# Hoffman, Lindsey v. HCA Health Services of Tennessee d/b/a Tristar Summit Medical Center

> Tennessee Court of Workers' Compensation Claims · May 21, 2025 · 2025 TN WC 30

URL: https://www.frixlaw.com/law-library/cases/11054808

## Case

- **Court:** Tennessee Court of Workers' Compensation Claims
- **Decided:** May 21, 2025
- **Citations:** 2025 TN WC 30
- **Precedential status:** Published
- **Opinion:** Opinion
- **Judges:** Switzer
- **Cited by:** 0 later opinions in the Frix Law Library

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## Opinion text

FILED
May 21, 2025
08:54 AM(CT)
TENNESSEE COURT OF
WORKERS' COMPENSATION
CLAIMS

TENNESSEE BUREAU OF WORKERS’ COMPENSATION
IN THE COURT OF WORKERS’ COMPENSATION CLAIMS
AT NASHVILLE

Lindsey Hoffman, ) Docket No. 2024-60-0181
Employee, )
v. )
HCA Health Services of Tennessee )
d/b/a Tristar Summit Medical ) State File No. 960009-2024
Center, )
Employer, )
And )
Indemnity Insurance Co. of America, ) Judge Kenneth M. Switzer
Carrier. )

EXPEDITED HEARING ORDER DENYING BENEFITS

This case presents a complicated issue: whether Lindsey Hoffman timely notified
HCA Health Services of Tennessee of her PTSD and major depression that she alleged
arose primarily out of her employment. After an expedited hearing on April 30, 2025, and
giving the evidence thorough consideration, the Court finds that she did not give timely
notice and holds she is not likely to prevail at a hearing on the merits that she is entitled to
benefits.

Claim History

Employee’s direct testimony

Ms. Hoffman worked for HCA as an emergency medicine clinical pharmacist at
Tristar Summit hospital. The job required her to respond to emergencies such as strokes
or intubations; she “dosed and managed everything in the moment in life-or-death
situations.”

She worked at Summit for over ten years. During that time, Ms. Hoffman believed
she filed no workers’ compensation claims but acknowledged she was hit in the chest with
a CPR stool in March 2023. She reported the injury in the hospital’s electronic system

1
described below as an “Employee Health” event. The injury did not result in her taking
any leave. Rather, “it was evaluated and cleared.”’

Ms. Hoffman testified that several events in the emergency department led to her
mental injuries.

First, Ms. Hoffman was sitting at her desk in a cubicle on April 9, 2023, with her
back toward the behavioral health hallway, when suddenly one of the most dangerous
patients approached her. He was under the influence of methamphetamine and came from
behind her, yelling, “Where is she?” The patient was unsupervised, despite hospital rules
that he be under one-to-one supervision by a sitter, and he was on “care alert,” the highest
security level for patients. Ms. Hoffman said she felt “helpless” and “traumatized.”

Ms. Hoffman testified that she reported the incident to the nursing supervisor and
her manager, Alex Stephens, that evening. She offered no details of those conversations.

She also reported the incident on April 10 in writing using Summit’s electronic
“Vigilanz” system. The parties stipulated that this system allows hospital staff to report
events occurring on the premises. Reportable events “include, but are not limited to,
employee work-injuries, patient safety concerns, behavioral events, environmental events
or concerns, near-miss incidents, and security events or concerns.” The parties further
agreed that work injuries should be reported under the Vigilanz “Non-Patient/Employee
Health” portal, but Ms. Hoffman instead created a “Security Event” in the system for the
incident.

The next day, the same patient again escaped his room without supervision. The
event “exacerbated” Ms. Hoffman’s fear from the previous evening. She testified that the
events were “uncommon,” and they were “extraordinary and unusual” for a pharmacist.

Ms. Hoffman reported the incident through Vigilanz using “Patient Provision of
Care.” She also told Mr. Stephens about “the situation with this patient” and that she felt
unsafe at work and was “terrified.” Mr. Stephens responded that he would ask about
erecting a barrier between her back and the behavioral health ward.

