Department of State Division of Publications

For Department of State Use Only

312 Rosa L. Parks Avenue, 8th Floor Snodgrass/TN Tower Nashville, TN 37243 Phone: 615-741 -2650 Fax: 615-741-5133 Email: reg ister.information@tn .gov

Proposed Rule(s) Filing Form

Sequence Number:

Rule ID(s):

File Date:

Effective Date: S(t,/@

Proposed rules are submitted pursuant to T. C.A. §§ 4-5-202, 4-5-207 in lieu of a rulemaking hearing. It is the intent of the Agency to promulgate these rules without a rulemaking hearing unless a petition requesting such hearing is filed within sixty (60) days of the first day of the month subsequent to the filing of the proposed rule with the Secretary of State. To be effective, the petition must be filed with the Agency and be signed by twenty-five (25) persons who will be affected by the amendments, or submitted by a municipality which will be affected by the amendments, or an association of twenty-five (25) or more members, or any standing committee of the General Assembly. The agency shall forward such petition to the Secretary of State.

~ ~-- - - - ... ~ -• Agen9/B~a!~l~(?m_~i~~io!1: Dep-9_rt_m_en!_ of__L§lbo_r a~~ \f\!orkforc~ D~~~lq~ment.

Djvisio~: Bu~ea!:J of Workers' Q_ompensation ___ . Contact Person: I_roy _l::lalE3_Y _ __ _

Address: . 220 French Landing Drive Side 1-B, Nashville.Tennessee Zip: 37243

Phone: (615) 532-0179 --- --Email: '. froy.haley@tn.gov

Revision Type (check all that apply): x Amendment

New Repeal

Rule(s) Revised (ALL chapters and rules contained in filing must be listed here. If needed, copy and paste additional tables to accommodate multiple chapters. Please enter only ONE Rule Number/Rule Title per row)

Chapter Number Chapter Title 0800-02-21 Mediation and Hearing Procedures Rule Number Rule Title 0800-02-21-.08 Forms

SS-7038 (October 2017) RDA 1693

(Place substance of rules and other info here. Statutory authority must be given for each rule change. For information on formatting rules go to http:l/state.tn.us/sos/rules/1360/1360.htm)

Amendments

Chapter 0800-02-21 Mediation and Hearing Procedures

Rule 0800-02-21-.08 is amended by adding the following:

(1) Pursuant to T.C.A. § 50-6-244, the following statistical data form is to be used for settlements approved by the court of workers' compensation claims involving injuries occurring on or after July 1, 2014:

Tennessee Bureau of Workers' Compensation 220 French Landing Drive, I-B

Nashville, TN 37243-1002 800-332-2667

STATISTICAL DATA FORM FOR INJURIES ON/AFTER JULY 1, 2014-Form SD-2

EMPLOYEE INFORMATION

Docket# _________ State File# ________ _ *Date of Injury

Employee Last Name _________ First Name ________ MI SSN -------

Date of Birth ____ Year of Hire Education Level D Less Than High School D High School D More than High

School

CLAIM/INJURY INFORMATION ~~~~~~~~== =~~~~~~

Employer _____________________ Is Employer Self-Insured? 0 Yes 0 No

Is Employer a member of the Bureau's Tennessee Drug Free Workplace Program? (select one) D Yes D No

Insurer ___________________ TPA _________________ _

Injury occurred in TN D Yes 0 No County of Injury _________ _

First date out of work Date of return to work Total # of days lost -------- --------

Date of MMI ________ ATP Impairment Rating% ___ _

Average Weekly Wage Compensation Rate ___________ _

Was claim denied? D Yes O No If yes, basis of denial? O Statute of limitations D Notice D Not Work-Related

Vocational Assessment performed? D Yes D No D Intoxication!+ Drug Test 0 0ther (Specify) ____ _

Nature of Primary Injury/Body Part _______________ Occupational lllness D Yes D No

