Wisconsin > Workers Comp
Medical Report On Industrial Injury WKC-16 - Wisconsin
| Medical Report On Industrial Injury Form. This is a Wisconsin form and can be used in Workers Comp . |
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MEDICAL REPORT ON INDUSTRIAL INJURY Department of Workforce Development Worker's Compensation Division 201 E. Washington Ave., Rm. C100 P.O. Box 7901 Madison, WI 53707-7901 Telephone: (608) 266-1340 Fax: (608) 267-0394 http://dwd.wisconsin.gov/wc e-mail: DWDDWC@dwd.wisconsin.gov Provision of your Social Security Number (SSN) is voluntary. Failure to provide it may result in an information processing delay. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m), Wisconsin Statutes]. WC Claim Number Employee Name Employee Social Security Number Injury Date History as described by patient Employee Address Employer Name Insurance Company PATIENT HISTORY DIAGNOSIS (Please be as detailed as possible) PERMANENT DISABILITY (Describe permanent elements of disability, such as limitation of motion, pain, weakness, etc., and describe effect on working ability.) What amputation present? Has permanent disability resulted? Yes No Comparative x-rays taken? Yes Date of Last Exam No Has healing period ended? Yes No Stump: hardy or tender Patient discharged? Yes No Description of permanent disability (Record finger motion losses on reverse.) Was surgery performed as a result of accident? Yes No If Yes, state type of surgery: If healing has not ended, what is minimum permanent disability expected? PRIOR DISABILITY PROGNOSIS What previous disability? Prognosis: Date injured was or will be able to return to a limited type of work: State any limitations: Date injured was or will be able to return to full-time work subject only to permanent limitations: What further treatment should be given? Additional comments, if any: Date City Physician or Chiropractor Signature (in own writing) Phone Number Typed or Printed Name ( WKC-16-E (R. 04/2010) ) - Employee Name Employee Social Security Number Instructions for finger injuries Please use statutory terms in referring to fingers, such as thumbs, index, middle, ring, and little fingers, and distal, middle, and proximal joints. Where there is limitation of motion, list separately the normal range of motion in degrees, the "degrees" loss of flexion, and the "degrees" loss of extension for each joint of each finger. The Worker's Compensation Division will evaluate the loss of use due to loss of motion of the fingers. Where there are other elements of disability of the fingers, such as deformity, weakness, pain, or lack of endurance, give your opinion on the percentage loss of use as compared to amputation for such elements of disability and specify the joint at which such loss is estimated. Digit Thumb Index Joint Dist Prox Dist Mid Prox Mid Dist Mid Prox Ring Dist Mid Prox Little Dist Mid Prox Angle Ext./Flex Normal Range of Motion Degrees Loss Extension Degrees Loss Flexion Estimate % loss of use for additional factors at joint involved and reason for additional allowance CIRCLE HAND INVOLVED: Right Middle Finger Ring Finger Left DOMINANT HAND: Right Left Index Finger Little Finger Thumb See DWD 80.32 & 80.33 for guides to evaluation for amputations, restrictions of motion, ankylosis, sensory loss, and surgical results for disability to the hip, knee, ankle, toes, shoulder, elbow, wrist, fingers and back. If fingertip amputation is present, submit comparative x-rays or a statement indicating whether the bone loss was less than one-third, between one-third and two-thirds, or more than two-thirds of the distal phalanx. If amputation is below the distal joint, submit comparative x-rays. Distal Joint Middle Joint Proximal Joint
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