Per her usual schedule, Ms. Hoffman was off for the next seven days, when Mr.
Stephens texted her on April 12 to tell her a work order had been entered for the barrier.
On April 19, she spoke with him again and texted him a photo of another barrier in the
hospital as an example. But on Ms. Hoffman’s return, no barrier was in place, and the
dangerous patient had been relocated closer to her desk, in the room directly behind it,
rather than moved farther away.

An additional injury-inducing event took place on April 23 and involved a patient
arriving at the emergency department with a gun on his person. Ms. Hoffman and others

2
were attending to him, giving him CPR. She testified that she was focused on her crash-
cart tray and the life-saving medications during the attempts to save the patient’s life. The
EMS coordinator saw the gun on the patient and secured it while the CPR continued. She
later learned that the gun had been “fumbled around” and pointed at her.

Ms. Hoffman reported this incident using Vigilanz the next day as a “close call/near
miss.” She also discussed it with Mr. Stephens and Martin Bruck, the pharmacy director,
during the shift, but she did not give details about these conversations. After this
“extraordinary” event, she felt worse and that her “safety wasn’t a priority.”

After the April 9 incident, Ms. Hoffman found another area to work, which was not
her designated desk. The temporary area was outside the emergency department, had a
door, and her back was not turned to the behavioral health ward. She did this for several
weeks until she was “kicked out.”

After the April 2023 events, Ms. Hoffman began experiencing flashbacks, panic
attacks, hypervigilance, insomnia, and nightmares. She also started isolating and eating
poorly, and she stopped working out. The events affected her ability to perform her job.
The position required the ability to think on her feet, but since she was not sleeping or
eating well, it became difficult for her to concentrate at work.

Ms. Hoffman said HCA never offered medical treatment, so she treated on her own
starting in late June. Rebecca Hill, a nurse practitioner, diagnosed adjustment disorder.
She did not introduce these records.

Ms. Hoffman worked during the summer months but also used paid time off. She
continued asking both Mr. Stephens and Mr. Bruck about a barrier. Mr. Bruck told her in
a work-messaging platform that he “found out about the situation and was escalating it to
administration.” Ms. Hoffman could not recall when this conversation happened. She also
expressed her concerns to the chief medical officer, who promised assistance. Neither Mr.
Bruck nor the CMO delivered on their promises.

As for Mr. Stephens, Ms. Hoffman spoke with him frequently and was crying and
“visibly distraught” during their conversations. During one discussion, he recommended
she use the hospital’s employee assistance program, and she told him she was seeing
someone. She also told Mr. Stephens that she missed being her old self; he responded that
he did, too. Ms. Hoffman did not say when this conversation took place.

During this time, the only action the hospital took was to place bicycle mirrors near
her desk and cubicle, which did not allay her fears.

Once Ms. Hoffman realized that no changes would be made, she decided to take
medical leave on September 6. She was told to contact the corporate human resources

3
department, “HCA HR Answers.” Ms. Hoffman submitted a form signed in late September
by Ms. Hill, who wrote that Ms. Hoffman suffered from “adjustment disorder-burn out,
PTSD” and other conditions. The form also stated that she “feels unsafe at work due to
recent guns in ER,” and that a barrier to return to work was “unsafe/secure work
environment-lacking gun control and staff for aggravated ER patients.”

Ms. Hoffman eventually saw Dr. Robert Jamieson, who diagnosed PTSD and major
depressive disorder in early October. Dr. Jamieson testified by declaration that “Ms.
Hoffman’s PTSD primarily, meaning more than 50% arose from the traumatic events she
experienced and witnessed while working at Tristar Summit Medical Center beginning on
or around April 9, 2023.” Ms. Hoffman said she did not report his diagnosis or make a
workers’ compensation claim afterward because she had no access to Vigilanz.