Chiropractic Treatment? D Yes D No Physical Therapy? D Yes D No Case Manager? D Yes D No

Was there an Employee IME?O Yes D No If yes, Impairment Rating% _____ _

Was there an Employer IME?O Yes D No If yes, Impairment Rating% _____ _

SETTLEMENT/ HEARING INFORMATION --------~-- --------Type of Conclusion: D Compensation Hearing D Settlement Approval

SS-7038 (October 2017) 2 RDA 1693

Was Bureau Mediation conducted? D Yes D No If yes, was dispute resolved in mediation? D Yes D No

If concluded by a Compensation Hearing: Style of Case

Date ofHearing ________ Name of Approving/Hearing Judge

Date of Settlement Approval ______ _ Impairment Rating % used to settle the claim _____ _

Has Initial Compensation Period expired? O Yes 0 No Ifno, insert date this Period will expire ______ _

PPD increased benefits awarded? 0 Yes 0 No Vocational Impairment for Increased Benefits

If yes, check all that apply: D Did not return to work D 40+ years old D County Unemployment Rate D Education level

Was there a trial for increased benefits 0 Yes 0 No Was there a judgment for increased benefits? 0Yes 0No

Was there a judgment for the Employer? D Yes O No If yes, what was the basis: O statute oflimitations 0 Notice

D Not work related D No permanency D Intoxication 0 Willful Misconduct Other

Did Employee return to work for any Employer? 0 Yes D No If yes, was return to work pay D Less D same D

Higher

Was claim settled pursuant to T.C.A. §50-6-240(e)? D Yes 0 No

I­I SECOND INJURY FUND INFORMATION

Was there a judgment entered against the Subsequent Injury and Vocational Recovery Fund? D Yes 0 No

Ifthere was a judgment against the Subsequent Injury and Vocational Recovery Fund, how was the settlement apportioned?

Employer% _____ # of Weeks ____ _

Subsequent Injury and Vocational Recovery Fund% _____ # of Weeks ____ _

MONETARY AMOUNTS PAID

I Temporary Total Disability # of weeks, or $ I

I

I # of days ! I __J I Temporary Partial Disability

i I Permanent Partial Disability I I I I

I Permanent Total Disability (including those to be I paid) ! i Increased PPD Benefits I

Death Benefits (including those to be paid)

Burial Benefits

Medical Benefits

SS-7038 (October 2017)

I PPD%

I i PTO%

I

3

# of weeks, or $ I # of days :

# of weeks, or $ I I

l # of days '

# of weeks, or $ I

i # of days I i

$ I I -I

1 $

· $

RDA 1693

Future Medical Expenses Closure $

0Yes 0No · ···----

) Date closed i After prior settlement?

--···- ··-·---·-·--·····---- --- --· -------- ------------------- -----------------'--- -----+-----· Lump Sum per §50-6-240(e)

Amount of Settlement Paid in Lump Sum: $ (SSA requirement) ( do not include this amount in total)

$ - -------------- ----------·-·-- ·-··-------- ------------- - -- ---------

Total Paid for all above columns $

Date Settlement Lump Sum I Paid:

Employee's Attorney Fee$ _______ % of Settlement ____ Was fee approved by Court? D Yes D No

Employer's Attorney Fee Range D Under $1,500 O$1,501-$3,000 D $3,001-$10,000 D Over $10,000

Certification and Signatures:

By providing my BPR Number and my signature, I hereby certify that I have read the contents of the form and the information provided is true and correct to the best ofmy knowledge.

Printed name of Employee Signature Date

Printed name of Employee's Attorney BPR# Signature Date

Printed name of Adjuster Signature Date

Printed name of Employer's Attorney BPR# Signature Date

Authority: T.C.A. §§ 4-3-1409, 50-6-101, 50-6-244.

