The opinion
FILED
Aug 09, 2022
03:50 PM(CT)
TENNESSEE COURT OF
WORKERS' COMPENSATION
CLAIMS
TENNESSEE BUREAU OF WORKERS’ COMPENSATION
IN THE COURT OF WORKERS’ COMPENSATION CLAIMS
AT JACKSON
DERRICK WILSON, ) Docket No.: 2021-07-0482
Employee, )
v. ) State File No.: 53458-2021
RANDSTAD, INC., )
Employer, ) Judge Robert Durham
And )
INDEMNITY INS. CO. OF N.A., )
Insurer. )
EXPEDITED HEARING ORDER GRANTING MEDICAL BENEFITS
This Court held an Expedited Hearing on July 28, 2022, where Mr. Wilson
requested an order requiring Randstad to offer a panel of physicians to treat his alleged
work-related left-shoulder injury. Randstad defended on the grounds of notice and
causation. The Court holds that Mr. Wilson is likely to prevail at trial on these issues and
orders Randstad to provide a panel of orthopedists.
History of Claim
Before outlining the events surrounding Mr. Wilson’s alleged work-related injury,
it is necessary to set out his medical history before working for Randstad.
In February 2009, Mr. Wilson filed a claim against his then-employer also alleging
a left-shoulder injury. The authorized physician eventually diagnosed him with left-
shoulder impingement syndrome and assigned a one-percent impairment. He also gave
Mr. Wilson permanent physical restrictions of no more than occasional lifting overhead
with the left shoulder and no lifting more than forty-five pounds overhead or sixty pounds
from floor to waist. Mr. Wilson obtained a five-percent impairment from an independent
medical examination. He settled that claim with open medical benefits in January 2010.
In 2010, Mr. Wilson stopped working due to multiple health complaints, primarily
sarcoidosis, a condition that affects his breathing, and diabetes, although he also treats for
chronic low-back pain and severe anxiety. In 2015, he began receiving disability benefits.
1
Mr. Wilson sees Dr. Stephen Collier monthly for maintenance of his health
problems. 1 According to Dr. Collier’s December 2020 note, Mr. Wilson suffered not only
from sarcoidosis and diabetes, but also chronic low-back pain and a “history of generalized
osteoarthritis shoulder pain.”
During the February 2021 visit, Dr. Collier noted that Mr. Wilson complained of
“chronic low back pain secondary to degenerative disc disease.” Mr. Wilson did not
mention shoulder pain, and he did not describe any recent acute injuries or accidents.
However, he did say that he had “trouble climbing stairs. Has to climb a lot of ladders.
His job at the factory is very stressful and repetitive, but that is the best he can do right
now.” The March record repeats the history given in the February note.
Regarding his employment history after receiving disability, Mr. Wilson testified
that while he worked at a couple of factories through temporary employment agencies, he
could not remember when he worked for them. Mr. Wilson did not elaborate on Dr.
Collier’s notes on his employment, either on direct or cross-examination.
On March 1, 2021, Mr. Wilson applied with Randstad, a temporary employment
agency. In the process, he signed acknowledgements that Randstad prohibited employees
from lifting more than fifty pounds, and it required them to immediately report any work
injury.
Randstad assigned Mr. Wilson to work at Sonoco, where he began on March 15.
Mr. Wilson’s job required him to remove cans from an assembly line and place them in
boxes. He did this assignment for thirty minutes and then stacked the boxes on pallets,
which required him to occasionally lift the boxes over his head. Mr. Wilson estimated the
boxes weighed between fifty and sixty pounds, but Brittany Bowles of Randstad testified
the boxes weighed fewer than thirty pounds.
Mr. Wilson testified that he could not remember the exact date he injured his left
shoulder, but it occurred when his shift was short-handed. He felt a pop in his left shoulder
but continued to work, thinking that he might have simply strained it. He did not report it
to his supervisor at the time. Over the next few weeks, his shoulder pain worsened, and he
told his wife that “something wasn’t right.” He estimated that the injury occurred a few
weeks before his regularly scheduled visit with Dr. Collier, which occurred on June 8.
