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303 N. Church St. RUTHERFORD COUNTY GOVERNMENT Phone: (615) 898-7715
Murfreesboro, TN 37130 "ON-THE-JOB INJURY" EMPLOYEE INJURY STATEMENT Fax: (615) 867-4602

Enter A Claim Supervisor's Report Witness Report

Information: This form must be completed by the injured employee at the time of any incident and sent with the OJI Claim Report. You are hereby instructed that all medical attention received for this injury must be with the immediate permission from the RC Insurance Department. Non-authorized treatment will void any future OJI benefits for this specific claim. PLEASE NOTE: Completion of an On-the-Job Injury Statement does not automatically ensure OJI program coverage. Inactivity of 30 consecutive days of an OJI filed claim will mean cessation of benefits.    
NOTE: All fields/information is required    

Employee Name:  *    
Social Security No:  *      
Time employee began work on the date of injury:  *      
Date of Injury:  *      
Work Location:  *    
Time work shift scheduled to end:  *      

What Job were you doing when the injury/illness occurred?

Is this the first time you reported this injury/illness?  *  
If "NO", when did you first report it?    

To whom did you first report it?

Was there anyone around at the time of the Injury?  *  

What safety equipment were you supposed to be wearing?

Were you wearing the safety equipment?  *  
If not, why not?    

Were any safety or work rules being violated at the time of the injury?  *  
If so, what were they?    

Were you performing your job as instructed?  *  
If not, what changes were made and why?    

Was any machine or other piece of equipment involved with your injury?  *  
If "YES", please explain in specifics?    

What part of the body do you believe to be involved with your injury?

Were you at your work station at the time of the injury?  *  
If not, please explain?    

Have you ever had a similar injury to the same or similar part of the body?  *  
If "YES", describe when and where?    

In your own words, describe what happened?  *

Employee Acknowledgement
Please read the statement below and enter your name and the last 4 digits of your SSN on the Employee Signature line and date. I understand all OJI Claims are investigated by the insurance department. Completion of an Employee Injury Statement or attempting to file an OJI Claim does not automatically guarantee acceptance of the individual claim. Therefore, after a full investigation of my OJI Claim, my claim may be non-compensable although I may have already seen an OJI Physician with OJI office approval. If this occurs, bills prior to the investigation will be paid in full by the Insurance Department and I understand that I will be responsible for any further treatment or medication. I also understand that any unauthorized medical treatment will be my sole responsibility, as there is no coverage provided when this occurs. I also hereby authorize the release of my protected health information from any and all health care providers, their employees, and agents and direct them to release or disclose to RC Insurance Department (address above) my complete medical record regardless of stated areas of injury. I waiver my right to confidentiality of these records for the purpose of an on-the-job injury. These records may be used by RC in making a determination as to my eligibility for benefits under the On-the-Job Injury program. Unless otherwise stated, this authorization expires 360 days from the date of execution. Making a false or fraudulent claim is an immediate ground for termination from RC. I also understand the Safety Coordinator or their representative has the right to attend all visits with me and my physician.

Employee's Signature:  *   Date:  Invalid Entry (Ex: 01/01/2011 or 1/1/11)
  Name and last 4 digits of SSN    

As is allowed by T.C.A. 50-6-106, Rutherford County (RC) has opted to withdraw from the Tennessee Worker's Compensation Act, and
instead has chosen to implement an On-The-Job Injury Program administered by the Rutherford County Insurance Department.

 * Please Complete the Missing Information