Supervisor's First Report of Injury

First Priority: Health & Safety - For Serious Injuries Dial 911 Immediately!


  1. Immediately report all work related injuries to Kimberly Worlow (615) 390-9552.
  2. Following the notice of work-related injury please complete all necessary paperwork as follows:
  3. Employee Injury Report or Refusal Of Medical Care Form
  4. Medical Treatment Authorization Form (If applicable)
  5. Supervisor First Report of Injury.
  6. Assist the injured employee by locating the nearest Occupational Medical facility, to find a local medical facility visit https://talispoint.com/cvty/agcs. The injured worker MUST be sent to the medical facility with a completed medical authorization form.
  7. Final Step - Please upload Employee Injury Report or Refusal of Medical Care and any other relevant documents when submitting this form.

   

Supervisor's - please complete this form with as much detail as possible.


Thank you!

 
 
 
 
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Drop your files here