| Name | Division | Form Number |
|---|
| Adjusting Entity Certification Application | Workers' Compensation | LB-3266 |
| Affidavit of Indigency | Workers' Compensation | LB-1108 |
| Affidavit of Indigency (Spanish) | Workers' Compensation
| LB-1108s |
| Amusement Accident Report | Amusement Devices | LB-3294
LB-3246 |
| Annual Inspection Report | Amusement Devices | LB-3300 |
| Application to Install Elevators | Elevator Unit | LB-0364 |
| Apply for a Repair/Erection License | Boiler Unit | LB-0386 |
| Boiler Inspection Variance Guide and Checklist | Boiler Unit | n/a |
| Boiler Installation Permit Application | Boiler Unit | LB-0936 |
| Certificate of Non-Representation (CNR) | Workers' Compensation | LB-3252 |
| Certificate of Non-Representation (CNR) (Spanish) | Workers' Compensation | LB-3252 |
| Combination of Application for Permit with Itinerary and Amusement Device List Form | Amusement Devices | LB-3298 |
| Dispute Certification Notice (DCN) | Workers' Compensation | LB-1096 |
| Dispute Certification Notice (Spanish) | Workers' Compensation | n/a |
| Drug-Free Workplace Form | Workers' Compensation | LB-0977 |
| Drug-Free Workplace Form (Spanish) | Workers' Compensation | LB-0977 |
| Employee Misclassification Tip Form | Workers' Compensation | LB-0977 |
| Employee Misclassification Tip Form (Spanish) | Workers' Compensation | LB-0977s |
| EMEEF Independent Contractor/Subcontractor List | Workers' Compensation | LB-3276 |
| Employment Complaint Form | Workforce Services | ETA 8429 |
| Employment Complaint Form (Spanish) | Workforce Services | ETA 8429 |
| Firefighter PTSD Grant Application | Workers' Compensation | n/a |
| Form C-20 | First Report of Injury | Workers' Compensation | LB-0021 |
| Form C-20 | TN First Report of Injury Form - Substitute for OSHA 301 | TOSHA | LB-0021 |
| Form C-22 | Notice of First Payment of Compensation | Workers' Compensation | LB-0024 |
| Form C-23 | Notice of Denial (Spanish) (Korean) | Workers' Compensation | LB-0283 |
| Form C-26 | Notice of Change or Termination of Benefits (Korean) | Workers' Compensation | LB-0285 |
| Form C-29 | Final Report of Payment | Workers' Compensation | LB-0020 |
| Form C-30a | Final Medical Report | Workers' Compensation | LB-0383 |
| Form C-31 | Medical Waiver and Consent (for injuries before 7/1/2014) | Workers' Compensation | LB-0379 |
| Form C-31sp | Medical Waiver and Consent (Spanish) (for injuries before 7/1/2014) | Workers' Compensation | LB-0379s |
| Form C-31B | Medical Waiver and Consent (for injuries on or after 7/1/2014) | Workers' Compensation | |
| Form C-31B_ES | Medical Waiver and Consent Spanish) (for injuries on or after 7/1/2014) | Workers' Compensation | |
| Form C-32 | Standard Form Medical Report | Workers' Compensation | LB-0369 |
| Form C-33 | Case Management Notification | Workers' Compensation | LB-0376 |
| Form C-34 | Case Management Closure Form | Workers' Compensation | LB-0377 |
| Form C-34 | Case Management Closure Instructions | Workers' Compensation | n/a |
| Form C-35 | Utilization Review Notification | Workers' Compensation | LB-0380 |
| Form C-35a | Utilization Review Denial Appeal | Workers' Compensation | LB-1023 |
| Form C-35a | Utilization Review Denial Appeal (Spanish) | Workers' Compensation | LB-1023s |
| Form C-36/C-37 | Utilization Review Closure | Workers' Compensation | LB-0375 |
| Form C-36/C-37 | Utilization Review Closure Form Completion Instructions | Workers' Compensation | n/a |
| Form C-38 | Case Management Registration | Workers' Compensation | LB-0965 |
| Form C-39 | Provider Registration for Utilization Review | Workers' Compensation | LB-0968 |
| Form C-40 | Request for Mediation (Spanish) | Workers' Compensation | LB-0381 |
| Form C-40 | Request for Mediation | Workers' Compensation | LB-0381 |
| Form C-41 | Wage Statement | Workers' Compensation | LB-0384 |
| Form C-42 | Agreement Between Employer/Employee Choice of Physician (Medical Panel) — Spanish | Korean | Workers' Compensation | LB-0382
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| Form C-43 | Permanent Total Disability Final Order | Workers' Compensation | LB- 0988 |
| Form C-44 | Request for Administrative Review of a WC Specialist's Order | Workers' Compensation | LB-1016 |
| Form C-47 | Medical Payment Committee Review Request | Workers' Compensation | LB-1017 |
| I-3 | Reduction in Workforce | Workers' Compensation | LB-0286 |
| I-4 | Sole Proprietor/Partner Selection / Notice of Election | Workers' Compensation | LB-0228 |
| I-4 | Aviso de Elección / Notice of Election | Workers' Compensation | LB-0228s |
| I-5 | Sole Proprietor/Partner Withdrawal of Election | Workers' Compensation | LB-0287 |
| I-5 | Aviso de Retiro / Notice of Withdrawal | Workers' Compensation
| LB-0287s |
| I-6 | Corporate Officer Election Not to Accept | Workers' Compensation | LB-0090 |
| I-7 | Corporate Officer Withdrawal of Election | Workers' Compensation | LB-0288 |