1
Although Mr. Wilson regularly treated with multiple physicians over the last decade, the only medical
records in evidence that preceded his alleged injury were from his previous workers’ compensation claim
and Dr. Collier’s records from December 2020 through March 2021. Randstad’s counsel said she had Dr.
Collier’s records from 2018, and she asked about Mr. Wilson’s failure to respond to her efforts to obtain
additional doctors’ notes as well as employment records. However, she did not file a motion to compel
discovery.
2
At that visit, Dr. Collier noted that Mr. Wilson was “working at a factory job” and
had the “same chronic dull ache and stiffness as before.” However, he further observed
that Mr. Wilson complained of “more shoulder pain” and recommended an MRI. He
diagnosed chronic pain syndrome secondary to degenerative disease and prescribed
medication for “left shoulder pain.” Mr. Wilson continued to work full-duty and had the
MRI on June 30. It revealed a “full thickness, full width tear” with retraction of the
supraspinatus tendon.
Mr. Wilson said that the next week, before he knew the MRI results, he told his shift
leader, Adriane Ingram, that his shoulder hurt. However, he asked her not to report it
because he wanted to give it the weekend to see if it would get better. Ms. Ingram’s
affidavit differs somewhat. She stated that she saw Mr. Wilson doing shoulder exercises
and asked him if he hurt it at work. She claimed he told her that he was not hurt at Sonoco
but on a previous job. He told her about the MRI, but he repeated that his problem did not
happen at Sonoco.
Ms. Ingram informed her supervisor of their conversation. She said that when Mr.
Wilson found out, he confronted her, stating that “he did not want anyone to know that his
shoulder was hurting, as it was not work-related.”
Randstad also provided the affidavit of Tony Phelps, Sonoco’s Production Shift
Supervisor. He said that he spoke with Mr. Wilson about his left shoulder, although he
could not remember the date. Mr. Wilson did not inform him of any specific work injury;
instead, he said his left shoulder was “ok” and he “was fine.” He asserted that Mr. Wilson
did not report an injury or ask for medical treatment, and he did not attend any meetings
with Mr. Wilson or other Sonoco employees about Mr. Wilson’s work status.
Mr. Wilson’s recollection was quite different. He testified that after speaking with
Ms. Ingram, he met with her, Mr. Phelps, and two other Sonoco employees, “Chris” and
“Oliver.” Mr. Phelps offered to move him to another position, but Mr. Wilson declined
because he liked his current job.
Regardless, Brittany Boles, manager for Randstad, texted Mr. Wilson and asked him
to come to Randstad’s office on July 9. At this meeting, Mr. Wilson filled out several
forms stating that he suffered a work-related injury to his left shoulder, although he could
not remember the exact date. Ms. Boles testified that he told her he had no idea when it
happened. It appears that for the sake of the forms, both Ms. Boles and Mr. Wilson used
July 8 or July 9 for the accident date. The incident form also stated that Mr. Wilson said
the injury occurred gradually while he was lifting boxes.
After this meeting, Randstad offered Mr. Wilson a panel of physicians. He chose
Dr. Gary McBride, whom he saw on July 10. The note stated that Mr. Wilson was suffering
from left shoulder pain for at least a month. Dr. McBride did not review the MRI, but Mr.
3
Wilson told him that it showed a tear. Dr. McBride placed Mr. Wilson on light duty and
referred him for orthopedic care.
Before Mr. Wilson could return to work on July 12, Randstad terminated his
assignment.
On July 14, he gave a recorded statement to Randstad’s carrier. In the statement,
Mr. Wilson referred to the time when he and a co-worker were working short-handed as
the date when he “felt like [his] arm popped.” Randstad did not authorize additional
medical care or provide additional employment. It eventually filed a Notice of Denial.
After the denial, Dr. Collier referred Mr. Wilson to orthopedist Jason Hutchison,
whom he saw on August 30. Dr. Hutchison diagnosed a full thickness tear of the
infraspinatus tendon and recommended surgery.