SS-7038 (October 2017) 4 RDA 1693

* If a roll-call vote was necessary, the vote by the Agency on these rules was as follows:

Board Member Aye No Abstain Absent Signature (if required)

I certify that this is an accurate and complete copy of proposed rules, lawfully promulgated and adopted by the (board/commission/other authority) on ll/ /01/7 (date as mmlddlyyyy), and is in compliance with the provisions of T.C.A. § 4-5-222. The Secretary of State is hereby instructed that, in the absence of a petition for proposed rules being filed under the conditions set out herein and in the locations described, he is to treat the proposed rules as being placed on file in his office as rules at the expiration of sixty (60) days of the first day of the month subsequent to the filing of the proposed rule with the Secretary of State.

Date:

Signature:

Name of Officer:

Title of Officer: _A_d_m_in_is_t_ra_t_or~, _B_u_re_a_u_o_f_W_o_rk_e_r_s'_C_o_m_,__pe_n_s_a_ti_o_n __ _

Subscribed and sworn to before me on: _4"1 __ ~--.---~-l-~--+f -o)__O_l-_l ____ _

Notary Public Signature: - ~~----~cl{~· =·_'.'.Ul\l __ ~----· __ , _____ _

My commission expires on: ___ ;;;____,/'-t_c,,_.l_'a!_D ___________ _

All proposed rules provided for herein have been examined by the Attorney General and Reporter of the State of Tennessee and are approved as to legality pursuant to the provisions of the Administrative Procedures Act, Tennessee Code Annotated, Title 4, Chapter 5.

Department of State Use Only

', ! :

r'""' .·

l.n l

CD w Li....

w r'-"'(:J.: f--cf) if) ;,i~ Lt.... c-­r=., ;=.

SS-7038 (October 2017)

-divJ.w- tL&~ Attorney ener I and~ eporter

J,O({ Date

Filed with the Department of State on:

Effective on:

, Tre Hargett

Secretary of State

5 RDA 1693

Regulatory Flexibility Addendum Pursuant to T.C.A. §§ 4-5-401 through 4-5-404, prior to initiating the rule making process as described in T.C.A. § 4-5-202(a)(3) and T.C.A. § 4-5-202(a), all agencies shall conduct a review of whether a proposed rule or rule affects small businesses.

1. The type or types of small business and an identification and estimate of the number of small businesses subject to the proposed rule that would bear the cost of, or directly benefit from the proposed rule: The rule will affect small employers that fall under the Tennessee Workers' Compensation Laws, which would be employers with at least five employees, or for those in the construction industry at least one employee. There should be no additional costs associated with these rule changes.

2. The projected reporting, recordkeeping and other administrative costs required for compliance with the proposed rule, including the type of professional skills necessary for preparation of the report or record : There is no additional record keeping requirement or administrative cost associated with these rule changes.

3. A statement of the probable effect on impacted small businesses and consumers: These rules should not have any impact on consumers or small businesses .

.4'. ·A description of any less burdensome, less intrusive or less costly alternative methods of achieving the purpose -':·and objectives o'f the proposed rule that may exist, and to what extent the alternative means might be less

burdensome to small business: There are no less burdensome methods to achieve the purposes and objectives of these rules.

5. Comparison of the proposed rule with any federal or state counterparts: None.

6. Analysis of the effect of the possible exemption of small businesses from all or any part of the requirements contained in the proposed rule: None.

SS-7038 (October 2017) 6 RDA 1693

Impact on Local Governments

Pursuant to T.C.A. §§ 4-5-220 and 4-5-228 "any rule proposed to be promulgated shall state in a simple declarative sentence, without additional comments on the merits of the policy of the rules or regulation, whether the rule or regulation may have a projected impact on local governments." (See Public Chapter Number 1070 (http: //state .tn . us/sos/acts/106/pub/pc1070. pdf) of the 2010 Session of the General Assembly)

This proposed rule will have little, if any, impact on these entities.

SS-7038 (October 2017) 7 RDA 1693

Additional Information Required by Joint Government Operations Committee

All agencies, upon filing a rule, must also submit the following pursuant to T.C.A. § 4-5-226(i)(1 ).

