Referral information

(For example: one injury for specific accident [such as a fall on a specific date], one injury over time [such as psychological]
Brief Summary of Accident (describe in space below):
During my work time in Kandahar Afghanistan, I experienced many times in a week incoming rocket attacks. The worst incoming attacks I experienced were 2007/2008. When we were having a dinner in “Main DFAC” which was built by tents. Then rocket exploded right near to us where many people injured and some passed away later after injuries. The second worst attack was 2008 when incoming rocket exploded 7-10 meters away from my tent where I sleep (We used to sleep in tents then) I could be killed both cases since those incoming rockets exploded very close to me. These cases were terrible. I was very close to explosion. In addition, after incoming rocket attacks administration block employees were responsible for sweeping tents. We had to go inside the tents to wake up people make them go in bunkers or inform Security or Safety guards if injured people were found. After these cases, I stressed a lot and my mental state was exhausted. I thought being quit my job and thought after being with my family everything could be better. Even after I was back my home a long time I was in depression could not sleep well, even I do I used to I wake up having nightmares. All this affected my personal life and a long time since now have been taking rehabilitation and therapy.

Did the employer refer/allow medical treatment? N/A If so, where/who?

Current Doctor (Name, Clinic/Hospital Name/Address): Farida Shermukhammedova / Fayz Medical

Since returning home, have you worked and earned wages? YES If so, please see below:
List any and all wage from employment or self-employment since returning home:

• 
  Name for each company self-employment you’ve worked since returning home
  

(for example, ‘ABC Inc’ or ‘freelance consulting’

• 
  Periods worked for reach company self-employment since returning home
  

(for example, ‘June 2018-December 2019 for ABC January 2020 for XXX’, etc.)

• 
  Earnings for reach company/self-employment since returning home
  

• 
  “Yukleks Equipment” private firm 2010-2013 owner (Fast food café)
  

• 
  Mobi UZ phone company 2014- 2018 specialist in department with working corporate clients
  

• 
  Guzor textile Impex Cluster 2018-2020 Business consultant
  

• 
  Uz Engineering construction NDH 2020-Current consultant
  

6. 
   CLAIMANT STATEMENT AND SIGNATURE
   

I attest that the information I have provided above is accurate and correct to the best of my knowledge. My signature below is my own and is intended to be used for the express purpose of electronically signing documents required to institute my Defense Base Act claim on my behalf.

_______________________________________________ ___________________________

CLIENT SIGNATURE DATE