TR-0175 (Rev. 6/12) RDA-413
Tennessee Consolidated Retirement System
502 Deaderick Street
Nashville, Tennessee 37243-0201
Please complete and sign this form to authorize the Tennessee Consolidated Retirement System to evaluate
your vocational history.
Member ID Last 4 SSN XXX-XX- Date of Birth
Full Name Age
Mailing Address
City State Zip Code
Email Phone Number
Highest Grade Completed in School
Additional Training or Education (brief description)
Type of Work Performed for the Greatest Length of Time
Name of Employer
Title of Position Year Started Year Ended
Length of Time to Learn Job
Types of Machines Operated
Manual Labor Involved (describe in terms of objects lifted or carried and weight)
Did You Supervise Other Employees?
Yes No
In Your Words, Describe Your Work During a Typical Day
List and Brie y Describe Any Other Jobs You Have Had in the Past 15 Years
SECTION 2. PHYSICIAN INFORMATION ( rst and last name of treating physician(s))
Member’s Signature Date