(A) A brief summary of the rule and a description of all relevant changes in previous regulations effectuated by such rule;

This form (SD-2), as promulgated, is a simplified version of the pre-reform SD-1 form that has been in both pre­reform and post-reform settlements. The SD-2 form will be used in workers' compensation settlements that are a roved b the Court of WC Claims in est-reform cases in·uries occurrin on/after 7/1/14 .

(B) A citation to and brief description of any federal law or regulation or any state law or regulation mandating promulgation of such rule or establishing guidelines relevant thereto;

T.C.A § 50-6-244(a) requires the development or alternation of the bureau's statistical data form to be promulgated by rule, pursuant to the Uniform Administrative Procedures Act, compiled in Tennessee Code Annotated, title 4, chapter 5.

(C) Identification of persons, organizations, corporations or governmental entities most directly affected by this rule, and whether those persons, organizations, corporations or governmental entities urge adoption or rejection of this rule;

Employees and employers may be affected by the promulgation of this form, which is a simplified version of an existin form. No entit has ur ed ado tion or re·ection of these rules.

(D) Identification of any opinions of the attorney general and reporter or any judicial ruling that directly relates to the rule;

None

(E) An estimate of the probable increase or decrease in state and local government revenues and expenditures, if any, resulting from the promulgation of this rule, and assumptions and reasoning upon which the estimate is based . An agency shall not state that the fiscal impact is minimal if the fiscal impact is more than two percent (2%) of the agency's annual budget or five hundred thousand dollars ($500,000), whichever is less;

I The effect of the rule change will be negligible.

(F) Identification of the appropriate agency representative or representatives, possessing substantial knowledge and understanding of the rule;

I Troy Haley, Director of Administrative Legal Services and Legislative Liaison

(G) Identification of the appropriate agency representative or representatives who will explain the rule at a scheduled meeting of the committees;

I Troy Haley, Director of Administrative Legal Services and Legislative Liaison

(H) Office address, telephone number, and email address of the agency representative or representatives who will explain the rule at a scheduled meeting of the committees; and

Tennessee Bureau of Workers' Compensation 220 French Landing Drive, Floor 1-B, Nashville TN 37243 (615) 532-0179 trov.halev@tn.qov

(I) Any additional information relevant to the rule proposed for continuation that the committee requests.

SS-7038 (October 2017) 8 RDA 1693

None

SS-7038 (October 2017) 9 RDA 1693

Department of State Division of Publications 312 Rosa L. Parks Avenue, 8th Floor SnodgrassrrN Tower Nashville , TN 37243 Phone: 615-741 -2650 Fax: 615-741-5133 Email: register.information@tn.gov

Proposed Rule{s) Filing Form

For Department of State Use Only

Sequence Number:

Rule ID(s) :

File Date:

Effective Date:

Proposed rules are submitted pursuant to TC.A. §§ 4-5-202, 4-5-207 in lieu of a rule making hearing. It is the intent of the Agency to promulgate these rules without a rulemaking hearing unless a petition requesting such hearing is filed within sixty (60) days of the first day of the month subsequent to the filing of the proposed rule with the Secretary of State. To be effective, the petition must be filed with the Agency and be signed by twenty-five (25) persons who will be affected by the amendments, or submitted by a municipality which will be affected by the amendments, or an association of twenty-five (25) or more members, or any standing committee of the General Assembly. The agency shall forward such petition to the Secretary of State.

Agency/Board/Commission: Division:

Contact Person: Address:

Zip: Phone: Email:

Department of Labor and Workforce Development Bureau of Workers' Compensation Troy Haley 220 French Landing Drive Side 1-B, Nashville, Tennessee 37243 (615) 532-0179 troy . haley@tn .gov

Revision Type (check all that apply): x Amendment

New Repeal

Rule(s) Revised (ALL chapters and rules contained in filing must be listed here. If needed, copy and paste additional tables to accommodate multiple chapters. Please enter only ONE Rule Number/Rule Title per row)

Chapter Number Chapter Title 0800-02-21 Mediation and Hearing Procedures Rule Number Rule Title - ·-- ---

L 0800-02-21-. 08 I Forms - ---------

SS-7038 (October 2017) RDA 1693

I -j

I !

