SOP_NUMBER: 104.22-att-1 TITLE: Employee Incident Notice REFERENCE_CODE: IVO04-0002 DIVISION: Administrative & Finance TOPIC_AREA: 104 Policy-HR Records/I.D./Criminal History EFFECTIVE_DATE: 2020-05-27 WORD_COUNT: 617 POWERDMS_URL: https://public.powerdms.com/GADOC/documents/105216 URL: https://gps.press/sop-data/104.22-att-1/ SUMMARY: This form is used to document occupational and other injuries requiring medical attention or lost workdays for Georgia Department of Corrections employees. Supervisors must complete this form for injured employees and contact Teleclaim within 24 hours if medical treatment is being sought. The form serves as an internal record and must be retained in the local medical file until replaced by the official WC-1 Employer's First Report of Injury. KEY_TOPICS: employee injury, occupational injury, workers' compensation, incident report, first aid, medical attention, lost workday, workplace injury, employee safety, incident documentation ATTACHMENTS: 1. Employee Incident Notice URL: https://gps.press/sop-data/104.22-att-1/ 2. Notice of Injury and Leave Election Form URL: https://gps.press/sop-data/104.22-att-2/ ======================================================================== FULL TEXT: ======================================================================== # **GEORGIA DEPARTMENT OF CORRECTIONS** **EMPLOYEE INCIDENT NOTICE** SOP 104.22 Attachment 1 5/27/20 |Instructions:
Complete this form for occupational and other injuries requiring medical attention or lost workdays. For occupational injuries,
call Teleclaim at 877-656-7475 within 24 hours or as soon as practical after the injury. If injured employee is seeking no
medical treatment at this time, DO NOT call Teleclaim. Complete this form and file.|Col2|Col3|Col4|Col5|Col6| |---|---|---|---|---|---| |EMPLOYEE INFORMATION|EMPLOYEE INFORMATION|EMPLOYEE INFORMATION|EMPLOYEE INFORMATION|EMPLOYEE INFORMATION|EMPLOYEE INFORMATION| |Name of injured employee:
|Name of injured employee:
|Job Title/Work Unit/Work Telephone #:|Job Title/Work Unit/Work Telephone #:|Job Title/Work Unit/Work Telephone #:|Job Title/Work Unit/Work Telephone #:| |Date of Hire:|Date of Hire:|Date of Hire:|Circle: Full-Time/ Part-Time/ Other|Circle: Full-Time/ Part-Time/ Other|Circle: Full-Time/ Part-Time/ Other| |Social Security #:|Social Security #:|Social Security #:|Employee ID #:|Employee ID #:|Employee ID #:| |Date of Birth:
|Date of Birth:
|Date of Birth:
|Gender:
Marital Status:|Gender:
Marital Status:|Gender:
Marital Status:| |
Home Address:|
Home Address:|
Home Address:|
Home Address:|
Home Address:|
Home Address:| |INCIDENT INFORMATION|INCIDENT INFORMATION|INCIDENT INFORMATION|INCIDENT INFORMATION|INCIDENT INFORMATION|INCIDENT INFORMATION| |Date of incident:

Return to Work Date:
|Time of incident:
|Time of incident:
|Place of incident (provide address if possible):

|Place of incident (provide address if possible):

|Place of incident (provide address if possible):

| |Type of incident (Cut, burn, scrape, etc.):
|Type of incident (Cut, burn, scrape, etc.):
|Type of incident (Cut, burn, scrape, etc.):
|Body part(s) affected (be specific, Left eye, etc.):|Body part(s) affected (be specific, Left eye, etc.):|Body part(s) affected (be specific, Left eye, etc.):| |Description of incident (How, where, why?):

|Description of incident (How, where, why?):

|Description of incident (How, where, why?):

|Description of incident (How, where, why?):

|Description of incident (How, where, why?):

|Description of incident (How, where, why?):

| |Witness [Name(s) and telephone #]:|Witness [Name(s) and telephone #]:|Witness [Name(s) and telephone #]:|Witness [Name(s) and telephone #]:|Witness [Name(s) and telephone #]:|Witness [Name(s) and telephone #]:| |Was first aid administered at the time of the incident?
YES
 NO
If YES, describe the type/by whom:
|Was first aid administered at the time of the incident?
YES
 NO
If YES, describe the type/by whom:
|Was first aid administered at the time of the incident?
YES
 NO
If YES, describe the type/by whom:
|Was first aid administered at the time of the incident?
YES
 NO
If YES, describe the type/by whom:
|Was first aid administered at the time of the incident?
YES
 NO
If YES, describe the type/by whom:
|Was first aid administered at the time of the incident?
YES
 NO
If YES, describe the type/by whom:
| |Medical Provider Address/Phone#:
|Medical Provider Address/Phone#:
|Medical Provider Address/Phone#:
|Medical Provider Address/Phone#:
|Medical Provider Address/Phone#:
|Medical Provider Address/Phone#:
| |INCIDENT REPORT INFORMATION|INCIDENT REPORT INFORMATION|INCIDENT REPORT INFORMATION|INCIDENT REPORT INFORMATION|INCIDENT REPORT INFORMATION|INCIDENT REPORT INFORMATION| |Name of person completing incident report:|Name of person completing incident report:|Name of person completing incident report:|Name of person completing incident report:|Name of person completing incident report:|Telephone #:| |Date/Timeemployeereported the incident:|Date/Timeemployeereported the incident:|Date/Timeemployeereported the incident:|Date/Timeemployeereported the incident:|Date report completed:|Date report completed:| |SUPERVISOR INFORMATION|SUPERVISOR INFORMATION|SUPERVISOR INFORMATION|SUPERVISOR INFORMATION|SUPERVISOR INFORMATION|SUPERVISOR INFORMATION| |Name:|Name:|Name:|Name:|Name:|Telephone #:| This report does **not** replace the WC1- Employer's First Report of Injury. This is for supervisor's records for **INTERNAL USE** **ONLY. Do not submit to DOAS, Risk Management.** Record Retention: Upon completion, this form shall be retained in the local medical file until replaced by the official copy of the WC-1, Employer's First Report of Injury.