On September 30, Dr. Hutchison responded to a letter from Mr. Wilson’s attorney
regarding causation. He said that Mr. Wilson suffered from a significant rotator cuff tear
that, in someone Mr. Wilson’s age, “generally occurs” with an acute injury. The letter
asked whether Mr. Wilson’s employment could have aggravated or exacerbated a pre-
existing condition. Dr. Hutchison stated that Mr. Wilson did not inform him of a pre-
existing condition, but lifting and stacking heavy items “certainly could” cause or
aggravate a rotator cuff tear. However, given that he might not know all of Mr. Wilson’s
history, he reserved the right to change his opinion.
On November 8, Mr. Wilson saw orthopedist Dr. Kenneth Nord for another
evaluation. Like Dr. Hutchison, Dr. Nord found a full thickness tear and recommended
surgery; however, to date Mr. Wilson has not had his shoulder repaired.
On May 31, 2022, Dr. Hutchison completed a form from Randstad’s counsel. On
the form, he acknowledged that it appeared from the records sent to him that Mr. Wilson
had problems with his shoulder before his alleged work injury. He modified his opinion
so that he was “unable to say with a reasonable degree of medical certainty” if the alleged
work incident primarily caused Mr. Wilson’s rotator cuff tear.
At the hearing, Mr. Wilson attempted to clarify several points. Concerning notice,
he explained that he had two reasons for not immediately notifying Sonoco or Randstad of
his shoulder problems. First, after he felt the initial pop, he hoped it was just a strain that
would improve over time. When the pain worsened over the next few weeks, he brought
it to Dr. Collier’s attention at his scheduled monthly appointment. Second, Mr. Wilson
testified that, upon seeing a co-worker lose his job after reporting an injury, he was afraid
he would as well.
As for causation, Mr. Wilson admitted that he did not inform any of the physicians
4
who treated him that he had a workers’ compensation claim for his left shoulder in 2009.
However, he said the pain was nothing like what he currently suffers, and he knew that his
shoulder was not torn in 2009 like it is now.
Finally, Mr. Wilson testified that he continues to suffer from pain and limitations in
his left shoulder. Despite his symptoms, he is currently working for Delta Faucets and can
do his job, although Delta has prohibited him from any heavy lifting.
Findings of Fact and Conclusions of Law
Mr. Wilson must present evidence from which this Court can determine that he is
likely to prove at trial that he provided sufficient notice of his alleged work injury and that
it primarily arose out of and in the course and scope of his employment with Randstad. See
McCord v. Advantage Human Resourcing, 2015 TN Wrk. Comp. App. Bd. LEXIS 6, at *9
(Mar. 27, 2015). The Court will address each in turn.
Notice
Tennessee Code Annotated section 50-6-201(a) (2021) requires injured employees
to provide written notice within fifteen days of the injury, and if they do not, compensation
is barred “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.”
Mr. Wilson did not dispute that he failed to give notice within fifteen days of hearing
the pop in his shoulder. Although he could not testify as to the exact date, he believed the
pop occurred a few weeks before he saw Dr. Collier on June 8. 2 His MRI occurred on June
30, but he did not notify Randstad of a potential work injury until July 9. Thus, at least six
weeks passed from the alleged injury date to Randstad receiving notice.
The question thus becomes whether Mr. Wilson had a “reasonable excuse” for
failing to provide notice. Mr. Wilson’s situation is like that in Scruggs v. Amazon.com
Services, LLC, 2022 TN Wrk. Comp. App. Bd. LEXIS 27, at *6-7 (June 27, 2022). In
Scruggs, the employee injured her knee but felt that it was a temporary strain, like aches
and pains she experienced every day, and she believed it would get better. She continued
to work daily despite her symptoms. Three weeks later, she suffered another acute event
that caused significant pain and swelling. It was only then that she reported the injury. The
Appeals Board held that, under the circumstances, the employee had a reasonable excuse
for not reporting the original injury within fifteen days. Id. at *8.
2
Mr. Scruggs’s inability to identify an exact date is not necessarily fatal to his claim. See Wolfe v. Mayes
Mortuary, No. E2009-00406-WC-R3-WC, 2010 Tenn. LEXIS 91, at *8-9 (Tenn. Workers’ Comp. Panel
Feb. 17, 2010) (Notice was adequate even though the employee could only identify the injury date as some
day in “May or June of 2006.”).