-j

(Place substance of rules and other info here. Statutory authority must be given for each rule change. For information on formatting rules go to http:l/state.tn .us/sos/ru les/1360/1360.htm)

Amendments

Chapter 0800-02-21 Mediation and Hearing Procedures

Rule 0800-02-21-.08 is amended by adding the following:

(1) Pursuant to TC.A.§ 50-6-244, the following statistical data form is to be used for settlements approved by the court of workers' compensation claims involving injuries occurring on or after July 1, 2014:

Tennessee Bureau of Workers' Compensation 220 French Landing Drive, 1-B

Nashville, TN 37243-1002 800-332-2667

ST A TIS TI CAL DATA FORM FOR INJURIES ON/ AFTER JULY 1, 2014-Form SD-2

Docket# ---------

EMPLOYEE INFORMATION

State File# --------- *Date of Injury

SSN Employee Last Name _________ First Name ________ MI -------

Date of Birth ____ Year of Hire Education Level D less Than High School D High School D More than High

School

CLAIM/INJURY INFORMATION - -

Employer _____________________ Is Employer Self-Insured? D Y es 0 No

ls Employer a member of the Bureau's Tennessee Drug Free Workplace Program? (select one) D Yes D No

Insurer ___________________ TPA _________________ _

Injury occurred in TN D Yes 0 No County of Injury _________ _

First date out of work ________ Date of return to work _______ Total # of days lost

Date of MMI ________ ATP Impairment Rating% ___ _

Average Weekly Wage Compensation Rate ___________ _

Was claim denied? D Yes O No If yes, basis of denial? O Statute of limitations D Notice D Not Work-Related

Vocational Assessment performed? 0 Yes D No D Intoxication!+ Drug Test O Other (Specify) ____ _

Nature of Primary Injury/Body Part _______________ Occupational Illness D Yes D No

Chiropractic Treatment? O Yes D No Physical Therapy? D Yes D No Case Manager? D Yes D No

Was there an Employee IME?O Yes D No If yes, Impairment Rating% _____ _

Was there an Employer IME? o Yes D No If yes, Impairment Rating% _____ _

SETTLEMENT/ HEARING INFORMATION

Type of Conclusion: D Compensation Hearing D Settlement Approval

SS-7038 (October 2017) 2 RDA 1693

Was Bureau Mediation conducted? D Yes D No If yes, was dispute resolved in mediation? D Yes D No

If concluded by a Compensation Hearing: Style of Case

Date of Hearing ________ Name of Approving/Hearing Judge

Date of Settlement Approval ______ _ Impairment Rating% used to settle the claim _____ _

Has Initial Compensation Period expired? O Yes 0 No Ifno, insert date this Period will expire ______ _

PPD increased benefits awarded? 0 Yes 0 No Vocational Impairment for Increased Benefits

If yes, check all that apply: D Did not return to work D 40+ years old D County Unemployment Rate D Education level

Was there a trial for increased benefits 0 Yes 0 No Was there a judgment for increased benefits? 0 Yes 0 No

Was there a judgment for the Employer? D Yes O No If yes, what was the basis: O statute oflimitations 0 Notice

D Not work related D No permanency D Intoxication o wmrul Misconduct Other

Did Employee return to work for any Employer? 0 Yes D No If yes, was return to work pay D Less O same D Higher

Was claim settled pursuant to T.C.A. §50-6-240(e)? D Yes 0 No

SECOND INJURY .FUND INFORMATION - - -

Was there a judgment entered against the Subsequent Injury and Vocational Recovery Fund? 0 Yes 0 No

If there was a judgment against the Subsequent Injury and Vocational Recovery Fund, how was the settlement apportioned?

