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Forms

Forms
Name Division Form Number File Format
Request for Tennessee High School Equivalency Verification, Transcript or Duplicate Diploma Adult Education n/a Online
Apply for Unemployment Benefits Unemployment Insurance n/a Online
Tennessee Public High School - Duplicate Diploma Request Department of Education ED-5175 PDF
License to Engage Boiler Unit LB-0386 PDF
Application for Certificate of Competency/Commission Boiler Unit LB-1009 PDF
Attendance Variance Guidelines Boiler Unit n/a PDF
Boiler Inspection Variance Guide and Checklist Boiler Unit n/a PDF
Boiler Accident Report Boiler Unit IN-0927 PDF
Boiler Installation Permit Application Boiler Unit LB-0936 PDF
Replacement of Stamped Data Form Boiler Unit NB-136 PDF
Application for Permission Boiler Unit LB-0324 PDF
Amusement Device Ride List Amusement Devices GS-0540 PDF
Application to Install Elevators Elevator Unit LB -0364 PDF
Application for Permit (with Itinerary) Amusement Devices GS-0540 PDF
Elevator Safety Test Report Elevator Unit LB-0313 PDF
Elevator/Escalator Accident Report Elevator Unit LB-0961 PDF
Parental Consent Form | Child Labor Laws Labor Standards LB-0355 PDF
Illegal Alien Complaint Form Labor Standards LB-0989 PDF
Request E-Verify Labor Standards n/a PDF
Violation of TN Lawful Employment Act Complaint Form Labor Standards LB-1082 PDF
Abatement Form TOSHA n/a PDF
Occupational Injury and Illness Record Keeping Forms TOSHA OSHA 300 PDF
Occupational Injury and Illness Record Keeping Forms TOSHA OSHA 300 Excel
Form C-20 | TN First Report of Injury Form - Substitute for OSHA 301 TOSHA LB-0021 PDF
Report a Safety or Health Hazard | Complaint Form TOSHA TOSHA-7 PDF
Request for Consultative Services TOSHA LB-1010 PDF
Work Search Log Unemployment Insurance - Claimants LB-1072 PDF
Appeal of Agency Decision Unemployment Insurance - Appeals n/a Online
Notice of Appeal Unemployment Insurance - Appeals LB-0897 PDF
Request to Withdraw Appeal Unemployment Insurance - Appeals LB-0894 PDF
Request to Subpoena Unemployment Insurance - Appeals LB-0895 PDF
Request to Reschedule Hearing Unemployment Insurance - Appeals LB-0896 PDF
Employers Report of Change Unemployment Insurance - Employers LB-0792 PDF
Report to Determine Status - Application for Employer Number Unemployment Insurance - Employers LB-0441 PDF
Report to Determine Status - State and Local Government Unemployment Insurance - Employers LB-0443 PDF
Report to Determine Status - Nonprofit Organizations, Private Primary, Secondary Schools Unemployment Insurance - Employers LB-0444 PDF
Claim for Adjustment or Refund Unemployment Insurance - Employers LB-0459 PDF
Application for Transfer of Experience Rating Record Unemployment Insurance - Employers LB-0483 PDF
Separation Notice Unemployment Insurance - Employers LB-0489 PDF
Job Order Transmittal Unemployment Insurance - Employers LB-0610 PDF
Social Security Number Correction Unemployment Insurance - Employers LB-0755 PDF
Application for Client Number (for Clients of a Professional Employer Organization) Unemployment Insurance - Employers LB-0910 PDF
Declaration of Representative Unemployment Insurance - Employers LB-0927 PDF
Electronic Funds Transfer Agreement Unemployment Insurance - Employers EA-EFTA PDF
Electronic Filing Agreement Unemployment Insurance - Employers EA-EFA PDF
Form C-20 | First Report of Injury Workers' Compensation LB-0021 PDF
Form C-22 | Notice of First Payment Workers' Compensation LB-0024 PDF
Form C-23 | Notice of Denial of Claim for Compensation Workers' Compensation LB-0283 PDF
Form C-26 | Notice of Change or Termination of Benefits Workers' Compensation LB-0285 PDF
Form C-27 | Notice of Controversy Workers' Compensation LB-0280  PDF
Form C-28 | Notice of Lawsuit Workers' Compensation LB-0284 PDF
Form C-29 | Final Report of Payment Workers' Compensation LB-0020 PDF
Form C-30a | Final Medical Report Workers' Compensation LB0383 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 | Form Workers' Compensation LB-0377 PDF
Form C-34 | Instructions Workers' Compensation n/a PDF
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-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 PDF
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-40a | Request for Assistance Workers' Compensation LB-0381 PDF
