Fillable ACCIDENT REPORT STATE OF TENNESSEE DIVISION OF CLAIMS (Motlow State Community College)

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ACCIDENT REPORT STATE OF TENNESSEE DIVISION OF CLAIMS (Motlow State Community College)

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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 ( _______)______________________
4 Supervisor ___________________________________ 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 __________________________
DESCRIPTION OF THE INJURY:
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?_______________________________________________________
State Agency ____________________
Budget Code # ___________________
Location # _______________________
ACCIDENT REPORT
STATE OF TENNESSEE
DIVISION OF CLAIMS ADMINISTRATION
9TH FLOOR ANDREW JACKSON BUILDING
NASHVILLE, TN 37243
(615) 741-2734
TR-0231 (Rev. 2-94) RDA 1178
Reset Form
TO BE COMPLETED BY SUPERVISOR:
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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ACCIDENT REPORT STATE OF TENNESSEE DIVISION OF CLAIMS (Motlow State Community College)

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Completed 27 July 2020

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