Ms. Hoffman filed her petition on January 9, 2024, listing an injury date of
September 6, 2023, the date her medical leave began.

As for her current circumstances, Ms. Hoffman treats with Ms. Hill. While her
condition has improved, she still suffers many of the same symptoms and cannot drive past
Summit because it “triggers everything that happened to me.” Ms. Hoffman returned to
work in her field at another hospital about a year ago. She cannot work in an emergency
department or in direct patient care anymore. She works in an office with a door that locks.
She feels regret and in a tearful moment said, “Emergency medicine was my passion. It’s
not a job you get right away out of pharmacy school. I worked really hard to get there.”

Cross-examination

HCA cross-examined Ms. Hoffman vigorously, and she responded in kind,
disagreeing with or evading many questions and occasionally expressing an inability to
recall. Yet, she did concede a few points.

For example, Ms. Hoffman acknowledged that she had expressed concerns about
her safety when the psych patients were moved closer to her desk and behind her back
before April 9. She said she was trained in how to de-escalate situations involving psych
patients many years ago. She also agreed that she did not see the EMS coordinator actually
“fumbling with” the loaded gun but merely “was told” it was pointed at her.

As to her use of Vigilanz, Ms. Hoffman agreed that she used the “Employee Health”
tab to report when she was struck in the chest at work before the April 2023 incidents. She
knew that “Employee Health” was the way to report a work injury. Ms. Hoffman agreed
that she used “Security Event,” “Patient Provision of Care,” and “Close-call/Near Miss”
but not “Employee Health” on April 9, 10, and 23. But a physical injury differs from a
mental injury, which occurs over time, she said, and she did not use “Employee Health”

4
because “the extent of my condition and diagnosis was not known, nor could it be made at
that time.”

Ms. Hoffman further conceded that she discussed other work stressors with her
supervisor, such as a bed bug situation. She agreed that she never requested medical care
for a work-related injury, nor did she request that a workers’ compensation claim be opened
while on the job. Moreover, she never doubted whether her PTSD related to work. Ms.
Hoffman never reached out to Kristen Dobsen, the HCA staff member who assisted her
after the chest injury, to ask about HCA’s response to the April events. She also never
submitted medical records or bills seeking to have the April events and resulting treatment
be considered as a workers’ compensation claim.

Ms. Hoffman maintained that HCA never asked about her mental health or if she
needed treatment, but instead she was instructed by “HCA HR Answers” to seek medical
leave.

Employer’s proof

Mr. Stephens attended the hearing but did not testify.

Rather, HCA offered his declaration, where Mr. Stephens did not mention the events
of April 9, 10, or 23 and instead focused on Ms. Hoffman’s other complaints. Mr. Stephens
testified that from April through August 2023, he and others spoke with Ms. Hoffman:

[T]o address her concerns with procedural and safety measures[.] . . .
Multiple ideas and possible solutions were discussed, and some were
implemented. However, Ms. Hoffman was not satisfied with any of the
suggested or attempted solutions. Based on her continued dissatisfaction
with the solutions offered and due to frustrations she raised around employee
relations in her department, I suggested Ms. Hoffman speak with someone in
our Employee Assistance Program[.]

Mr. Stephens added that during this time, Ms. Hoffman worked her regular shifts
without attendance problems. Mr. Stephens testified that Ms. Hoffman never advised him
that “she suffered a work-related mental injury” or that “she was in need of medical
treatment for a work-related mental injury.” Mr. Stephens learned that Ms. Hoffman
requested FMLA leave on September 6, 2023, and per protocol he was not told why. Ms.
Hoffman never returned from this leave.

Mr. Stephens testified he first learned that Ms. Hoffman filed a workers’
compensation claim in May 2024, when Ms. Dobson informed him.

5
For her part, Ms. Dobson testified via declaration that she was notified of Ms.
Hoffman’s alleged injury on May 16, 2024, when she received copies of the pleadings in
this case. In response, Ms. Dobson contacted HCA’s workers’ compensation third-party
administrator. Adjuster Stephanie Edgison’s declaration states that she denied the claim
on July 30, 2024, after Ms. Hoffman’s deposition.

