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The University of Tennessee at Martin

The University of Tennessee - Martin

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Office of Human Resources
112 Administration Building
University of TN at Martin
Martin, TN 38238
(731) 881-7845
Director: J. Phillip Bright
pbright@utm.edu

 

 
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Workers' Compensation Forms

Remember!  All work related accidents should be reported, even if the employee does not seek medical attention.

 

 

 

 

 

Click below for the list of Workers' Comp approved healthcare providers:

 

PRIME HEALTH Primary Care Provider Directory


To view Weakley County, go to Pages 88-89.


To view Obion County, go to Page 57.

 

IMPORTANT INFORMATION FOR FILING A WORKERS' COMP CLAIM
The following three (3) forms must be filled out for every work-related accident.

(1) State of Tennessee Accident Report (PDF format)

This form was created in Knoxville and shows the location as Knoxville.
Please change UT Knoxville to UT MARTIN and 01000 to 05000.
(2) Supervisor's Report of Employee Accident (PDF format) or
(2) Supervisor's Report of Employee Accident (Excel format)
(3) Initial Medical Information Checklist (Excel format)
Lost Time / Return to Work Calendar (Excel format)
*****Calendar needed only if workdays were missed after date of accident.*****

Supervisor's Checklist (Excel format)
*****Checklist for Supervisor's reference and file only.*****
These forms can be filled out on the computer and printed. All forms can be saved except the State Accident Report and the Supervisor's Report, which are in PDF format, which requires Acrobat Reader 4.0 or higher.  Those forms will be downloaded to your computer and can be opened and filled out multiple times, but additional information cannot be saved. You will get a "blank form" each time. (Go to www.adobe.com to download the latest version of Acrobat Reader.)