| Name |
Division |
Form Number |
File Format |
|---|
| Abatement Form |
TOSHA |
n/a |
PDF |
| Adjusting Entity Certification Application |
Workers' Compensation |
LB-3266 |
PDF |
| Affidavit for RTAA Regarding Trade Affected Separating Employer |
Trade Adjustment Assistance TAA |
LB-1049 |
PDF |
| Affidavit of Indigency |
Workers' Compensation |
LB-1108 |
PDF |
| Affidavit of Indigency (Spanish) |
Workers' Compensation
|
LB-1108s
|
PDF |
| Amusement Accident Report |
Amusement Devices |
LB-3294
LB-3246 |
Online |
| Annual Inspection Report |
Amusement Devices |
LB-3300 |
PDF |
Appeal of Agency Decision
|
Unemployment Insurance - Appeals |
n/a |
Online |
| Application for Certificate of Competency/Commission |
Boiler Unit |
LB-1009 |
PDF |
| Application for Client Number (for Clients of a Professional Employer Organization) |
Unemployment Insurance - Employers |
LB-0910 |
PDF |
| Application for Permission |
Boiler Unit |
LB-0324 |
PDF |
| Application for Transfer of Experience Rating Record |
Unemployment Insurance - Employers |
LB-0483 |
PDF |
| Application to Install Elevators |
Elevator Unit |
LB -0364 |
PDF |
| Apply for Unemployment Benefits |
Unemployment Insurance |
n/a |
Online |
| Assessment of SCSEP Host Agency Training |
Workforce Services |
LB-1080 |
PDF |
| Attendant Variance Guidelines |
Boiler Unit |
LB-3253 |
PDF |
| Authorization and Invoice |
Trade Adjustment Assistance TAA |
LB-1121 |
PDF |
| Boiler Accident Report |
Boiler Unit |
IN-0927 |
PDF |
| Boiler Inspection Variance Guide and Checklist |
Boiler Unit |
n/a |
PDF |
| Boiler Installation Permit Application |
Boiler Unit |
LB-0936 |
PDF |
| Certificate of Non-Representation (CNR) |
Workers' Compensation |
LB-3252 |
PDF |
| Certificate of Non-Representation (CNR) (Spanish) |
Workers' Compensation |
LB-3252 |
PDF |
| Claim for Adjustment or Refund |
Unemployment Insurance - Employers |
LB-0459 |
PDF |
| Combination of Application for Permit with Itinerary and Amusement Device List Form |
Amusement Devices |
LB-3298 |
PDF |
| Declaration of Representative |
Unemployment Insurance - Employers |
LB-0927 |
PDF |
| Dispute Certification Notice (DCN) |
Workers' Compensation |
LB-1096 |
PDF |
| Dispute Certification Notice (Spanish) |
Workers' Compensation |
|
PDF |
| Drug-Free Workplace Form |
Workers' Compensation |
LB-0977 |
PDF |
| Drug-Free Workplace Form (Spanish) |
Workers' Compensation |
LB-0977 |
PDF |
| EDPF (Spanish) |
Workforce Services |
LB-0624 SP |
PDF |
| Employee Misclassification Tip Form |
Workers' Compensation |
LB-0977 |
PDF |
| Employee Misclassification Tip Form (Spanish) |
Workers' Compensation |
LB-0977s |
PDF |
| Election for Seasonal Employers |
Unemployment Insurance - Employer |
LB-3304 |
PDF |
| Electronic Funds Transfer Agreement |
Unemployment Insurance - Employers |
LB-0963 |
PDF |
| EMEEF Independent Contractor/Subcontractor List |
Workers' Compensation |
LB--3276 |
PDF |
| Employer's Report of Change |
Unemployment Insurance - Employers |
LB-3288 (replaces LB-0792) |
Online |
| Employability Development Plan (Arabic) |
Workforce Services |
LB-0624 AB |
PDF |
| Form C-20 | First Report of Injury |
Workers' Compensation |
LB-0021 |
PDF |
| Form C-20 | TN First Report of Injury Form - Substitute for OSHA 301 |
TOSHA |
LB-0021 |
PDF |
| Form C-23 | Notice of Denial (Spanish) (Korean) |