Ms. Dobson further testified that Ms. Hoffman reported a work injury in the
Vigilanz system in March 2023. She treated on her own in an emergency room and
followed up with Ms. Dobson, a registered nurse, for that injury, but Ms. Hoffman did not
request or require further care. Ms. Dobson wrote that the Vigilanz system informs her
when an injury report is filed. No other reports of work injuries for Ms. Hoffman were
made in Vigilanz.

Findings of Fact and Conclusions of Law

Ms. Hoffman must prove she is likely to prevail at a hearing on the merits that she
gave timely notice and is entitled to the requested benefits. Tenn. Code Ann. § 50-6-
239(c)(6) (2024); McCord v. Advantage Human Resourcing, 2015 TN Wrk. Comp. App.
Bd. LEXIS 6, at *7-8, 9 (Mar. 27, 2015).

Notice is a threshold issue. Tennessee Code Annotated section 50-6-201(a)(1)
requires an employee to “immediately upon the occurrence of an injury, or as soon
thereafter as is reasonable and practicable, give or cause to be given to the employer who
has no actual notice, [notice] of the accident.” In addition, “No compensation shall be
payable under this chapter, unless the written notice is given to the employer within fifteen
(15) days after the occurrence of the accident, unless reasonable excuse for failure to give
the notice is made to the satisfaction of the tribunal to which the claim for compensation
may be presented.” Id.

Ms. Hoffman argued that after each sudden and disturbing event at work, she gave
timely written notice via the Vigilanz reports in compliance with the statute. In the
alternative, she asserted that HCA had actual notice through her many conversations with
Mr. Stephens and others in the weeks and months after the incidents. At trial, she further
contended that on September 6, 2023, the 15-day notice requirement began to run.

HCA countered that, given that Ms. Hoffman is claiming a “standalone” mental
injury with no accompanying physical injury, the 15 days began to run on April 9—yet it
did not receive notice until May 2024. A gradual mental injury is not compensable under
Tennessee law, it stated. HCA argued that “knowledge is not notice,” meaning an
employer’s notice of incidents is insufficient, and Ms. Hoffman’s conduct did not
reasonably convey that she suffered an injury as defined in the statute.

6
Turning first to Ms. Hoffman’s contention that the Vigilanz reports constitute timely
written notice, she agreed that she did not report the April 2023 incidents under “Employee
Health.” Rather, she reported, respectively, a “Security Event,” “Patient Provision of
Care,” and “Close-call/Near Miss.” However, she reported the chest injury just one month
before using “Employee Health,” as protocol required. Ms. Hoffman used those alternative
classifications despite admitting that she experienced severe symptoms immediately after
the stressful events and never doubted that work caused her symptoms.

HCA convincingly argued that Masters v. Industrial Garments Manufacturing Co.,
595 S.W.2d 811 (Tenn. 1980), controls. In Masters, the Tennessee Supreme Court held
that where an employee had previously been injured on the job and made a proper report
at that time, but did not follow procedure in a later claim, it “cannot be doubted that she
was aware of the proper procedure to follow in the event she wished to make a claim or
give notice of an alleged on the job injury.” Id. at 815. The same holds true for Ms.
Hoffman.

As for Ms. Hoffman’s assertions that HCA had actual notice, in Masters, the Court
further held that “an employee who relies upon alleged actual knowledge of the employer
must prove that the employer had actual knowledge of the time, place, nature and cause of
the injury.” Id. at 816 (citations omitted)(emphasis added). In addition, “In order for a
communication to constitute either written notice or actual knowledge on the part of the
employer it must be calculated to reasonably convey the idea to the employer that the
employee claims to have suffered an injury arising out of and in the course of her
employment.” Id.