Employer% ____ # of Weeks ___ _

Subsequent Injury and Vocational Recovery Fund% _____ # of Weeks ____ _

Temporary Total Disability

Temporary Partial Disability

Permanent Partial Disability

Permanent Total Disability (including those to be paid)

Increased PPD Benefits

Death Benefits (including those to be paid)

Burial Benefits

Medical Benefits

SS-7038 (October 2017)

MONETARY AMOUNTS PAID

# of weeks, or $

# of days

# of weeks, or $

# of days

PPD % # of weeks, or $

# of days

PTO% # of weeks, or $

# of days

$

$

$

$

3 RDA 1693

Future Medical Expenses Closure ---j-Date closed After prior settlement? $

J 0Yes 0No f------ ------------·- --·-------~----

Lump Sum per §50-6-240(e) $

Amount of Settlement Paid in Lump Sum: $ (SSA requirement) ( do not include this amount in total)

Total Paid for all above columns $

Date Settlement Lump Sum Paid:

Employee's Attorney Fee$ _______ % of Settlement ____ Was fee approved by Court? D Yes D No

Employer's Attorney Fee Range D Under $1,500 O$1,501-$3,000 D $3,001-$10,000 D Over $10,000

Certification and Signatures:

By providing my BPR Number and my signature, I hereby certify that I have read the contents of the form and the information provided is true and correct to the best of my knowledge.

Printed name of Employee Signature Date

Printed name of Employee's Attorney BPR# Signature Date

-Printed name of Adjuster Signature Date

Printed name of Employer's Attorney BPR# Signature Date

Authority: T.C.A. §§ 4-3-1409, 50-6-101, 50-6-244.

SS-7038 (October 2017) 4 RDA 1693

* If a roll-call vote was necessary, the vote by the Agency on these rules was as follows:

Board Member Aye No Abstain Absent Signature (if required)

I certify that this is an accurate and complete copy of proposed rules, lawfully promulgated and adopted by the (board/commission/other authority) on _______ (date as mmldd/yyyy), and is in compliance with the provisions of T.C.A. § 4-5-222. The Secretary of State is hereby instructed that, in the absence of a petition for proposed rules being filed under the conditions set out herein and in the locations described, he is to treat the proposed rules as being placed on file in his office as rules at the expiration of sixty (60) days of the first day of the month subsequent to the filing of the proposed rule with the Secretary of State.

Date:

Signature:

Name of Officer: _A_b_bi_e_H_u_d_g~e_n_s ______________ _

Title of Officer: Administrator, Bureau of Workers' Compensation

Subscribed and sworn to before me on:

Notary Public Signature:

My commission expires on: ------------------

All proposed rules provided for herein have been examined by the Attorney General and Reporter of the State of Tennessee and are approved as to legality pursuant to the provisions of the Administrative Procedures Act, Tennessee Code Annotated, Title 4, Chapter 5.

Department of State Use Only

Filed with the Department of State on:

Effective on:

SS-7038 (October 2017) 5

Herbert H. Slatery Ill Attorney General and Reporter

Date

---------------

---------------

Tre Hargett Secretary of State

RDA 1693

Regulatory Flexibility Addendum Pursuant to T.C.A. §§ 4-5-401 through 4-5-404, prior to initiating the rule making process as described in T.C.A. § 4-5-202(a)(3) and T.C.A. § 4-5-202(a), all agencies shall conduct a review of whether a proposed rule or rule affects small businesses.

1. The type or types of small business and an identification and estimate of the number of small businesses subject to the proposed rule that would bear the cost of, or directly benefit from the proposed rule: The rule will affect small employers that fall under the Tennessee Workers' Compensation Laws, which would be employers with at least five employees, or for those in the construction industry at least one employee. There should be no additional costs associated with these rule changes.

