Page 208 - Personnel Policy and Procedures Manual
P. 208
AUGUSTA, GEORGIA
PERSONNEL ACTION REQUEST
(SAFETY REVIEW COMMITTEE DAMAGE ASSESSMENT)
Employee Name - Dept No.
Social Sec No. Emp No.
Miscellaneous -
PLEASE DEDUCT $ IN PAYMENT(S) OF $______
THIS IS A SAFETY REVIEW COMMITTEE DAMAGE ASSESSMENT
CREDIT ACCOUNT - #611-01-5214 35-19902
DATE OF ACCIDENT -
DATE OF LAST PAYMENT -
x X
DATE EMPLOYEE SIGNITURE
IMPORTANT - PLEASE RETURN this form to RISK MANAGEMENT to ensure the automatic deduction
mentioned in your Safety Review Committee letter is not activated. Thank you for your assistance.
All Rights Reserved – As approved by the Commission on 05-07-2019 207 | P a g e
