Fill and Sign the Concentra Authorization Form Fillable

Reset Form ACCIDENT REPORT STATE OF TENNESSEE DIVISION OF CLAIMS ADMINISTRATION State Agency ____________________ 9TH FLOOR ANDREW JACKSON BUILDING NASHVILLE, TN 37243 (615) 741-2734 Location # _______________________ Budget Code # ___________________ 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 2. Last Birthdate _______________________ Sex __________ Job Title __________________________________________ Mo. 3. M.I. Day Year 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? _______________________________________________________ TR-0231 (Rev. 2-94) RDA 1178 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