Updated Tennessee First Work Injury Report Details

The Tennessee First Report Form is the first step in the process of becoming a licensed veterinary technician (LVT) in the state of Tennessee. This form must be completed and submitted to the Veterinary Technician National Board (VTNE) to begin your application for licensure. In this blog post, we'll provide an overview of what's included in the First Report Form and how to submit it. We'll also discuss some of the important eligibility requirements for becoming a LVT in Tennessee.

Here is the information relating to the form you were looking for to complete. It will tell you the amount of time you will need to complete tennessee first report, exactly what parts you need to fill in and a few other specific facts.

QuestionAnswer
Form NameTennessee First Report
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namestennessee department of labor forms employers first report of injury, tn first injury report form, tn first report of injury, first report work

Form Preview Example

TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT

EMPLOYER’S FIRST REPORT OF WORK INJURY OR ILLNESS

 

 

JURISDICTION CLAIM # (STATE FILE #)

 

 

 

CLAIM TYPE CODE

 

THE USE OF THIS FORM IS REQUIRED UNDER THE PROVISIONS OF THE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MED ONLY

 

 

TENNESSEE

WORKERS'

COMPENSATION

LAW

AND

MUST

BE

 

 

 

 

 

 

 

 

 

 

 

 

 

INDEMNITY

 

 

 

 

CLAIMS ADM CLAIM # (INSURER CLAIM #)

 

 

 

 

 

 

 

 

 

 

 

 

 

COMPLETED

AND

FILED

WITH YOUR

 

 

INSURANCE

CARRIER

 

 

 

 

 

 

 

 

 

 

 

 

 

BECAME LOST TIME

 

 

 

CARRIER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BECAME MED ONLY

 

IMMEDIATELY AFTER NOTICE OF INJURY.

 

 

 

 

 

 

 

 

 

OSHA LOG CASE #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NOTIFY ONLY

 

IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TRANSFER

 

 

MISLEADING

INFORMATION

TO

ANY

PARTY

TO

A

WORKERS'

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADM

NAME OF INSURANCE CARRIER

 

 

 

 

 

 

CARRIER FEIN

 

 

COMPENSATION TRANSACTION FOR THE PURPOSE OF COMMITTING

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FRAUD.

PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF

CLAIMS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INSURANCE BENEFITS.

 

 

 

 

 

 

 

 

 

 

 

 

 

CLAIMS ADMIN FIRM NAME (IF DIFFERENT FROM

 

 

 

FEIN OF CLMS ADM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IF YOU HAVE QUESTIONS, THE STATE NOW HAS A BENEFIT REVIEW

 

 

 

 

 

 

 

 

CARRIER)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WORKERS'

COMPENSATION

SPECIALIST

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SYSTEM

WHERE A

CAN

 

 

CLAIMS ADJUSTER NAME

 

 

 

 

 

 

CLMS ADJ PHONE #

 

 

 

 

 

 

 

 

 

 

PROVIDE ASSISTANCE. CALL 1-800-332-2667 (TDD).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CLAIM HANDLING OFFICE ADDRESS LINE 1 AND LINE 2

 

 

 

 

 

 

 

 

 

 

CITY

 

 

 

 

STATE

 

 

 

 

 

 

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYER NAME

 

 

 

 

 

 

EMPLOYER FEIN

 

 

SIC CODE

 

 

 

 

 

PHONE NUMBER

 

 

MPLOYERE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

 

 

 

 

 

STATE

ZIP

 

 

INSURED REPORT #

 

 

 

EMPLOYER LOCATION

 

 

 

EMPLOYER ADDRESS LINE 1 AND LINE 2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NATURE OF BUSINESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

POLICY

INSURED NAME (PARENT CO. IF DIFFERENT THAN

 

 

 

POLICY NUMBER

 

EFF DATE

 

 

 

 

 

EMPLOYMENT STATUS CODE

 

EMPLOYER)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FULL TIME/REGULAR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SELF INSURED?