Applying these principles, Ms. Hoffman testified that she told Mr. Stephens and the
nursing supervisor on April 9 or 10 about the first incident, but she gave no details of those
conversations. After the patient returned unsupervised the very next shift, she told Mr.
Stephens about “the situation with this patient” and that she felt unsafe at work, and he
responded that he would ask about building a barrier. He confirmed this in a text on April
12. Then, after the April 23 incident, Ms. Hoffman said she discussed that event with Mr.
Stephens and Mr. Bruck, but she did not give details about these conversations, either.

In sum, in the days after each stressful event, apparently Ms. Hoffman talked to her
supervisors about what transpired and her safety concerns. But the lack of detail she
offered is troubling. On this record, the Court cannot find that they discussed the “time,
place, nature and cause” of a work injury.

Ms. Hoffman also testified to several conversations afterward with Mr. Stephens, in
which he recommended the employee assistance program, she responded that she was
seeing a counselor, and he said he missed “the old Lindsey.” They also discussed other
complaints, such as a problem with bed bugs.

7
In contrast, Mr. Stephens testified that from April through August 2023, he and
others spoke with Ms. Hoffman “to address her concerns with procedural and safety
measures[,]” and “[b]ased on her continued dissatisfaction with proposed solutions and
employee relations in her department, [he] suggested Ms. Hoffman speak with someone in
[the] Employee Assistance Program[.]” But he also testified that Ms. Hoffman never
advised him that “she suffered a work-related mental injury” or that “she was in need of
medical treatment for a work-related mental injury.”

What the Court divines from both versions of these conversations is that Ms.
Hoffman and Mr. Stephens discussed her safety concerns and mental health—but,
significantly, it is unclear whether they discussed a mental injury relating to work.

Ms. Hoffman testified that she began suffering severe symptoms immediately after
the April 9 incident. After much back-and-forth on cross-examination, she testified that
she never doubted that she suffered a work injury—yet she never clearly conveyed that to
HCA until filing her petition.

Ms. Hoffman also contended she had no diagnosis in April 2023, stating: “[T]he
extent of my condition and diagnosis was not known, nor could it be made at that time.”
Following this line of reasoning, her counsel alternatively argued that the day she took
leave, September 6, 2023, is when the clock began to run on the notice requirement.

The Court disagrees. In Nickerson v. Knox County, No. E2020-01286-SC-R3-WC,
2021 Tenn. LEXIS 124 (Tenn. Workers’ Comp. Panel June 8, 2021), a Supreme Court
Panel adopted the Appeals Board’s opinion, where an employee similarly argued onset of
PTSD from a series of work events and contended the “last day worked rule” applied. The
Board wrote, “[W]hile separate, identifiable work-related events resulting in a sudden or
unusual stimulus can form the basis of a mental injury claim, a ‘gradual’ or
cumulative mental injury claim has not been recognized as viable under Tennessee’s
Workers’ Compensation Law.” 2020 TN Wrk. Comp. App. Bd. LEXIS 52, at *16 (Sept.
2, 2020). Even if the Court were to accept this line of reasoning, Ms. Hoffman offered no
proof that she gave sufficient notice within 15 days of September 6.

Rather, as HCA urged, the Court finds that the statute required Ms. Hoffman to give
written notice within 15 days of the occurrence of the incident on April 9, which she did
not do, unless HCA had actual notice, which it did not have. The statute goes on to say
that benefits might still be payable when the requisite notice was not given when
“reasonable excuse for failure to give the notice is made to the satisfaction of the
tribunal[.]” Here, Ms. Hoffman gave no reasonable excuse for this failure. She admitted
the immediate onset of symptoms but never told HCA she suffered a work-related mental
injury or needed medical treatment for a work-related mental injury.

8
Therefore, the Court holds Ms. Hoffman is unlikely to show at a hearing on the
merits that: she gave timely written notice; HCA had actual notice; or she had a reasonable
excuse for her failure to give timely notice. Her request for benefits is denied at this time.

