"Incident Notice Only" - Georgia (United States)

What Is a Georgia DOAS Incident Report Form?

A Georgia DOAS Incident Report Form is a form that is used by workers to report a work based incident. This form was developed for the Workers' Compensation Program which provides medical care, recovery, and expenses associated with job-related injuries.

In the case of getting occupational injuries that require medical attention or become the cause of lost working days, a worker should call the Telephonic Reporting Center within 24 hours of being injured. Workers' Compensation Incident Notice has to be filled out for all other injuries such as injuries that require only first aid or no medical care at all. The agency records them as an incident only.

This form was released by the Georgia Department of Administrative Services (DOAS) along with Risk Management Services and the latest version of it was issued on January 1, 2018. A Georgia Incident Report Form fillable version is available for download below.

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Georgia Incident Report Instructions

An Incident Report Form must be filled in as follows:

  1. The name of the agency and the date of the incident reported by the employee should be entered.
  2. The name of the injured employee, their office phone number, job title, Social Security number should be provided.
  3. The date and time of the incident should be entered.
  4. The filer has to provide a complete description of the incident, its detailed circumstances, and reasons.
  5. The filer should indicate the type of injury caused. It can be cut, scrape, or burn.
  6. The place of occurrence should be specified, including the address if it is possible.
  7. All the witnesses of the incident, including their names and phone numbers, should be indicated.
  8. The filer should provide information about getting the first aid at the time of the incident, and its type if the aid was administered.
  9. Enter the name and phone number of the supervisor, and the name and phone number of the person filling out the report.
  10. Provide the date of filling out the form.
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Download "Incident Notice Only" - Georgia (United States)

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Workers’ Compensation
(Agency Name)
Incident Notice Only
Instructions: For occupational injuries requiring medical attention or lost work days, call the
Telephonic Reporting Center at 1-877-656-RISK (7475) as soon as possible within 24 hours of
knowledge of injury. Complete this form for the agency’s record for all other injuries.
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) ___________________________________________
Witness/es (Name/s and telephone #) ___________________________________________________
Was First Aid administered at time of incident? Yes, No
What type? __________________
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.
FOR INTERNAL USE -
PERSONNEL RECORDS ONLY
Risk Management Services
Phone: 404-656-6245
200 Piedmont Avenue SE  Suite 1220 West Tower  Atlanta, Georgia 30334-9010
Fax: 404-657-1188
www.doas.ga.gov
Revision 2018
Workers’ Compensation
(Agency Name)
Incident Notice Only
Instructions: For occupational injuries requiring medical attention or lost work days, call the
Telephonic Reporting Center at 1-877-656-RISK (7475) as soon as possible within 24 hours of
knowledge of injury. Complete this form for the agency’s record for all other injuries.
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) ___________________________________________
Witness/es (Name/s and telephone #) ___________________________________________________
Was First Aid administered at time of incident? Yes, No
What type? __________________
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.
FOR INTERNAL USE -
PERSONNEL RECORDS ONLY
Risk Management Services
Phone: 404-656-6245
200 Piedmont Avenue SE  Suite 1220 West Tower  Atlanta, Georgia 30334-9010
Fax: 404-657-1188
www.doas.ga.gov
Revision 2018