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

Enter A Claim Employee Injury Report Witness Report

Information: This form must be completed by the supervisor of the injured employee following their investigation.    
NOTE: All fields/information is required    

Name of injured employee:  *  
Supervisor's Name:     
Date of injury:  *    
Supervisor Phone Number:  *    

What job/task was the employee performing when the injury occurred?  *

As a result of your investigation, do you support this claim?  *
If so, why?  *
In your own words, explain what the employee was doing and how the accident occurred:  *    
In your opinion, could this accident have been prevented?  *
Explain  *    
What changes or recommendations would you support to prevent this injury from reoccurring?  *    
Supervisor'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.