§ Title 34 Appx. r. 622-1-.05 - Employer's knowledge statement - Georgia Statutes

O.C.G.A. Title 34 Appx. r. 622-1-.05 (2010)
622-1-.05. Employer's knowledge statement

The employer is required to submit a notarized knowledge affidavit containing information outlined in the following format:

On , I , the

(Date of first knowledge) (Name) (Title)

for , learned that ,

(Employer) (Employee)

SSN had .

(Type of prior impairment)

I received this information in the following manner: .

I considered it a permanent physical impairment because .

In addition, I considered the impairment likely to be a hindrance to

employment because .

If this affidavit is prepared by someone other than the appropriate
employer representative, please identify:

Name

NOTICE TO EMPLOYER:

If this document is pre-prepared and submitted to you for signature,
carefully review this document to make sure the information outlined is
consistent with your knowledge of the prior impairment.

I, the undersigned employer representative, hereby provide the above
information under oath.

Employer Representative

Title
Telephone No.

Notary Public

Expiration date: Date:

IF YOU HAVE A DISABILITY AND NEED ASSISTANCE IN COMPLETING THIS FORM,
PLEASE CONTACT THE SUBSEQUENT INJURY TRUST FUND'S ADA COORDINATOR AT SUITE
500, NORTH TOWER, 1720 PEACHTREE ST. NW, ATLANTA, GA 30309-2462, TELEPHONE NO.
(404) 206-6360; FAX NO. (404) 206-6363; TDD NO. (404) 206-5053

IMPORTANT: SEE REVERSE SIDE FOR INSTRUCTIONS

.............................................................................

(REVERSE SIDE OF FORM)

INSTRUCTIONS

1. The affiant must be someone who has firsthand knowledge of the
worker's pre-existing condition such as an individual in an executive,
personnel, or personnel-advisory capacity, or, if an employer is subject to
the Americans With Disabilities Act, the designated custodian of (medical)
records.

2. Attach any documentation or records that were in the employer's
possession prior to the subsequent injury. If you attach documents, these
must be accompanied by certification on employer's letterhead that said
documents were contained in the employer's files.

Any reports specifically referred to in the affidavit must be attached and
certified.

3. The employer should identify the actual date of knowledge of the
prior impairment.

4. The employer, if possible, should list any individuals either
currently or formerly working for the employer who may have firsthand
knowledge of the employee's pre-existing disabilities.

a.

Name Address Telephone No.

b.

Name Address Telephone No.

c.

Name Address Telephone No.

.............................................................................

Authority O.C.G.A. Sec. 34-9-354(d). Administrative History. Original Rule
entitled "Employer's Knowledge Statement" was filed on May 26, 1987; effective
June 15, 1987. Repealed: New Rule of same title adopted. F. Sept. 9, 1993;
eff. Sept. 29, 1993; Amended: eff. Apr. 7, 2002.
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