Wisconsin > Workers Comp
Physicians Report On Eye Injuries WKC-16A - Wisconsin
| Physicians Report On Eye Injuries Form. This is a Wisconsin form and can be used in Workers Comp . |
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PHYSICIAN'S REPORT ON EYE INJURIES Refer to Ind. 80.26, Loss of vision; determination 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: DWD.DWC@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]. PATIENT WC Claim Number Social Security Number Injury Date Date of First Treatment Employee Name Employee Address Employer Name Date of Last Treatment or Exam Yes No If yes, explain. Insurance Company Name Which eye is injured? Right Left Both HISTORY If only one eye is injured, is the other eye affected? Please be as detailed as possible: NATURE OF INJURY AND DIAGNOSIS Is physical condition of the eyes stationary? Yes No If no, explain: 1) 2) Have all adequate and reasonable operations Yes No been attempted? 3) Did cataract form as a result of injury? Yes No If cataract formed, was lens removed? Yes No Has there been a surgical implant of lens? Yes No Danger of further impairment? Yes No If yes, explain: CENTRAL VISUAL READINGS IMPORTANT: PLEASE FILL OUT EACH LINE COMPLETELY FOR EACH EYE Distance Near Use Snellen test letters or characters up to 20/800. Use AMA Reading Card up to 14/560. After Injury Pre-existing before injury, including presbyopia and other conditions clearly not the result of the injury. Without Correction Distance Near Right Left Without Correction Distance Near Right Left With Correction Distance Near With Correction Distance Near PRIOR DISABILITY Did the employee wear glasses for pre-existing subnormal vision? Is there a record or positive indication of pre-existing subnormal vision? Is the remaining impairment due to the injury? Is there absence of useful binocular vision? Yes Yes Yes No No If yes, Explain: No Explain: BINOCULAR VISION Yes No Explain cause: _____________________________________________________________________________________________ If a result of the injury, what is the percentage of additional permanent disability? Industrial Motor Field Chart Is there any diplopia present? Yes No If yes, this should be plotted in the chart at the right by placing an X in each square in which diplopia is found. The test is to be made with any industrially useful correction applied. Was such correction used? Yes No WKC-16-A (R. 03/2009) American LegalNet, Inc. www.FormsWorkflow.com FIELD VISION Field vision taken without correction if possible using a white test object which subtends one degree and a standard perimeter with a radius of 12.9 inches (330 mm). The test object shall measure 0.223 inches (5.8 mm). Is there any loss of the field of vision? Yes No Is it the result of the injury? Yes No If so, indicate on the charts and table below. Sketch impaired area. Sketch areas of any scotomata. When did the last trace of inflammation disappear from the eye? ______________________________________________________ Date able to return to work: _____________________________________________ _______________________________________________________________________________________ OTHER FUNCTIONS Certain ocular disabilities are not covered in the foregoing sections, such as disturbance of accommodation, of color vision, of adaptation to light and dark, metamorphosia, entropion, ectropion, lagophthalmos, epiphora, and muscle disturbances not included under diplopia. Is any such disability present? If so, explain under "Remarks" below, stating whether it results from the injury, what it is, which eye, or whether both eyes are affected, and your percentage estimate of the impairment of the eye or eyes for industrial use. __________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Remarks: __________________________________________________________________________________________ Doctor Signature: _______________________________________________________ Date Signed: _____________________ (Required in doctor's own handwriting) Address: _____________________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com
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