EMPLOYER'S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE GEORGIA STATE BOARD OF WORKERS' COMPENSATION

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1 GEORGIA STATE UNIVERSITY MODIFIED WC-1 EMPLOYER'S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE GEORGIA STATE BOARD OF WORKERS' COMPENSATION Assigned Workers Compensation Claim No.: WC NOTE: FAILURE TO SUBMIT THIS REPORT TO INSURER IMMEDIATELY MAY RESULT IN PENALTY IDENTIFYING INFORMATION EMPLOYEE Last Name First Name M.I. Male Date of Birth Address Street City State Zip Code EMPLOYER Nature of Business Female Home Phone Number Employee EMPLOYEE'S DEPARTMENT NAME: Social Security Number Georgia State University University Address Employer's Workers' Compensation Employer's Workers' Department of Safety and Risk Management Contact Phone Number Compensation Contact 75 Piedmont, Suite 506, P. O. Box 3961 FAX Number Atlanta, GA (404) (404) Employer Contact INSURER/ Name Claims Office Address SELF-INSURER Department of Administrative Services 200 Piedmont Ave., SE, Suite 1208 West, CLAIMS OFFICE Name ATLANTA, GA Risk Management Services / Workers' Compensation Unit Claims Reporting: Contact Department of SPECIFIC location where employee was injured or accident occurred: Safety and Risk Management for assistance. List Normally Scheduled Days Off EXACT Date Hired by Employer Month Day Year Time Employee Workday Employee s Job Title Started: Number of Days Worked Per Week Wage rate at time of injury or Disease: _$ AMOUNT per Hour per Day per Week per Month per Year INJURY/ILLNESS & MEDICAL Did Employee Receive Full Pay on Date of Injury? Date of Injury EXACT Time of Injury am pm Did Injury/Illness Occur on Employer's premises? County of Injury Type of injury/illness Date Employer Notified Enter First Date Employee Failed to Work Full Day Body Part(s) Affected Yes No Yes No If Returned to Work, Give Returned at what If Fatal, Enter Date of Death Date:wage: How Injury or Illness / Abnormal Health Condition Occurred: per Week Treating Physician (Name and Address) Initial Treatment Given: Hospital / Treating Facility (Name and Address) None Minor: By Employer Minor: By Clinical/Hospital Emergency Room Hospitalized > 24hrs Report Prepared By (Injured Employee s Supervisor or designee), (Print or Type Signature) Office Date Report Signed Telephone Number Address Of Person Preparing Report: IF YOU HAVE QUESTIONS PLEASE CONTACT ONE OF THE FOLLOWING: THE DEPARTMENT OF SAFETY AND RISK MANGEMENT, OCCUPATIONAL HEALTH AND SAFETY OFFICER, AT GEORGIA STATE UNIVERSITY ( ), REVISION 02/10/17

2 GEORGIA STATE UNIVERSITY LEAVE ELECTION MEMORANDUM Date: To: Co: From: Re: Department of Administrative Services, Workers Compensation Unit Benefits Office of Human Resources, Georgia State University Georgia State University, Department of Safety and Risk Management, Selection of Workers Compensation Pay Options for Injured Employee On the Date of, I, was injured on the job while working for the Department of at Georgia State University. If I lose any time because of this injury, I request that I be paid in the following manner: ( ) From my accumulated sick leave, and ( ) from my accumulated vacation leave before receiving Workers Compensation benefits for loss of wages. ( ) Workers Compensation benefits from the State of Georgia for loss of wages instead of full pay from accumulated sick and vacation leave from my employer, Georgia State University. Note: If this selection is made, the employee must initial all of the statements below. I understand that I will be compensated at no more than 66 2/3% of my weekly wage (max. of $500/week). I understand that I will not be paid for the first five workdays that I am out of work, unless I am out of work, due to my injury/illness for 21 consecutive days. I understand that I will need to contact Georgia State University, Human Resources Benefits, and make arrangements to keep my employee benefits current while I am out of work. ( ) From my accumulated sick leave, and if necessary, from my accumulated vacation leave from the date of until the date of after which time I wish to be paid Workers Compensation benefits instead of full, regular pay. I understand that I may change my Leave Election at any time, by filling out another Form and submitting the original to the Department of Safety and Risk Management. Note: Employee must initial above statement before signing. Signature of Employee (as shown on payroll) Date Signed GSU Human Resources to complete this section. The GSU Employee,, SSN: has a balance of vacation hrs and sick leave hrs. Leave will end as of. Weekly Wage Rate$ Short Term Disability Enrollment Verified by: Date (Name of Human Resources Employee)