5
Like the employee in Scruggs, Mr. Wilson testified that he suffered from daily pain.
He initially believed his shoulder pain was no different and would eventually resolve, and
he continued to work at full duty. Mr. Wilson’s situation differs from Scruggs, in that
several weeks passed while his symptoms grew more severe. He sought treatment from
his family doctor, who ordered an MRI, and he did not give notice until his supervisors
forced the issue.
However, Mr. Wilson also explained his delay even after seeing Dr. Collier. He
testified that he watched a co-worker get fired after reporting a work injury, and he feared
the same would happen to him. It appears his fears were justified, since Sonoco terminated
his “assignment” the next business day, and Randstad did not offer any other employment.
Although it is close, the Court holds that Mr. Wilson’s excuses for failing to provide
notice within fifteen days were reasonable under the circumstances.
However, even if the excuses were not reasonable, Randstad has an additional
hurdle before it could prevail on a notice defense—it must show prejudice. Tennessee
Code Annotated section 50-6-201(a)(3) states:
No defect or inaccuracy in the notice shall be a bar to compensation, unless
the employer can show, to the satisfaction of the workers’ compensation
judge before which the matter is pending, that the employer was prejudiced
by the failure to give the proper notice, and then only to the extent of the
prejudice.
In Scruggs, the Board held that this means the employer must prove “actual
prejudice” caused by the employee’s late notice. Id. at *7. The employer in Scruggs
asserted that the failure to give notice was “in and of itself” a clear prejudice; however, the
Board noted that if this were true, subsection 201(a)(3) serves no purpose. The employer
also made a general claim that the late notice “prejudiced” its ability to investigate the
claim without providing any facts detailing how it did so. The Board found this general
assertion insufficient and held that the employer had not established prejudice. Id.
Here, Randstad also failed to show prejudice. It offered no evidence as to how the
late notice might have obstructed its investigation. It obtained statements and affidavits
from all interested parties, including Mr. Wilson. Mr. Wilson continued to work full duty
without restrictions after his alleged injury, and Randstad introduced no evidence that his
injury worsened while he did so. Mr. Wilson’s only unauthorized treatment before giving
notice, for which he is not seeking reimbursement, was the MRI.
Given the findings above, the Court holds that Mr. Wilson is likely to prove at trial
that his late notice is not sufficient reason to deny his claim for benefits.
6
Causation
To prevail on this issue, Mr. Wilson must show that his shoulder tear was caused by
a “specific incident or set of incidents, arising primarily out of and in the course and scope
of employment” with Randstad. Tenn. Code Ann. § 50-6-102(14)(A). Further, he must
prove causation “to a reasonable degree of medical certainty,” through an expert medical
opinion. Id.; Tenn. Code Ann. § 50-6-102(14)(D).
The facts conflict regarding the “specific incident” element, and Randstad made
several points against causation. Mr. Wilson admitted that he did not inform anyone at
Sonoco or Randstad that he suffered an injury until his supervisors approached him about
it. According to Ms. Ingram’s and Mr. Phelps’s affidavits, he never informed them of a
specific injury once they confronted him. Instead, he told Ms. Ingram that the injury
occurred at a previous job. The incident report completed by Ms. Boles on July 9 states
that the injury occurred gradually due to lifting boxes. In addition, none of the medical
records mentions a specific work incident.
Mr. Wilson’s history raises other concerns. He had a workers’ compensation claim
in 2009 for the same shoulder that left him with permanent restrictions. Dr. Collier’s notes
before the alleged injury state that one of Mr. Wilson’s complaints was shoulder pain,
although the records do not specify which shoulder. Finally, Dr. Collier’s February and
March 2021 notes clearly state that Mr. Wilson was working at a factory and was suffering
from increased pain as a result. Mr. Wilson did not clarify these statements at the hearing,
other than to admit in his deposition that he said he worked for other temporary
employment agencies after his 2009 workers’ compensation injuries, but he could not
remember when. 3
However, several points can also be made in Mr. Wilson’s favor. He testified that,
while he suffered from chronic pain in various body parts, including his left shoulder,
before his injury, his left-shoulder pain did not limit his work, and he never sought specific
treatment for it. However, he claimed his symptoms changed significantly after his injury.