2. The projected reporting, recordkeeping and other administrative costs required for compliance with the proposed rule, including the type of professional skills necessary for preparation of the report or record: There is no additional record keeping requirement or administrative cost associated with these rule changes.

3. A statement of the probable effect on impacted small businesses and consumers: These rules should not have any impact on consumers or small businesses.

4. A description of any less burdensome, less intrusive or less costly alternative methods of achieving the purpose and objectives of the proposed rule that may exist, and to what extent the alternative means might be less burdensome to small business: There are no less burdensome methods to achieve the purposes and objectives of these rules.

5. Comparison of the proposed rule with any federal or state counterparts: None.

6. Analysis of the effect of the possible exemption of small businesses from all or any part of the requirements contained in the proposed rule: None.

SS-7038 (October 2017) 6 RDA 1693

Impact on Local Governments

Pursuant to T.C.A. §§ 4-5-220 and 4-5-228 "any rule proposed to be promulgated shall state in a simple declarative sentence, without additional comments on the merits of the policy of the rules or regulation, whether the rule or regulation may have a projected impact on local governments." (See Public Chapter Number 1070 (http://state.tn.us/sos/acts/106/pub/pc1070.pdf) of the 2010 Session of the General Assembly)

This proposed rule will have little, if any, impact on these entities.

SS-7038 (October 2017) 7 RDA 1693

Additional Information Required by Joint Government Operations Committee

All agencies, upon filing a rule, must also submit the following pursuant to T.C.A. § 4-5-226(i)(1 ).

(A) A brief summary of the rule and a description of all relevant changes in previous regulations effectuated by such rule;

This form (SD-2), as promulgated, is a simplified version of the pre-reform SD-1 form that has been in both pre­reform and post-reform settlements. The SD-2 form will be used in workers' compensation settlements that are a roved b the Court of WC Claims in est-reform cases in·uries occurrin on/after 7/1/14 .

(B) A citation to and brief description of any federal law or regulation or any state law or regulation mandating promulgation of such rule or establishing guidelines relevant thereto;

T.C.A § 50-6-244(a) requires the development or alternation of the bureau's statistical data form to be promulgated by rule, pursuant to the Uniform Administrative Procedures Act, compiled in Tennessee Code Annotated, title 4, chapter 5.

(C) Identification of persons, organizations, corporations or governmental entities most directly affected by this rule, and whether those persons, organizations, corporations or governmental entities urge adoption or rejection of this rule;

Employees and employers may be affected by the promulgation of this form, which is a simplified version of an existin form . No entit has ur ed ado t ion or re·ection of these rules.

(D) Identification of any opinions of the attorney general and reporter or any judicial ruling that directly relates to the rule;

None

(E) An estimate of the probable increase or decrease in state and local government revenues and expenditures, if any, resulting from the promulgation of this rule, and assumptions and reasoning upon which the estimate is based. An agency shall not state that the fiscal impact is minimal if the fiscal impact is more than two percent (2%) of the agency's annual budget or five hundred thousand dollars ($500,000), whichever is less;

I The effect of the rule change will be negligible.

(F) Identification of the appropriate agency representative or representatives, possessing substantial knowledge and understanding of the rule;

I Troy Haley, Director of Administrative Legal Services and Legislative Liaison

(G) Identification of the appropriate agency representative or representatives who will explain the rule at a schedu led meeting of the committees;

I Troy Haley, Director of Administrative Legal Services and Legislative Liaison

(H) Office address, telephone number, and email address of the agency representative or representatives who will explain the rule at a schedu led meeting of the committees; and

Tennessee Bureau of Workers' Compensation 220 French Landing Drive, Floor 1-B, Nashville TN 37243 (615) 532-0179 troy. haley@tn. qov

(I) Any additional information relevant to the rule proposed for continuation that the committee requests.

SS-7038 (October 2017) 8 RDA 1693

None

SS-7038 (October 2017) 9 RDA 1693