3 GEORGIA STATE UNIVERSITY ACCEPTANCE / DECLINATION OF WORKERS COMPENSATION BENEFITS FOR AN ON THE JOB INJURY / ILLNESS Date: To: Co: From: Re: Department of Administrative Services, Workers Compensation Unit Benefits Office of Human Resources, Georgia State University Georgia State University, Department of Safety and Risk Management, Employee Acceptance / Declination of Workers Compensation Benefits On the Date of, I,, was injured on the job while working for the Department of at Georgia State University. I do not want medical treatment for my injuries at this time. I understand that I may change my mind at anytime within 30 days of my reported accident date, by contacting the Department of Safety and Risk Management. I do want medical treatment for my injuries at this time. I am requesting that a Workers Compensation Claim be filed so that I may select a physician to treat my injuries. Once my Workers Compensation Claim is filed I understand that I must: o Schedule a doctor s appointment before returning to work. o Keep all scheduled doctor s appointments, or reschedule them. o Provide my Supervisor AND the Department of Safety and Risk Management with a doctor s status slip every time I see a medical professional, for my injuries. If I am not offered a status slip, I understand I must ask for one. Signature of Employee (as shown on payroll) Date Signed

4 GEORGIA STATE UNIVERSITY ACCIDENT WITNESS STATEMENT This form is to be completed by either witness to the accident or by the injured employee. Injured employee s name: LAST FIRST MIDDLE Name of person filling out this form: LAST FIRST MIDDLE Phone number of person filling out this form: Job title of person filling out this form: Home address of person filling out this form: Street: City: State: Zip Code: County: Specific location of accident: Address/Name of building Date of accident: Time of accident: Time I began workday: Describe fully how the accident occurred: (including events that occurred immediately before the accident) Describe bodily injury sustained (please be specific about body part(s) affected): Recommendation on how to prevent this accident from recurring: Name of the supervisor of person filling out this form: LAST FIRST Telephone number of the supervisor of person filling out this form: Signature of person filling out this form: Date:

5 State of Georgia Workers Compensation Temporary Prescription Information State of Georgia Employee: The State of Georgia has partnered with mymatrixx to make filling workers compensation prescriptions easy. This document serves as a temporary prescription card. A permanent prescription card specific to your injury will be forwarded directly to you within the next 3 to 5 business days. Please take this letter and your prescription(s) to a pharmacy near you. mymatrixx has a network of over 60,000 pharmacies nationwide. If you need assistance locating a network pharmacy near you, please call mymatrixx toll free at (877) Please fill out employee information below and provide this document to any pharmacy with prescriptions. Employee Name: Group#: Member ID (SSN): Date of Injury: Processor: mymatrixx Bin#: Day supply is limited to 3 days for a new injury. mymatrixx Help Desk: (877) IF YOU ARE DENIED MEDICATION(S) AT THE PHARMACY PLEASE CALL (877) Pharmacist: Please obtain above information from the injured employee to process prescriptions for the workers compensation injury only. For questions or rejections please call (877) Please do not send patient home or have patient pay for medication(s) before calling mymatrixx for assistance. NOTE: Certain medications are pre-approved for this patient; these medications will process without an authorization. All others will require prior approval. *Employer Authorized Signature & Phone # J.Kit Ramdeen FOR ALL REJECTIONS OR QUESTIONS CALL: (877)