Workers' Compensation |
LB-0283 |
PDF |
| Form C-26 | Notice of Change or Termination of Benefits (Korean) |
Workers' Compensation |
LB-0285 |
PDF |
| Form C-30a | Final Medical Report |
Workers' Compensation |
LB-0383 |
PDF |
| Form C-31 | Medical Waiver and Consent |
Workers' Compensation |
LB-0379 |
PDF |
| Form C-31sp | Medical Waiver and Consent (Spanish) |
Workers' Compensation |
LB-0379s |
PDF |
| Form C-32 | Standard Form Medical Report |
Workers' Compensation |
LB-0369 |
PDF |
| Form C-33 | Case Management Notification |
Workers' Compensation |
LB-0376 |
PDF |
| Form C-34 | Case Management Closure Form |
Workers' Compensation |
LB-0377 |
PDF |
| Form C-34 | Case Management Closure Instructions |
Workers' Compensation |
n/a |
Online |
| Form C-35 | Utilization Review Notification |
Workers' Compensation |
LB-0380 |
PDF |
| Form C-35a | Utilization Review Denial Appeal |
Workers' Compensation |
LB-1023 |
PDF |
| Form C-35a | Utilization Review Denial Appeal (Spanish) |
Workers' Compensation |
LB-1023s |
PDF |
| Form C-36/C-37 | Utilization Review Closure |
Workers' Compensation |
LB-0375 |
PDF |
| Form C-36/C-37 | Utilization Review Closure Form Completion Instructions |
Workers' Compensation |
n/a |
Online |
| Form C-38 | Case Management Registration |
Workers' Compensation |
LB-0965 |
PDF |
| Form C-39 | Provider Registration for Utilization Review |
Workers' Compensation |
LB-0968 |
PDF |
| Form C-40 | Request for Mediation (Spanish) |
Workers' Compensation |
LB-0381 |
PDF |
| Form C-40 | Request for Mediation |
Workers' Compensation |
LB-0381 |
PDF |
| Form C-41 | Wage Statement |
Workers' Compensation |
LB-0384 |
PDF |
| Form C-42 | Agreement Between Employer/Employee Choice of Physician (Panel) (Spanish) (Korean) |
Workers' Compensation |
LB-0382 |
PDF |
| Form C-43 | Permanent Total Disability Final Order |
Workers' Compensation |
LB- 0988 |
PDF |
| Form C-44 | Request for Administrative Review of a WC Specialist's Order |
Workers' Compensation |
LB-1016 |
PDF |
| Form C-47 | Medical Payment Committee Review Request |
Workers' Compensation |
LB-1017 |
PDF |
| I-3 | Reduction in Workforce |
Workers' Compensation |
LB-0286 |
PDF |
| I-4 | Sole Proprietor/Partner Selection / Notice of Election |
Workers' Compensation |
LB-0228 |
PDF |
| I-4 | Aviso de Elección / Notice of Election |
Workers' Compensation |
LB-0228s |
PDF |
| I-5 | Sole Proprietor/Partner Withdrawal of Election |
Workers' Compensation |
LB-0287 |
PDF |
| I-5 | Aviso de Retiro / Notice of Withdrawal |
Workers' Compensation
|
LB-0287s |
PDF |
| I-6 | Corporate Officer Election Not to Accept |
Workers' Compensation |
LB-0090 |
PDF |
| I-7 | Corporate Officer Withdrawal of Election |
Workers' Compensation |
LB-0288 |
PDF |
| I-8 | Exempt Employers Notice of Acceptance |
Workers' Compensation |
LB-0014 |
PDF |
| I-8 | Exempt Employers Notice of Acceptance (Spanish) |
Workers' Compensation |
LB-0014s |
PDF |
| I-9 | Exempt Employers Withdrawal of Notice |
Workers' Compensation |
LB-0289 |
PDF |
| I-9 | Exempt Employers Withdrawal of Notice (Spanish) |
Workers' Compensation |
LB-0289s |
PDF |
| I-10 | Notice of Waiver of Workers' Compensation Benefits for Specific Medical Conditions |
Workers' Compensation |
LB-0030 |
PDF |
