purpose of assisting personal injury claims on behalf of you or others who have been exposed to asbestos and establishing the nature and extent of asbestos exposure in the fire service. If you require legal assistance as a result of your asbestos exposure or any other injury, you should call the FBU legal assistance helpline on 0808 100 60 61.