Finally, HCA contended it first learned of Ms. Hoffman’s claim in May 2024 and
denied it more than two months later. The Court refers HCA to the Compliance Program
for investigation and the potential imposition of penalties regarding its failure to make a
timely decision on compensability. Tenn. Comp. R. & Regs. 0800-02-14.04(6) (2022).

The Court sets a status hearing on September 15 at 10:00 a.m. Central Time. You
must dial 615-532-9552 or 866-943-0025 to participate.

IT IS ORDERED.

ENTERED May 21, 2025.

________________________________________
JUDGE KENNETH M. SWITZER
Court of Workers’ Compensation Claims

Premarked Exhibits:

1. Declaration of Lindsey Hoffman
2. Declaration of Alex Stephens
3. Declaration of Kristen Dobson
4. Declaration of Stephanie Edgison
5. Declaration of Dr. Jamieson
6. Medical records, Dr. Jamieson
7. Stipulations
8. Declaration of Beverly Adkins1
9. Deposition of Beverly Adkins
10. Text messages
11. Medical leave requests

1
Ms. Hoffman moved to exclude the declaration from evidence, arguing that Ms. Adkins signed it under
coercion, or alternatively asking that the Court also admit Ms. Adkins’s deposition. HCA opposed the
admission of the discovery deposition as hearsay, contending that Ms. Adkins was not unavailable. After
hearing the parties’ positions, the Court admitted both documents and explained that it would give them
whatever weight is appropriate to the determinative issue. On further reflection, neither document bears on
the outcome of this hearing.
9
CERTIFICATE OF SERVICE

I certify that a copy of this Order was sent as indicated on May 21, 2025.

Name Certified Regular Email Sent to
Mail mail
Ashley McGee, X ashleymcgee@rockylawfirm.com
employee’s attorney paige@rockylawfirm.com
carleypodlasek@rockylawfirm.com
smartadvocate@rockylawfirm.com

Taylor Pruitt, X CLG@feeneymurray.com
Catheryne Grant, TRP@feeneymurray.com
employer’s attorneys shelby@feeneymuray.com
Compliance X WCCompliance.Program@tn.gov
Program

_______________________________________
Penny Shrum
Clerk, Court of Workers’ Compensation Claims
WC.CourtClerk@tn.gov

10
Right to Appeal:
If you disagree with the Court’s Order, you may appeal to the Workers’ Compensation
Appeals Board. To do so, you must:
1. Complete the enclosed form entitled “Notice of Appeal” and file it with the Clerk of the
Court of Workers’ Compensation Claims before the expiration of the deadline.
¾ If the order being appealed is “expedited” (also called “interlocutory”), or if the
order does not dispose of the case in its entirety, the notice of appeal must be filed
within seven (7) business days of the date the order was filed.
¾ If the order being appealed is a “Compensation Order,” or if it resolves all issues
in the case, the notice of appeal must be filed within thirty (30) calendar days of
the date the Compensation Order was filed.
When filing the Notice of Appeal, you must serve a copy on the opposing party (or attorney,
if represented).

2. You must pay, via check, money order, or credit card, a $75.00 filing fee within ten calendar
days after filing the Notice of Appeal. Payments can be made in-person at any Bureau office
or by U.S. mail, hand-delivery, or other delivery service. In the alternative, you may file an
Affidavit of Indigency (form available on the Bureau’s website or any Bureau office)
seeking a waiver of the filing fee. You must file the fully-completed Affidavit of Indigency
within ten calendar days of filing the Notice of Appeal. Failure to timely pay the filing
fee or file the Affidavit of Indigency will result in dismissal of your appeal.

3. You are responsible for ensuring a complete record is presented on appeal. If no court
reporter was present at the hearing, you may request from the Court Clerk the audio
recording of the hearing for a $25.00 fee. If you choose to submit a transcript as part of your
appeal, which the Appeals Board has emphasized is important for a meaningful review of
the case, a licensed court reporter must prepare the transcript, and you must file it with the
Court Clerk. The Court Clerk will prepare the record for submission to the Appeals Board,
and you will receive notice once it has been submitted. For deadlines related to the filing of
transcripts, statements of the evidence, and briefs on appeal, see the applicable rules on the
Bureau’s website at https://www.tn.gov/wcappealsboard. (Click the “Read Rules” button.)

