Negligence Law Evaluation Survey
Please complete this survey to assist in evaluating potential negligence in a legal context. Your responses will help in assessing the main elements of a negligence claim.
Full Name of Respondent
*
First Name
Last Name
Email Address
*
example@example.com
Date and Time of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Please describe the incident in detail
*
Was there a duty of care owed by the alleged negligent party?
*
Yes
No
Uncertain
Do you believe there was a breach of that duty of care?
*
Yes
No
Uncertain
Did the breach directly cause harm or damages?
*
Yes
No
Uncertain
Please describe the damages or harm suffered (if any)
Additional Comments or Overall Assessment
Submit Survey
Should be Empty: