Fill and Sign the Dime Examiners Summary Sheet Coloradogov Form

WC132 Rev 12/18Page 1 of 2COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT DIVISION OF WORKERS' COMPENSATION DIME Examiner's Summary Sheet 1. Claimant Name: 2. DIM E Physician: 3. Is the claimant at MMI for this injury?WC #: Date of Injury: Appointment Date: Report Due Date: Yes, the claimant reached MMI on (date)No, the claimant is not at MMI4. DIME Physician’s Rating (Unapportioned Ratings)Spine % WPRight upper extremity % UE Convert to WP % WP Left upper extremity % UE Convert to WP % WP Right lower extremity % UE Convert to WP % WP ExtremitiesLeft lower extremity % UE Convert to WP % WP Psychological % WPOther % % WPFinal Combined Unapportioned Impairment Rating % WPFinal Combined Apportioned Impairment Rating(*Desk Aid #14, Apportionment Calculation Worksheet must be attached) * % WP5. Signature Date REMEMBER TO ADDRESS ALL ISSUES ON THE DIME APPLICATIONThis form, your narrative report, and applicable worksheets must be completed. Send the report to the Division with copies to both parties (or their attorneys) within 20 calendar days from the appointment date. WC132 Rev 12/18Page 2 of 2Calculate impairment for this work-related injury (no apportionment)Deduct past impairment from current totalIssued October 2008 APPORTIONMENT OF IMPAIRMENT Guideline for Accredited Physicians – Injuries pre-and post- 7/1/2008 Changes per Senate Bill 08-241 and Workers’ Compensation Rule 12-3 MEDICAL RECORDS OR OTHER OBJECTIVE EVIDENCE SUBSTANTIATES PRE-EXISTING IMPAIRMENTApportioned rating(1) ‘Disabled’ requires information that the prior injury was identified, treated, and independently disabling at the time of the current injury. ‘Disability’ is expected to include conditions which adversely impact the claimant’s ability to perform his job, or limits the claimant’s access to other jobs. Permanent work restrictions would generally fall in this category. Previous Work-related injuryCurrent Injury Before July 1, 2008Current Injury After July 1, 2008Calculate and clearly state current total impairment rating including past impairmentPatient was disabled prior to and at time of current injury (1)Previous Non-work- related injury identified & treatedPatient not disabled