 

EXP DATE

 

 

 

 

PART TIME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

PIECE WORKER

 

 

 

 

 

 

 

 

 

EMPLOYEE LAST NAME

 

 

 

 

 

 

PHONE INCL AREA CODE

 

GENDER

 

 

 

 

 

 

SEASONAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MALE

 

 

 

 

 

 

VOLUNTEER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FEMALE

 

 

 

 

APPRENTICE FULL TIME

 

 

 

 

 

FIRST

 

 

 

 

 

 

MI

 

DEPARTMENT REGULARLY

 

 

 

 

 

 

 

 

EMPLOYEE

 

 

 

 

 

 

 

 

 

 

WORKED

 

 

UNKNOWN

 

 

 

 

APPRENTICE PART TIME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADRRESS LINE 1 & 2

 

 

 

 

 

 

 

 

 

 

 

 

OCCUPATION DESCRIPTION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

 

 

 

 

 

STATE

ZIP

 

 

MARITAL STATUS

 

 

 

MARRIED

 

 

 

 

NCCI CLASS CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

UNMARRIED, SINGLE,

 

SEPARATED

 

 

 

 

 

 

 

 

 

SSN

 

 

 

 

DATE OF BIRTH

 

 

DATE OF HIRE

 

DIVORCED

 

 

 

UNKNOWN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WAGE

WAGE

 

PERIOD

WEEKLY

 

NUMBER OF DAYS WORKED PER

 

SALARY CONTINUED IN LIEU OF COMPENSATION

YES

NO

 

$

 

HOURLY

BI-WEEKLY

 

 

 

 

 

WEEK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FULL WAGES PAID FOR DATE OF INJURY

YES

NO

 

 

 

 

 

 

 

DAILY

MONTHLY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE OF INJURY

 

 

 

 

TIME OF INJURY

 

AM PM

 

TIME EMPLOYEE BEGAN WORK ON INJURY DATE

 

 

 

 

 

 

 

 

 

 

 

 

COULD NOT BE DETERMINED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AM

PM

 

 

 

 

DATE EMPLOYER NOTIFIED OF INJURY

 

BODY PART AFFECTED CODE

 

NATURE OF INJURY CODE

 

 

 

CAUSE OF INJURY CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE CLAIM ADM NOTIFIED OF INJURY

 

HOW INJURY OR ILLNESS OCCURRED. DESCRIBE THE INCIDENT INCLUDING WHAT THE EMPLOYEE WAS DOING

 

 

 

 

 

 

 

 

 

 

JUST BEFORE, THE PART OF THE BODY AFFECTED AND HOW, AND OBJECT OR SUBSTANCE THAT DIRECTLY

INJURY

DATE LAST DAY WORKED

 

 

 

 

HARMED THE EMPLOYEE.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE DISABILITY BEGAN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACCIDENT/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RETURN TO WORK DATE (IF APPLICABLE)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE OF DEATH (IF APPLICABLE)

 

 

 

 

IF DEATH CLAIM, GIVE #

DEPENDENTS FOR EACH RELATIONSHIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WIDOW

 

 

 

FATHER

 

____ SISTER

 

 

 

 

 

 

TOTAL # DEPENDENTS

 

 

 

 

 

 

 

WIDOWER

 

 

____ DAUGHTER

 

____ BROTHER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DID INJURY/ILLNESS OCCUR ON EMPLOYERS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PREMISES?

YES NO

 

 

 

 

 

MOTHER

 

 

____ SON

 

____ HANDICAPPED CHILD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS WHERE INJURY OCCURRED (IF OTHER THAN EMPLOYERS PREMISES)

 

 

 

 

 

 

 

 

 

 

COUNTY OF INJURY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

STATE

 

 

 

 

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHYSICIAN NAME

 

 

 

 

 

 

 

 

 

 

 

 

HOSPITAL OR OFF SITE TREATMENT NAME

 

 

 

 

TREATMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS LINE 1 AND 2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS LINE 1 AND 2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

 

 

 

STATE

 

ZIP

 

CITY

 

 

 

 

 

 

 

 

 

STATE

 

 

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INITIAL TREATMENT

 

 

MINOR BY EMPLOYER

 

 

HOSPITALIZED > 24 HRS

 

 

 

 

 

 

FUTURE MAJOR MEDICAL/LOST TIME

 

 

 

NO MEDICAL TREATMENT

 

 

MINOR BY CLINIC/HOSPITAL

EMERGENCY CARE

 

 

 

 

 

 

ANTICIPATED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER

DATE PREPARED

 

PREPARERS NAME & TITLE

 

PREPARERS COMPANY NAME

 

 

PHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LB-0021 (REV. 12/07)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RDA 10183