| I-10 | Notice of Waiver of Workers' Compensation Benefits for Specific Medical Conditions (Spanish) |
Workers' Compensation |
LB-0290s |
PDF |
| I-13 | Waiver Withdrawal |
Workers' Compensation |
LB-0290 |
PDF |
| I-14 | Common Carrier Election / Termination of Coverage Form |
Workers' Compensation |
LB-0300 |
PDF |
| I-14 | Common Carrier Election / Termination of Coverage Form (Spanish) |
Workers' Compensation |
LB-0300s |
PDF |
| I-15 | General Contractor Acceptance / Termination of Coverage Agreement Form |
Workers' Compensation |
LB-0301 |
PDF |
| I-18 | Notice of Discontinuance |
Workers' Compensation |
n/a |
PDF |
| Illegal Alien Complaint Form |
Labor Standards |
LB-0989 |
PDF |
| Incumbent Worker/On the Job Training Grant | Procedures and Application Requirements |
Workforce Services |
LB-3250 |
PDF |
| Instructions for Completing the Petition |
TAA & ATAA Petitions |
ETA-9042 |
PDF |
| Instructions for Completing the Petition (Spanish) |
TAA & ATAA Petitions |
ETA-9042A |
PDF |
| Job Order Transmittal |
Unemployment Insurance - Employers |
LB-0610 |
PDF |
| Job Placement Verification |
Workforce Services |
LB-1124 |
PDF |
| Job Placement Verification (Spanish) |
Workforce Services |
LB-1124 SP |
PDF |
| Job Search Activity Verification |
Trade Adjustment Assistance TAA |
LB-1119 |
PDF |
| Job Search Allowances Application |
Trade Adjustment Assistance TAA |
LB-1117 |
PDF |
| Job Search Payment Form |
Trade Adjustment Assistance TAA |
LB-1116 |
PDF |
| License to Engage |
Boiler Unit |
LB-0386 |
PDF |
| Medical Record Certification |
Workers' Compensation |
LB-1097 |
PDF |
| Medical Record Certification (Spanish) |
Workers' Compensation
|
LB-1097 |
PDF |
| Request for Medical Impairment Rating (MIR) |
Workers' Compensation |
LB-0930 |
PDF |
| Request for Medical Impairment Rating (MIR) (Spanish) |
Workers' Compensation |
LB-0930s |
PDF |
| MIR Application for Appointment to the Medical Impairment Rating Registry |
Workers' Compensation |
LB-928A |
PDF |
| CPP Application for Appointment to the Certified Physician Program Registry |
Workers' Compensation |
LB-928A |
PDF |
| MIR Impairment Rating Report - 5th Edition |
Workers' Compensation |
LB-0931 |
PDF |
| MIR Impairment Rating Report - 6th Edition |
Workers' Compensation |
LB-0931A |
DOCX |
| MIR Medical Waiver and Consent Form |
Workers' Compensation |
LB-0929 |
PDF |
| MIR Medical Waiver and Consent Form (Spanish) |
Workers' Compensation |
LB-0929 |
PDF |
| Notice of Demand for Examination |
Workers' Compensation
|
LB-201 |
PDF |
| Notice of Employer Rights and Responsibilities |
Workers' Compensation |
LB-3265 |
PDF |
| Notice of Appeal |
Unemployment Insurance - Appeals |
LB-0897 |
PDF |
| Workers' Compensation Notice of Appeal |
Workers' Compensation |
LB-1099 |
PDF |
| Workers' Compensation Notice of Appeal (Spanish) |
Workers' Compensation
|
LB-1099 |
PDF |
| Notice of Primary Liaison |
Workers' Compensation |
LB-3263 |
PDF |
| Notice of Reported Work Injury (Spanish) (Korean) |
Workers' Compensation |
|
PDF |
| Occupational Injury and Illness Record Keeping Forms |
TOSHA |
OSHA 300 |
PDF |
| Occupational Injury and Illness Record Keeping Forms |
TOSHA |
OSHA 300 |
Excel |
| Parental Consent Form | Child Labor Laws |
Labor Standards |
LB-0355 |
PDF |
| Petition for Benefit Determination (PBD) |
Workers' Compensation |
LB-1095 |
PDF |