Form C-40a | Request for Assistance (Spanish) 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 Workers' Compensation LB-0382 PDF
Form C-42 SPAgreement Between Employer/Employee Choice of Physician (Spanish) Workers' Compensation LB-0382  PDF
Form C-42g | Governmental Entities Agreement Between Employer/Employee Choice of Physician Workers' Compensation n/a 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
CMUR Guidelines Workers' Compensation n/a PDF
Drug-Free Workplace Form Workers' Compensation LB-0393 PDF
Drug-Free Workplace Form (Spanish) Workers' Compensation LB-0977 PDF
I-01 | Certificate of Insurer Workers' Compensation LB-0043 PDF
I-02 | Notice of Cancellation Workers' Compensation LB-0004 PDF
I-03 | Reduction in Workforce Workers' Compensation LB-0286 PDF
I-04 | Sole Proprietor/Partner Selection Workers' Compensation LB-0228 PDF
I-05 | Sole Proprietor/Partner Withdrawal of Election Workers' Compensation LB-0287 PDF
I-06 | Corporate Officer Election Not to Accept Workers' Compensation LB-0090 PDF
I-07 | Corporate Officer Withdrawal of Election Workers' Compensation LB-0288 PDF
I-08 | Exempt Employers Notice of Acceptance Workers' Compensation LB-0014 PDF
I-09 | Exempt Employers Withdrawal of Notice Workers' Compensation LB-0289 PDF
I-10 | Notice of Waiver of Workers' Compensation Benefits for Specific Medical Conditions Workers' Compensation LB-0030 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-15 | General Contractor Acceptance / Termination of Coverage Agreement Form Workers' Compensation LB-0301 PDF
I-18 | Notice of Discontinuance Workers' Compensation n/a PDF
MIR Application for a Medical Impairment Rating Workers' Compensation LB-0930 PDF
MIR Application for Appointment to the Medical Impairment Rating Registry Workers' Compensation LB-0928 PDF
MIR Medical Waiver and Consent Form Workers' Compensation LB-0929 PDF
MIR Impairment Rating Report - 5th Edition Workers' Compensation LB-0931 PDF
MIR Impairment Rating Report - 6th Edition Workers' Compensation LB-0931A PDF
Posting Notice Workers' Compensation LB-0922  PDF
Posting Notice (Spanish) Workers' Compensation LB-0922SP  PDF
Request for Investigation Workers' Compensation LB-0977 PDF
Request for Investigation (Spanish) Workers' Compensation LB-0977SP DOCX
Request for Settlement Approval Workers' Compensation LB-0932 PDF
SD1 Statistical Data Form Workers' Compensation LB 0904 PDF
Petition for Benefit Determination Workers' Compensation LB-1095 PDF
Petition for Benefit Determination (Spanish) Workers' Compensation LB-1095 PDF
Expedited Hearing Notice of Appeal Workers' Compensation LB-1099 PDF
Request for Expedited Hearing Workers' Compensation LB-1100 PDF
Request for Scheduling Hearing Workers' Compensation LB-1098 PDF
Dispute Certification Notice Workers' Compensation LB-1096 PDF
Medical Record Certification Workers' Compensation LB-1097 PDF
Subpoena Workers' Compensation LB-0476 PDF
Compensation Hearing Notice of Appeal Workers' Compensation LB-1103 PDF
Joint Task Force on Employee Misclassification Tip Form Workers' Compensation n/a Online
Assessment of SCSEP Host Agency Training Workforce Services LB-1080 PDF
Petition for Benefit Determination Settlement Approval Only Workers' Compensation LB-1120 PDF
Physician Certification Form Workers' Compensation LB-1109 PDF
Affidavit of Indigency Workers' Compensation LB-1108 PDF
Wage and Premium Reports Unemployment Insurance LB-0456
LB-0851
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 Search Payment Form Trade Adjustment Assistance TAA LB-1116 PDF
Job Search Allowances Application Trade Adjustment Assistance TAA LB-1117 PDF
Job Search Activity Verification Trade Adjustment Assistance TAA LB-1119 PDF
Authorization and Invoice Trade Adjustment Assistance TAA LB-1121 PDF
Affidavit for RTAA Regarding Trade Affected Separating Employer Trade Adjustment Assistance TAA LB-1069 PDF
Request for Eligibility Reemployment Trade Adjustment Assistance (RTAA) Trade Adjustment Assistance TAA LB-1053 PDF
Request for Initial Reemployment Data on RTAA Trade Adjustment Assistance TAA LB-1122 PDF
Verification of Employment for Monthly Wage Supplement Trade Adjustment Assistance TAA LB-1050 PDF
Training Facility TAA Follow-Up Notice Trade Adjustment Assistance TAA LB-0785 PDF
Taxable Wage Correction Unemployment Insurance - Employers LB-3241 PDF
Federal Funding Workforce Services LB-0539 PDF

 

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