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
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:
Alan Farley - Election Commission
Anthony Tuggle - Agriculture Extension
Ben Mankin - Maintenance
Benard Salandy - Work Center
Brian Robertson - OIT
Dana Garrett - Health Dept
David Jones - Building Codes
Donna Scott - Juvenile Judge
Doug Demosi - Planning Dept
Ernest Burgess - Mayors Office
Heather Dawbarn - Register of Deeds
Jim Cope - County Attorney
Joe Haffner - Ambulance
Joe Russell - Sheriff’s Dept
John Bratcher - Chancery Court
John Lodl - Archives
Larry Farley - Fire Dept
Lisa Duke Crowell - County Clerk
Lisa Nolen - Finance
Lise Crowell - Circuit Court Clerk
Lynn Duke - Juvenile Detention
Mac Nolen - Landfill
Mac Nolen - Solid Waste
Mark King - Community Care
Melissa Street - Risk Management
Merry Hickerson - Hwy Dept
Michael Gregory - PAWS
Michael Payne - Community Learning
Mike Hughes - Engineer
Mike Nunley - Ambulance
Pam Fone - Domestic Violence
Rob Mitchell - Property Assessors
Sonya Stephenson - HR
Teb Batey - Trustees
Teena Sanders Bigbee - Youth Services
TK Kast - EMA
Trey King - Drug Court
Vickie Clay - Community Care
Wanda Watkins - Gen Sessions Court
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?
What changes or recommendations would you support to prevent this injury from reoccurring?
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.