University of West Georgia
Injury Incident Report

Notice to Claimant: In order to expedite the claims process, please have any and all documentation prior to filling out this form (pictures, police report, incident report from other areas on campus, doctors bills, etc.). Attach these to this form in the space provided. If you do not have access to one or more of these documents, or receive them after filing the claim, please email them to cbackstr@westga.edu so that they may be added.

Initiator Name

Initiator Email

INCIDENT INFORMATION

Date of Incident

mm/dd/yyyy

Time of Incident

Date Employer Notified

mm/dd/yyyy

Time Employer Notified

mm/dd/yyyy

EMPLOYEE INFORMATION

Social Security Number *

*Your social security number is necessary if you seek treatment for your injury. If you are uncomfortable providing this information on this form, you may provide it over the phone.

Name

Home Telephone Number

Work Telephone Number

Cell Telephone Number

Email Address

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth

mm/dd/yyyy

Gender

Male

Female

Number of Dependents (including spouse)

Job Title

Date of Hire

mm/dd/yyyy

Full/Part Time

Full Time

Part Time

Hours per Week

Wage Rate

SUPERVISOR INFORMATION

Supervisor Name

Supervisor Email

Supervisor Title

Supervisor Phone Number

INJURY INFORMATION

Injury Description

Type of injury

Include location (ex. bruised left arm, cut right leg, etc)

Were there witnesses?

Yes

TREATMENT INFORMATION

Was treatment received at a medical facility?

Yes

LOST TIME INFORMATION

Did the employee work a full day the day of the injury?

Yes

Is the employee currently out of work due to the injury?

Yes

What is the date of the first FULL day the employee did NOT work?

mm/dd/yyyy

DEPARTMENT INFORMATION

What time did work begin the day of injury?

What is the employee's department name?

What is the department's phone number?

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University of West Georgia Injury Incident Report

INCIDENT INFORMATION

EMPLOYEE INFORMATION

SUPERVISOR INFORMATION

INJURY INFORMATION

TREATMENT INFORMATION

LOST TIME INFORMATION

DEPARTMENT INFORMATION

University of West Georgia
Injury Incident Report