The fact that he worked full duty at Randstad for several weeks before his alleged injury
tends to corroborate this statement. Mr. Wilson also explained that he did not initially
report a work injury because of his concern, apparently legitimate, that he would lose his
job.
The Court also finds it significant that in Mr. Wilson’s recorded statement, taken
only a few days after he gave notice, he told the adjuster that he first felt his shoulder pop
when he and a co-worker completed a shift short-handed. This statement is consistent with
his hearing testimony.
3
The Court finds it curious that neither party elaborated on Mr. Wilson’s employment and the difficulties
he had at work immediately before he began working for Randstad.
7
His medical records also contain points that corroborate causation. While he
suffered a work injury to his left shoulder in 2009, the MRI did not reveal a tear. His
records after the alleged injury clearly show a complete tear without atrophy, which
suggested an acute injury to Dr. Hutchison. In addition, none of Dr. Collier’s records
specifically mentions increased left-shoulder pain before Mr. Wilson began working at
Randstad.
Finally, the Court finds that Mr. Wilson appeared candid and straightforward, and
Randstad did not offer sufficient evidence to cause the Court to doubt Mr. Wilson’s
veracity. The Court cannot find, given the evidence before it, that Mr. Wilson’s testimony
as to his alleged injury lacked credibility.
In summary, although this issue is again close, the Court holds that Mr. Wilson
provided sufficient facts to show he is likely to prove a “specific event or series of events”
while working at Randstad that injured his left shoulder.
Mr. Wilson must, however, still prove causation by expert medical opinion. Dr.
McBride, the authorized physician, did not address causation. Dr. Hutchison did. After
first stating that if Mr. Wilson’s history was correct, the tear “certainly could” have been
caused by his employment. However, he later said that he was unable to address causation
“to a reasonable degree of medical certainty” after being presented with information about
Mr. Wilson’s previous workers’ compensation claim. Thus, Mr. Wilson did not show a
likelihood of prevailing on causation through expert opinion.
However, that does not end the query. The Court must still consider Mr. Wilson’s
entitlement to a panel of orthopedists as recommended by Dr. McBride. Tennessee Code
Annotated section 50-6-204(a)(3)(A)(i). The Appeals Board has long held that a lack of
medical evidence regarding causation does not necessarily eliminate the employer’s
obligation to provide a physician panel. Lewis v. Molly Maid, 2016 TN Wrk. Comp. App.
Bd. LEXIS 19, at *8-9 (Apr. 20, 2016); Hawes v. McLane Co., Inc., 2021 TN Wrk Comp.
App. Bd. LEXIS 30, at *10 (Aug. 25, 2021).
In Hawes, the only medical evidence was from a non-doctor clinician, who gave an
opinion that the employee’s condition was not work-related. The Appeals Board
distinguished the case from Berdnik v. Fairfield Glade Com’ty Club, 2017 TN Wrk. Comp.
App. Bd. LEXIS 32, at *10-11 (May 18, 2017), where the only evidence from a doctor was
that the employee’s condition was not causally related to employment, leading the Appeals
Board to deny the employee a panel. Id. Thus, the Appeals Board in Hawes held that a
non-medical opinion against causation was not enough reason to deny the provision of a
panel. Id.
As with Hawes, no doctor opinion exists in this case as to whether Mr. Wilson’s
8
rotator cuff tear is or is not causally related to his employment with Randstad. Thus, the
Court holds that Randstad must provide Mr. Wilson with a panel of orthopedists from
which he may choose an authorized physician under Tennessee Code Annotated section
50-6-204(a)(3)(A)(i).
IT IS, THEREFORE, ORDERED THAT:
1. Randstad shall provide Mr. Wilson with a panel of orthopedists, from which he
may select a physician to treat any injury he sustained to his left shoulder while
working for Randstad.
