University of West Georgia Injury Incident Report

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*

Time of Incident*

Date Employer Notified*

Time Employer Notified*

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*

Gender*

Male

Female

Marital Status*

Single

Married

Divorced

Widowed

Separated

Number of Dependents (including spouse)*

Job Title*

Date of Hire*

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

No

Witness 1 Name

Witness 1 Phone Number

Was there a 2nd witness?*

Yes

No

Witness 2 Name

Witness 2 Phone Number

Was there a 3rd witness?*

Select

Witness 3 Name

Witness 3 Phone Number

TREATMENT INFORMATION

Was treatment received at a medical facility?*

Yes

No

Name of Treatment Facility

Facility Address, City, State, Zip

Facility Phone #

Treating Physician

Who drove the employee?

LOST TIME INFORMATION

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

Yes

No

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

Yes

No

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

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?*

File Upload

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