Form Tr 0231 PDF Details

In the realm of workplace safety, reporting and documenting incidents are critical aspects of managing workers' compensation claims. Among the essential documents in this process is the TR-0231 form, a comprehensive Injury and Illness Incident Report designed for state employees in Tennessee. This form plays a pivotal role from the moment a work-related injury or illness is identified, guiding the injured or ill employee and their supervisor through a detailed account of the incident. It mandates meticulous adherence to instructions, including the dual-sided printing requirement, aiming for a thorough capture of the incident's specifics. The form complements OSHA’s Form 301, necessitating prompt completion to expedite claims processing. With specific fields catering to personal and incident-related information, the form acts as a foundational document, ensuring accurate claims presentation for workers' compensation. Its structured format, requiring typewritten entries for clarity, and the obligation to answer all questions irrespective of their apparent relevance, underscores the documentation's legal and procedural importance. Completion and submission details, down to the precise office address, stress the form's role in a broader bureaucratic framework aiming to support state employees through their recovery and claims process efficiently.

QuestionAnswer
Form NameForm Tr 0231
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesTNAccidentRepor t pdf fillable basic incident report tennessee form

Form Preview Example

THIS INJURY AND ILLNESS INCIDENT REPORT IS ONE

OF THE FIRST FORMS THAT MUST BE FILLED OUT WHEN A RECORDABLE WORK-RELATED INJURY OR ILLNESS HAS OCCURRED. PLEASE FOLLOW THE FORM INSTRUCTIONS CAREFULLY.

PLEASE NOTE: The form must be printed on one sheet of paper with the first page of the form printed on the front and the second page of the form printed on the back.

This form, along with the OSHA’s Form 301 – Injury and

Illness Incident Report, should be completed as soon as possible after an accident or illness.

This form should be typed.

This form must be used exclusively by all state employees in presenting claims for workers’ compensation. All questions

must be answered.

Question 4 – State Agency should be “ ETSU- ” department

name.

Question 5 – Office Address should be “807 University Pkwy,

Box” and the box number of the department.

Upon completion, please sign and return the completed form to:

HUMAN RESOURCES

BOX 70564

Your assistance in completing this form correctly is appreciated.

Version0109

ACCIDENT REPORT STATE OF TENNESSEE

DIVISION OF CLAIMS ADMINISTRATION

9TH FLOOR ANDREW JACKSON BUILDING NASHVILLE, TN 37243

(615) 741-2734

State Agency ____________________

Budget Code # ___________________

Location # _______________________

This form must be used exclusively by all state employees in presenting claims for workers’ compensation. All questions must be answered.

TO BE COMPLETED BY EMPLOYEE: Social Security # ___________ - ___________ - ___________

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

Employee’s name

_________________________________________________________________________________

 

 

 

 

First

 

M.I.

 

 

Last

 

 

 

 

 

 

 

2.

Birthdate

_______________________

Sex

__________

Job Title

__________________________________________

 

 

Mo.

Day

Year

 

 

 

 

 

 

3.Home Address _________________________________________________________ City ______________________

State ___________________ Zip __________________________ Home Phone ( _______) ______________________

4Supervisor ___________________________________ State Agency ________________________________________

5.Office Address _________________________________________________________ City _____________________

State ___________________ Zip __________________________ Work Phone ( _______) ______________________

6.Date Employed by State ____________________

7.Exact location of project where injury occurred __________________________________________________________

__________________________________________________________________ County _______________________

8.Do duties of employee require being at this location? _____________________________________________________

9.Did employee leave work on day of injury? __________ If not, when did incapacity begin? ______________________

10.Date of Accident __________________________

DESCRIPTIONOFTHEINJURY:

1.State name of machine, tool, or other appliance with which injury occurred ___________________________________

2.Describe the injury in detail and state how it occurred _____________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

3.What part of person was injured? _____________________________________________________________________

4.Probable length of disability _________________________________________________________________________

5.Did employee lose time from work? ____________________________ How much time? ________________________

6.Physician’s name ________________________________ Address __________________________________________

City ____________________________ State ______ Zip ____________ Phone # ( _______)____________________

7.Date of first visit _____________________________

8.Who authorized visit to physician? ____________________________________________________________________

9.Was employee hospitalized? ___________ Where?_______________________________________________________

TR-0231 (REV. 2-94)

RDA 1178

TOBECOMPLETEDBYSUPERVISOR:

1.What position did employee hold when injured? _________________________________________________________

2.

Was injury caused by (a) employee’s willful misconduct?

_____________________________

 

 

 

 

(b) intentional self-inflicted injury?

_____________________________

 

 

 

 

(c) intoxication?

_____________________________

 

 

 

 

(d) failure or refusal to use safety appliance furnished him?

_____________________________

 

 

 

 

(e) failure to perform a duty required by law?

_____________________________

3.When was first notice of injury given to employer? Date ____________________________ Time ________________

To Whom? _____________________________________________ Position _________________________________

4.Monthly salary on date of injury $_________________

5.If disabled, will employee be on leave without pay during disability? ________________________________________

6.Relate any knowledge you may have of injury or what the employee reported to you ____________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

We, the undersigned, certify that all statements contained herein and on any attachments hereto are true and that the injuries reported were actually incurred. We also acknowledge that it is a misdemeanor to file a false claim with the Division of Claims Administration.

____________________________________________________

____________________

Claimant

Date

____________________________________________________

____________________

Supervisor

Date

TR-0231 (REV. 2-94)

RDA 1178

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Step 1: Press the "Get Form" button above. It is going to open up our tool so you can begin filling out your form.

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As for the fields of this particular PDF, here is what you want to do:

1. The Form Tr 0231 will require certain information to be inserted. Make certain the following fields are finalized:

The right way to fill in Form Tr 0231 part 1

2. Soon after filling in the previous part, go to the subsequent part and fill in the essential details in all these blanks - DESCRIPTION OF THE INJURY, State name of machine tool or, Describe the injury in detail and, What part of person was injured, Probable length of disability, Did employee lose time from work, Physicians name Address, City State Zip Phone, Date of first visit, Who authorized visit to physician, Was employee hospitalized Where, TR Rev, and RDA.

How to fill out Form Tr 0231 step 2

3. Completing TO BE COMPLETED BY SUPERVISOR, What position did employee hold, Was injury caused by a employees, b intentional selfinflicted injury, c intoxication, d failure or refusal to use safety, e failure to perform a duty, When was first notice of injury, To Whom Position, Monthly salary on date of injury, If disabled will employee be on, and Relate any knowledge you may have is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Best ways to fill out Form Tr 0231 step 3

As for Monthly salary on date of injury and Was injury caused by a employees, ensure you do everything right here. Those two are viewed as the key fields in this document.

4. The fourth subsection comes next with the following blanks to complete: We the undersigned certify that, Claimant, Date, Supervisor, Date, TR Rev, and RDA.

Date, Claimant, and RDA of Form Tr 0231

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