Section 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. 
[phone]; FAX NO. [phone]; TDD NO. [phone]
 
   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.