FOR REPORTING PURPOSES ONLY

INCIDENT NOTICE ONLY

Instructions: Only use this form if no injury is claimed and/or no medical treatment was

needed. For occupational injuries requiring medical attention or lost work days, call the

Office of Human Resources immediately upon notification of the injury. Only use this form if no injury is claimed and/or no medical treatment was needed.

Date incident reported by employee ____________________

Name of injured employee ___________________________ Office phone# ________________

Job Title: _____________________________________________________________________

Social Security # _____________________________

Date of incident ____________________ Time of incident __________________

Description of incident (how, where, why?) __________________________________________

Type of injury (cut, scrape, burn, etc.) _______________________________________________

Place of occurrence (provide address if possible) ______________________________________

Was First Aid administered at time of incident? Yes _____ No _____ What type? ___________

Witnesses (provide names and contact numbers)_______________________________________

Supervisor’s name __________________________________ Telephone # _________________

Person completing report _____________________________ Telephone # _________________

Date Report completed ______________

This form does not replace the WC-1, Employer’s First Report of Injury and

should only be used if there is no injury being claimed by the employee or that

no medical treatment was needed. This form should be kept as part of the

employee’s personnel file and be made available if requested or forwarded to

DOAS/Division of Risk Management Services by fax (404) 657-1188..

Updated 7/04