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* 1. What is your name?

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* 2. What is your email address?

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* 3. What is your mobile number?

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* 4. What is your worksite?

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* 5. Have you ever been injured at work?

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* 6. Did you receive WorkCover?

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* 7. How long were you on WorkCover for?

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* 8. Did you receive compensation based on 85% of your normal earnings (including entitled penalties) or based on your base earnings (excluding penalties you would have otherwise received if you worked during that time)?

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* 9. If you were paid base earnings would you like your union to represent you in seeking a review of your payment to ensure you were paid the correct entitlement?

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* 10. Would you sign a petition calling on the Minister to support SNOs by providing for a top up of WorkCover payments to be 100% of your average weekly earnings for staff injured in the course of their duties?

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* 11. How important is this issue to you?

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