CITY OF ATLANTA

Employer’s Supplemental Report of Injury

Use this form if

(1) Employee returns to light or full duty status.

(2) Employee suffers a recurrence of the injury.

(3) Employee died as a result of injury.

Date:
Department:	Police Department
Bureau:
Name of injured employee:
First	Middle	Last
Social Security Number:
Date of injury:
Date of death:
Indicate part of body injured:
First full day of work missed:
Intermittent days missed:
RETURN TO WORK DATE:

Send form and report to Risk Management Division, Workers Compensation Unit.

__________________________________

Signature

Form 29-S-24 7/90

D:\RCwork\forms\Employers Supplemental Report of Injury.doc

CITY OF ATLANTA

Richard Clarke

2002-04-15