4. After the Workers’ Compensation Judge approves the record and the Court Clerk transmits
it to the Appeals Board, a docketing notice will be sent to the parties.
If neither party timely files an appeal with the Appeals Board, the Court Order
becomes enforceable. See Tenn. Code Ann. § 50-6-239(d)(3) (expedited/interlocutory
orders) and Tenn. Code Ann. § 50-6-239(c)(7) (compensation orders).

For self-represented litigants: Help from an Ombudsman is available at 800-332-2667.
NOTICE OF APPEAL
Tennessee Bureau of Workers’ Compensation
www.tn.gov/workforce/injuries-at-work/
wc.courtclerk@tn.gov | 1-800-332-2667

Docket No.: ________________________

State File No.: ______________________

Date of Injury: _____________________

___________________________________________________________________________
Employee

v.

___________________________________________________________________________
Employer

Notice is given that ____________________________________________________________________
[List name(s) of all appealing party(ies). Use separate sheet if necessary.]

appeals the following order(s) of the Tennessee Court of Workers’ Compensation Claims to the
Workers’ Compensation Appeals Board;ĐŚĞĐŬŽŶĞŽƌŵŽƌĞĂƉƉůŝĐĂďůĞďŽdžĞƐĂŶĚŝŶĐůƵĚĞƚŚĞĚĂƚĞĨŝůĞͲ
ƐƚĂŵƉĞĚŽŶƚŚĞĨŝƌƐƚƉĂŐĞŽĨƚŚĞŽƌĚĞƌ;ƐͿďĞŝŶŐĂƉƉĞĂůĞĚͿ͗

□ Expedited Hearing Order filed on _______________ □ Motion Order filed on ___________________
□ Compensation Order filed on__________________ □ Other Order filed on_____________________
issued by Judge _________________________________________________________________________.

Statement of the Issues on Appeal
Provide a short and plain statement of the issues on appeal or basis for relief on appeal:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

Parties
Appellant(s) (Requesting Party): _________________________________________ ‫܆‬Employer ‫܆‬Employee
Address: ________________________________________________________ Phone: ___________________
Email: __________________________________________________________
Attorney’s Name: ______________________________________________ BPR#: _______________________
Attorney’s Email: ______________________________________________ Phone: _______________________
Attorney’s Address: _________________________________________________________________________
* Attach an additional sheet for each additional Appellant *

LB-1099 rev. 01/20 Page 1 of 2 RDA 11082
Employee Name: _______________________________________ Docket No.: _____________________ Date of Inj.: _______________

Appellee(s) (Opposing Party): ___________________________________________ ‫܆‬Employer ‫܆‬Employee
Appellee’s Address: ______________________________________________ Phone: ____________________
Email: _________________________________________________________
Attorney’s Name: _____________________________________________ BPR#: ________________________
Attorney’s Email: _____________________________________________ Phone: _______________________
Attorney’s Address: _________________________________________________________________________
* Attach an additional sheet for each additional Appellee *

CERTIFICATE OF SERVICE

I, _____________________________________________________________, certify that I have forwarded a
true and exact copy of this Notice of Appeal by First Class mail, postage prepaid, or in any manner as described
in Tennessee Compilation Rules & Regulations, Chapter 0800-02-21, to all parties and/or their attorneys in this
case on this the __________ day of ___________________________________, 20 ____.

______________________________________________
[Signature of appellant or attorney for appellant]

LB-1099 rev. 01/20 Page 2 of 2 RDA 11082

---

Source: Frix Law Library, https://www.frixlaw.com/law-library/cases/11054808. Public record. Not legal advice.