| Petition for Benefit Determination (Spanish) |
Workers' Compensation |
LB-1095 |
PDF |
| Petition for Benefit Determination Settlement Approval Only |
Workers' Compensation |
LB-1120 |
PDF |
| Addendum to PBD (for Death Claims Only) |
Workers' Compensation |
LB-1095-A |
PDF |
Addendum to PBD (for Death Claims Only) (Spanish)
|
Workers' Compensation |
LB-1095-A |
PDF |
| Addendum to PBD (for Multiple Employers Only) |
Workers' Compensation
|
|
PDF |
| Addendum to PBD (for Multiple Employers Only) (Spanish) |
Workers' Compensation
|
|
PDF |
| Physician Certification Form |
Workers' Compensation |
LB-1109 |
PDF |
| Posting Notice (Spanish) (Korean) |
Workers' Compensation |
LB-0922 |
PDF |
| Re-Employment Services (RESEA) Employability Development Plan |
Workforce Services |
LB-0624 |
PDF |
| Re-Employment Services (RESEA) Initial Assessment |
Workforce Services |
LB-1084 |
PDF |
| Re-Employment Services (RESEA) Initial Assessment (Spanish) |
Workforce Services |
LB-1084 SP |
PDF |
| Replacement of Stamped Data Form |
Boiler Unit |
NB-136 |
PDF |
| Report a Safety or Health Hazard | Complaint Form |
TOSHA |
TOSHA-7 |
PDF |
| Report to Determine Status - Application for Employer Number |
Unemployment Insurance - Employers |
LB-0441 |
PDF |
| Report to Determine Status - Nonprofit Organizations, Private Primary, Secondary Schools |
Unemployment Insurance - Employers |
LB-0444 |
PDF |
| Report to Determine Status - State and Local Government |
Unemployment Insurance - Employers |
LB-0443 |
PDF |
| Request for Benefits from the UEF |
Workers' Compensation |
LB-3284 |
PDF |
| Request E-Verify |
Labor Standards |
n/a |
PDF |
| Request for Completion TRA Benefits |
Trade Adjustment Assistance TAA |
LB-1106 |
PDF |
| Request for Consultative Services |
TOSHA |
LB-1010 |
PDF |
| Request for Consultative Services |
TOSHA |
LB-1010 |
Online |
| Request for Eligibility Reemployment Trade Adjustment Assistance (RTAA) |
Trade Adjustment Assistance TAA |
LB-1053 |
PDF |
| Request for Expedited Determination - Appeal of a Denied Prescription |
Workers' Compensation |
LB-1123 |
PDF |
| Request for Translation of Document for WC Appeal |
Workers' Compensation |
|
PDF |
| Request for Translation of Document for WC Appeal (Spanish) |
Workers' Compensation |
|
PDF |
| Hearing Request |
Workers' Compensation |
LB-1098
|
PDF |
| Hearing Request (Spanish) |
Workers' Compensation |
|
PDF |
| Request for Initial Reemployment Data on RTAA |
Trade Adjustment Assistance TAA |
LB-1122 |
PDF |
| Request for Investigation |
Workers' Compensation |
LB-0977 |
PDF |
| Request for Investigation (Spanish) |
Workers' Compensation |
LB-0977s |
PDF |
| Request For Prior Work Injury Information |
Workers' Compensation |
LB-3271 |
PDF |
| Request for Settlement Approval (RSA) |
Workers' Compensation |
LB-0932 |
PDF |
| Request for Tennessee High School Equivalency Verification, Transcript or Duplicate Diploma |
Adult Education |
n/a |
Online |
| Request to Reschedule Hearing |
Unemployment Insurance - Appeals |
LB-0896 |
PDF |
| Request to Subpoena |
Unemployment Insurance - Appeals |
LB-0895 |
PDF |
| Request to Withdraw Appeal |
Unemployment Insurance - Appeals |
LB-0894 |
PDF |
| RESEA Checklist |
Workforce Services |
LB-1084 |
PDF |
| RESEA Checklist (Arabic) |
Workforce Services |
LB-3279 AB |
PDF |