| I-8 | Exempt Employers Notice of Acceptance | Workers' Compensation | LB-0014 |
| I-8 | Exempt Employers Notice of Acceptance (Spanish) | Workers' Compensation | LB-0014s |
| I-9 | Exempt Employers Withdrawal of Notice | Workers' Compensation | LB-0289 |
| I-9 | Exempt Employers Withdrawal of Notice (Spanish) | Workers' Compensation | LB-0289s |
| I-10 | Notice of Waiver of Workers' Compensation Benefits for Specific Medical Conditions | Workers' Compensation | LB-0030 |
| I-10 | Notice of Waiver of Workers' Compensation Benefits for Specific Medical Conditions (Spanish) | Workers' Compensation | LB-0290s |
| I-13 | Waiver Withdrawal | Workers' Compensation | LB-0290 |
| I-14 | Common Carrier Election / Termination of Coverage Form | Workers' Compensation | LB-0300 |
| I-14 | Common Carrier Election / Termination of Coverage Form (Spanish) | Workers' Compensation | LB-0300s |
| I-15 | General Contractor Acceptance / Termination of Coverage Agreement Form | Workers' Compensation | LB-0301 |
| Job Order Transmittal | Unemployment Insurance - Employers | |
| Medical Record Certification | Workers' Compensation | LB-1097 |
| Medical Record Certification (Spanish) | Workers' Compensation
| LB-1097 |
| Request for Medical Impairment Rating (MIR) | Workers' Compensation | LB-0930 |
| Request for Medical Impairment Rating (MIR) (Spanish) | Workers' Compensation | LB-0930s |
| MIR Application for Appointment to the Medical Impairment Rating Registry | Workers' Compensation | LB-928A |
| CPP Application for Appointment to the Certified Physician Program Registry | Workers' Compensation | LB-928A |
| MIR Impairment Rating Report - 5th Edition | Workers' Compensation | LB-0931 |
| MIR Impairment Rating Report - 6th Edition | Workers' Compensation | LB-0931A |
| MIR Medical Waiver and Consent Form | Workers' Compensation | LB-0929 |
| MIR Medical Waiver and Consent Form (Spanish) | Workers' Compensation | LB-0929 |
| Notice of Demand for Examination | Workers' Compensation
| LB-201 |
| Notice of Employer Rights and Responsibilities | Workers' Compensation | LB-3265 |
| Workers' Compensation Notice of Appeal | Workers' Compensation | LB-1099 |
| Workers' Compensation Notice of Appeal (Spanish) | Workers' Compensation
| LB-1099 |
| Notice of Primary Liaison, Adjusters, and Bill Review Contacts (.xlsx) | Workers' Compensation | LB-3263 |
| Notice of Reported Work Injury (Spanish) (Korean) | Workers' Compensation | |
| Occupational Injury and Illness Record Keeping Forms | TOSHA | OSHA 300 |
| Occupational Injury and Illness Record Keeping Forms | TOSHA | OSHA 300A |
| Occupational Injury and Illness Record Keeping Forms | TOSHA | OSHA 301 |
| Parental Consent Form | Child Labor Laws | Labor Standards | LB-0355 |
| Petition for Benefit Determination (PBD) | Workers' Compensation | LB-1095 |
| Petition for Benefit Determination (Spanish) | Workers' Compensation | LB-1095 |
| Petition for Benefit Determination Settlement Approval Only | Workers' Compensation | LB-1120 |
| Addendum to PBD (for Death Claims Only) | Workers' Compensation | LB-1095-A |
Addendum to PBD (for Death Claims Only) (Spanish)
| Workers' Compensation | LB-1095-A |
| Addendum to PBD (for Multiple Employers Only) | Workers' Compensation
| |
| Addendum to PBD (for Multiple Employers Only) (Spanish) | Workers' Compensation
| |
| Physician Certification Form | Workers' Compensation | LB-1109 |
| Posting Notice (Spanish) (Korean) | Workers' Compensation | LB-0922 |
| Request for Benefits from the UEF | Workers' Compensation | LB-3284 |
| Request for Benefits from the UEF (Spanish / Bilingual) | Workers' Compensation | LB-3284 |
| Request for Consultative Services | TOSHA | LB-1010 |
| Request for Expedited Determination - Appeal of a Denied Prescription | Workers' Compensation | LB-1123 |
| Request for Translation of Document for WC Appeal | Workers' Compensation | |
| Request for Translation of Document for WC Appeal (Spanish) | Workers' Compensation | |
| Hearing Request | Workers' Compensation | LB-1098
|
| Hearing Request (Spanish) | Workers' Compensation | |
| Request for Investigation | Workers' Compensation | LB-0977 |
| Request for Investigation (Spanish) | Workers' Compensation | LB-0977s |
| Request For Prior Work Injury Information | Workers' Compensation | LB-3271 |
| Request for Settlement Approval (RSA) | Workers' Compensation | LB-0932 |
| Request for Tennessee High School Equivalency Verification, Transcript or Duplicate Diploma | Adult Education | n/a |
| SD1 Statistical Data Form | Workers' Compensation | LB 0904 |
| SD-2 Statistical Data Form | Workers' Compensation | |
| Separation Notice | Unemployment Insurance - Employers | LB-0489 |
| Subpoena | Workers' Compensation | LB-0476 |
| Subpoena (Spanish) | Workers' Compensation
| LB-0476 |
| Wage Complaint Form | Workplace Regulations & Compliance (Labor Standards Unit) | LB-0995 |
| Workplace Safety or Health Complaint | TOSHA | |