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

Enter A Claim Employee Injury Statement Supervisor's 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:  *    
Name of Witness:  *    
Date of Injury:  *      
Phone Number of Witness:  *      

What job were you doing when the injury occurred?

Did you actually witness the accident or injury?  *  
Please explain what you witnessed.  *  

What safety equipment was the injured employee wearing?  *  

Was the injured employee required to wear safety equipment?  *  
If so, what type?    

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

Was the injured employee performing their job as instructed?  *  
If not, what changes were made and why?    

What body part did the employee injury? ( head, back, nect, etc.)

Describe the injury. (strain, bruise, cut, etc.)

What did the injured employee say at the time of the accident or injury?  *  

Did the employee complain of pain?  *  
If so, where?    

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  *  

Witness'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.