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.

 
 
 

 

INCIDENT INFORMATION

 
 
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EMPLOYEE INFORMATION

 

*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.

 
 
 
 
 
 
 
 
 
 
 
 
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SUPERVISOR INFORMATION

 
 
 
 
 

INJURY INFORMATION

 
 
 

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

 
 
 

TREATMENT INFORMATION

 
 

LOST TIME INFORMATION

 
 
 
 
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DEPARTMENT INFORMATION

 
 
 
 

Upload any and all documentation here.

Drop your files here