2. This case is set for a Status Hearing on September 26, 2022, at 9:00 a.m.
Central Time. The parties must call 615-253-0010. Failure to appear might
result in a determination of the issues without the party’s participation.
3. Unless interlocutory appeal of the Expedited Hearing Order is filed, compliance
with this Order must occur no later than seven business days from the date of
entry of this Order as required by Tennessee Code Annotated section 50-6-
239(d)(3). The Insurer or Self-Insured Employer must submit confirmation of
compliance with this Order to the Bureau by email to
WCCompliance.Program@tn.gov no later than the seventh business day after
entry of this Order. Failure to submit the necessary confirmation within the
period of compliance might result in a penalty assessment for non-compliance.
For questions regarding compliance, please contact the Workers’ Compensation
Compliance Unit via email at WCCompliance.Program@tn.gov.
ENTERED on August 9, 2022.
_____________________________________
ROBERT DURHAM, JUDGE
Court of Workers’ Compensation Claims
APPENDIX
Technical Record:
1. Petition for Benefit Determination
2. Dispute Certification Notice
3. Request for Expedited Hearing
4. Notice of Hearing
5. Mr. Wilson’s Pre-Hearing Brief
6. Randstad’s Witness and Exhibit List
7. Randstad’s Pre-Hearing Brief
9
Exhibits:
1. Mr. Wilson’s affidavit
2. The Jackson Clinic’s medical record
3. West Tennessee Bone and Joint’s medical record
4. Sports Orthopedic and Spine medical record
5. Randstad’s collective exhibit of medical records
6. Affidavits of Tangie Barlow, Adriane Ingram, and Tony Phelps
7. First Report of Injury
8. Wage Statement
9. Notice of Denial
10. C-42
11. Recorded Statement
12. Documents from 2010 worker’s compensation settlement
13. Mr. Wilson’s deposition
CERTIFICATE OF SERVICE
I certify that a copy of the Order was sent as indicated on August 9, 2022.
Name Certified Via Via Service sent to:
Mail Fax Email
Jeffrey Boyd X jboyd@borenandboyd.com
Laurenn Disspayne X ldisspayne@manierherod.com
_____________________________________
PENNY SHRUM, Court Clerk
WC.CourtClerk@tn.gov
10
Expedited Hearing Order Right to Appeal:
If you disagree with this Expedited Hearing Order, you may appeal to the Workers’
Compensation Appeals Board. To appeal an expedited hearing order, you must:
1. Complete the enclosed form entitled: “Notice of Appeal,” and file the form with the
Clerk of the Court of Workers’ Compensation Claims within seven business days of the
date the expedited hearing order was filed. When filing the Notice of Appeal, you must
serve a copy upon all parties.
2. You must pay, via check, money order, or credit card, a $75.00 filing fee within ten
calendar days after filing of 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 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 the appeal.
3. You bear the responsibility of ensuring a complete record on appeal. You may request
from the court clerk the audio recording of the hearing for a $25.00 fee. If a transcript of
the proceedings is to be filed, a licensed court reporter must prepare the transcript and file
it with the court clerk within ten business days of the filing the Notice of
Appeal. Alternatively, you may file a statement of the evidence prepared jointly by both
parties within ten business days of the filing of the Notice of Appeal. The statement of
the evidence must convey a complete and accurate account of the hearing. The Workers’
Compensation Judge must approve the statement before the record is submitted to the
Appeals Board. If the Appeals Board is called upon to review testimony or other proof
concerning factual matters, the absence of a transcript or statement of the evidence can be
a significant obstacle to meaningful appellate review.
4. If you wish to file a position statement, you must file it with the court clerk within ten
business days after the deadline to file a transcript or statement of the evidence. The
party opposing the appeal may file a response with the court clerk within ten business
days after you file your position statement. All position statements should include: (1) a
statement summarizing the facts of the case from the evidence admitted during the
expedited hearing; (2) a statement summarizing the disposition of the case as a result of
the expedited hearing; (3) a statement of the issue(s) presented for review; and (4) an
argument, citing appropriate statutes, case law, or other authority.
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 (check one or more applicable boxes and include the date file-
stamped on the first page of the order(s) being appealed):
□ 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 *
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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]
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