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Department of Labor and Workforce Development
James G. Neeley, Commissioner
Forms
UNEMPLOYMENT INSURANCE FORMS - Appeals
Notice of Appeal
Request to Withdraw Appeal
Request for Subpoena
Request to Reschedule Hearing
UNEMPLOYMENT INSURANCE FORMS - Employers
Job Order Transmittal
Report to Determine Status Application for Employer Number
Report to Determine Status - State and Local Government
Report to Determine Status - Nonprofit Organizations
Claim for Adjustment or Refund
Application for Transfer of Experience Rating Record
Joint Low Earnings and Claim for Benefits for Partial Unemployment
Separation Notice
Mass Separation Notice
Social Security Number Correction
Application for Client Number (for clients of staff leasing cos.)
Power of Attorney
Electronic Funds Transfer Agreement
Electronic Filing Agreement
TAA AND ATAA PETITIONS - English and Spanish
Revised TAA Petition Modifications
Instructions for Completing Petition for TAA and ATAA -
English
Instructions for Completing Petition for TAA and ATAA -
Spanish
WORKERS' COMPENSATION FORMS
C20 First Report of Injury
C22 Notice of First Payment
C23 Notice of Denial of Claim for Compensation
C26 Notice of Change or Termination of Benefits
C27 Notice of Controversy
C28 Notice of Lawsuit
C29 Final Report of Payment
C30 Attending Physicians Report
C30A Final Medical Report
C31 Medical Waiver and Consent
C32 Medical Report in Lieu of Deposition
C33 Case Management Notification (NEW)
C34 Form
C34 Instructions
C35 Utilization Review Notification
C36-37 Utilization Review Closure
C36-37 Form Completion Instructions
C38 Case Management Registration
C39 Provider Registration for Utilization Review
C40A Request for Assistance (NEW)
C40B Request for Benefit Review Conference (BRC)
C40R Certificate of Readiness (NEW)
C41 Wage Statement
C42 Agreement Between Employer/Employee Choice of Physician
C42 Agreement Between Employer/Employee Choice of Physician (Spanish)
C42G Governmental Entities Agreement Between Employer/Employee Choice of Physician
C43 Permanent Total Disability Final Order
CMUR Guidelines
Drug-Free Workplace Form
I-1 Certificate of Insurer
I-2 Notice of Cancellation
I-3 Reduction in Workforce
I-4 Sole Proprietor/Partner Selection
I-5 Sole Proprietor/Partner Withdrawal of Election
I-6 Corporate Officer Election Not to Accept
I-7 Corporate Officer Withdrawal of Election
I-8 Exempt Employers Notice of Acceptance
I-9 Exempt Employers Withdrawal of Notice
I-10 Heart Waiver
I-11 Occupational Disease Waiver
I-12 Epilepsy Waiver
I-13 Waiver Withdrawal
I-14 Leased Operator/Common Carrier Election
I-15 Subcontractor/General Contractor Election
I-16 Leased Operator/Common Carrier Withdrawal
I-17 Subcontractor/General Contractor Withdrawal
I-18 Notice of Discontinuance
MIR Application for a Medical Impairment Rating
MIR Application for Appointment to the Medical Impairment Rating Registry
MIR Medical Waiver and Consent Form
MIR Impairment Rating Report-5th Edition
MIR Impairment Rating Report-6th Edition
Posting Notice
Posting Notice (Spanish)
Request for Investigation
Request for Investigation -
Spanish
Request for Settlement Approval
SD1 Statistical Data Form
SD1 Statistical Data Form fillable version
ADULT EDUCATION FORMS
Eligibility Form
BOILER FORMS
Application for Examination
Application for Repair/Erection License
Application for Installation of Second Hand Boiler
Application for Certificate of Competence/Commission
Attendance Variance Guidelines
Boiler Accident Report
Boiler Installation Permit Application
Replacement of Stamped Data Form
ELEVATOR FORMS
Application to Install Elevators
Elevator Safety Test Report
Elevator/Escalator Accident Report
TOSHA FORMS
Abatement Form
Occupational Injury and Illness Record Keeping Forms (PDF Format)
Occupational Injury and Illness Record Keeping Forms (Excel Format)
TN First Report of Injury Form - Substitute for OSHA 301
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Department of Labor and Workforce Development
220 French Landing Drive
Nashville, TN 37243
(615) 741-6642
TDLWD@tn.gov