| RESEA Checklist (Spanish) |
Workforce Services |
LB-3279 SP |
PDF |
| RESEA Claimant's Statement |
Workforce Services |
LB-1021 |
PDF |
| RESEA Claimant's Statement (Arabic) |
Workforce Services |
LB-1021 AB |
PDF |
| RESEA Claimant's Statement (Spanish) |
Workforce Services |
LB-1021 SP |
PDF |
| RESEA Control Form |
Workforce Services |
LB-3280 |
PDF |
| RESEA Control Form (Arabic) |
Workforce Services |
LB-3280 AB |
PDF |
| RESEA Eligibility Review |
Workforce Services |
LB-1022 |
PDF |
| RESEA Eligibility Review (Arabic) |
Workforce Services |
LB-1022 AB |
PDF |
| RESEA Eligibility Review (Spanish) |
Workforce Services |
LB-1022 SP |
PDF |
| RESEA Initial Assessment (Arabic) |
Workforce Services |
LB-1084 AB |
PDF |
| RESEA Job Placement Verification (Arabic) |
Workforce Services |
LB-1124 AB |
PDF |
| RESEA Subsequent Visit Acknowledgement Form (Arabic) |
Workforce Services |
LB-3286 AB |
PDF |
| SCSEP IEP |
Workforce Services |
n/a |
PDF |
| SCSEP Participant Packet |
Workforce Services |
n/a |
PDF |
| SCSEP Quarterly Progress Data |
Workforce Services |
n/a |
PDF |
| SD1 Statistical Data Form |
Workers' Compensation |
LB 0904 |
PDF |
| SD-2 Statistical Data Form |
Workers' Compensation |
|
PDF |
| Separation Notice |
Unemployment Insurance - Employers |
LB-0489 |
PDF |
| Signature of Authority for Training Facility Officials (TAA) |
Workforce Services |
LB-0898 |
PDF |
| SNAP E&T Monthly Attendance Record |
Workforce Services |
LB-3258 |
PDF |
| SNAP E&T Potential Partner Assessment |
Workforce Services |
LB-3255 |
PDF |
| SNAP E&T Title I Referral |
Workforce Services |
LB-3259 |
PDF |
| Social Security Number Correction |
Unemployment Insurance - Employers |
LB-0755 |
PDF |
| Subpoena |
Workers' Compensation |
LB-0476 |
PDF |
| Subpoena (Spanish) |
Workers' Compensation
|
LB-0476 |
PDF |
| TAA-ATAA Participant Selection Form |
TAA & ATAA |
|
PDF |
| TAA Participant Non-Compliance Warning |
Trade Adjustment Assistance TAA |
LB-1107 |
PDF |
| TAA Release of Information Agreement |
Trade Adjustment Assistance TAA |
LB-3281 |
PDF |
| TAA Training Financial Support Statement |
Workforce Services |
LB-1090 |
PDF |
| TAA Training Packet Checklist |
Workforce Services |
LB-1047 |
PDF |
| TAA Training Provider Checklist |
Trade Adjustment Assistance TAA |
LB-0948 |
PDF |
| TAA-WIOA Training Referral |
Trade Adjustment Assistance TAA |
LB-0738 |
PDF |
| Taxable Wage Correction |
Unemployment Insurance - Employers |
LB-3241 |
PDF |
| Tennessee Public High School - Duplicate Diploma Request |
Department of Education |
ED-5175 |
PDF |
| Training Facility TAA Follow-Up Notice |
Trade Adjustment Assistance TAA |
LB-0785 |
PDF |
| Verification of Employment for Monthly Wage Supplement |
Trade Adjustment Assistance TAA |
LB-1050 |
PDF |
| Violation of TN Lawful Employment Act Complaint Form |
Labor Standards |
LB-1082 |
PDF |
| Wage and Premium Reports |
Unemployment Insurance |
LB-0456
LB-0851 |
PDF |
| Wage Complaint Form |
Workplace Regulations & Compliance (Labor Standards Unit) |
LB-0995 |
Form |
| Weekly Request for Allowance by Worker in Training |
Trade Adjustment Assistance TAA |
LB-0429 |
PDF |
| Willing to Commute |
Trade Adjustment Assistance TAA |
LB-1089 |
PDF |
| Worker Training Agreement and Responsibilities |
Trade Adjustment Assistance TAA |
LB-1092 |
PDF |