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.
Question | Answer |
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Form Name | Tennessee First Report |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | tennessee department of labor forms employers first report of injury, tn first injury report form, tn first report of injury, first report work |
TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
EMPLOYER’S FIRST REPORT OF WORK INJURY OR ILLNESS
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JURISDICTION CLAIM # (STATE FILE #) |
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CLAIM TYPE CODE |
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THE USE OF THIS FORM IS REQUIRED UNDER THE PROVISIONS OF THE |
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MED ONLY |
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TENNESSEE |
WORKERS' |
COMPENSATION |
LAW |
AND |
MUST |
BE |
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INDEMNITY |
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CLAIMS ADM CLAIM # (INSURER CLAIM #) |
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COMPLETED |
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FILED |
WITH YOUR |
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INSURANCE |
CARRIER |
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BECAME LOST TIME |
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CARRIER |
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BECAME MED ONLY |
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IMMEDIATELY AFTER NOTICE OF INJURY. |
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OSHA LOG CASE # |
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NOTIFY ONLY |
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IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR |
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TRANSFER |
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MISLEADING |
INFORMATION |
TO |
ANY |
PARTY |
TO |
A |
WORKERS' |
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/ |
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ADM |
NAME OF INSURANCE CARRIER |
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CARRIER FEIN |
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COMPENSATION TRANSACTION FOR THE PURPOSE OF COMMITTING |
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FRAUD. |
PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF |
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CLAIMS |
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INSURANCE BENEFITS. |
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CLAIMS ADMIN FIRM NAME (IF DIFFERENT FROM |
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FEIN OF CLMS ADM |
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IF YOU HAVE QUESTIONS, THE STATE NOW HAS A BENEFIT REVIEW |
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CARRIER) |
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WORKERS' |
COMPENSATION |
SPECIALIST |
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SYSTEM |
WHERE A |
CAN |
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CLAIMS ADJUSTER NAME |
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CLMS ADJ PHONE # |
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PROVIDE ASSISTANCE. CALL |
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CLAIM HANDLING OFFICE ADDRESS LINE 1 AND LINE 2 |
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CITY |
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ZIP |
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EMPLOYER NAME |
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EMPLOYER FEIN |
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SIC CODE |
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PHONE NUMBER |
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MPLOYERE |
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CITY |
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STATE |
ZIP |
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INSURED REPORT # |
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EMPLOYER LOCATION |
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EMPLOYER ADDRESS LINE 1 AND LINE 2 |
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NATURE OF BUSINESS |
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POLICY |
INSURED NAME (PARENT CO. IF DIFFERENT THAN |
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POLICY NUMBER |
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EFF DATE |
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EMPLOYMENT STATUS CODE |
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EMPLOYER) |
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FULL TIME/REGULAR |
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SELF INSURED? |
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EXP DATE |
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PART TIME |
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YES |
NO |
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PIECE WORKER |
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EMPLOYEE LAST NAME |
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PHONE INCL AREA CODE |
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GENDER |
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SEASONAL |
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MALE |
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VOLUNTEER |
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FEMALE |
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APPRENTICE FULL TIME |
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FIRST |
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MI |
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DEPARTMENT REGULARLY |
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EMPLOYEE |
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WORKED |
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UNKNOWN |
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APPRENTICE PART TIME |
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ADRRESS LINE 1 & 2 |
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OCCUPATION DESCRIPTION |
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CITY |
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STATE |
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MARITAL STATUS |
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MARRIED |
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NCCI CLASS CODE |
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UNMARRIED, SINGLE, |
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SEPARATED |
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SSN |
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DATE OF BIRTH |
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DATE OF HIRE |
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DIVORCED |
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UNKNOWN |
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WAGE |
WAGE |
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PERIOD |
WEEKLY |
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NUMBER OF DAYS WORKED PER |
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SALARY CONTINUED IN LIEU OF COMPENSATION |
YES |
NO |
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$ |
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HOURLY |
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WEEK |
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FULL WAGES PAID FOR DATE OF INJURY |
YES |
NO |
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DAILY |
MONTHLY |
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DATE OF INJURY |
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TIME OF INJURY |
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AM PM |
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TIME EMPLOYEE BEGAN WORK ON INJURY DATE |
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COULD NOT BE DETERMINED |
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AM |
PM |
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DATE EMPLOYER NOTIFIED OF INJURY |
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BODY PART AFFECTED CODE |
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NATURE OF INJURY CODE |
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CAUSE OF INJURY CODE |
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DATE CLAIM ADM NOTIFIED OF INJURY |
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HOW INJURY OR ILLNESS OCCURRED. DESCRIBE THE INCIDENT INCLUDING WHAT THE EMPLOYEE WAS DOING |
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JUST BEFORE, THE PART OF THE BODY AFFECTED AND HOW, AND OBJECT OR SUBSTANCE THAT DIRECTLY |
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INJURY |
DATE LAST DAY WORKED |
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HARMED THE EMPLOYEE. |
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DATE DISABILITY BEGAN |
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ACCIDENT/ |
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RETURN TO WORK DATE (IF APPLICABLE) |
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DATE OF DEATH (IF APPLICABLE) |
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IF DEATH CLAIM, GIVE # |
DEPENDENTS FOR EACH RELATIONSHIP |
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WIDOW |
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FATHER |
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____ SISTER |
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TOTAL # DEPENDENTS |
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WIDOWER |
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____ DAUGHTER |
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____ BROTHER |
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DID INJURY/ILLNESS OCCUR ON EMPLOYER’S |
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PREMISES? |
YES NO |
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MOTHER |
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____ SON |
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____ HANDICAPPED CHILD |
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ADDRESS WHERE INJURY OCCURRED (IF OTHER THAN EMPLOYER’S PREMISES) |
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COUNTY OF INJURY |
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CITY |
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PHYSICIAN NAME |
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HOSPITAL OR OFF SITE TREATMENT NAME |
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TREATMENT |
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ADDRESS LINE 1 AND 2 |
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ADDRESS LINE 1 AND 2 |
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CITY |
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STATE |
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CITY |
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STATE |
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INITIAL TREATMENT |
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MINOR BY EMPLOYER |
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HOSPITALIZED > 24 HRS |
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FUTURE MAJOR MEDICAL/LOST TIME |
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NO MEDICAL TREATMENT |
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MINOR BY CLINIC/HOSPITAL |
EMERGENCY CARE |
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ANTICIPATED |
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OTHER |
DATE PREPARED |
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PREPARER’S NAME & TITLE |
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PREPARER’S COMPANY NAME |
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PHONE NUMBER |
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RDA 10183 |