Fill and Sign the Wkc 16 Medical Report on Industrial Injury This Form is to Be Filed by the Insurer or Self Insured Employer When Temporary

MEDICAL REPORT ON INDUSTRIAL INJURY *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 PATIENT Employee Social Security Number * Employee Address Injury Date Employer Name Insurance Company HISTORY History as described by patient DIAGNOSIS (Please be as detailed as possible) PERMANENT DISABILITY What amputation present? Comparative x -rays taken? Yes No Stump: hardy or tender (Describe permanent elements of disability, such as limitation of Has permanent disability resulted? Yes No Date of Last Exam Has healing pe riod ended? Yes No Patient discharged? Yes No motion, pain, weakness, etc., and describe effect on working ability.) Description of permanent disability (Record finger motion losses o n 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 DIS ABILITY What previous disability? PROGNOSIS Prognosis: Date injured was or will be able to return to a limited type of work : State any limitations: Date injured was or wil l 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 (R. 06/201 7) 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 Employee Name Employee Social Securi ty Number Instructions for finger injuries Please use statutory terms in referring to fingers, such as thumbs, index, middle, ring, and little fingers, and distal, midd le, 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. Wher e 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 Joint 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 Thumb Dist Prox Index Dist Mid Prox Mid Dist Mid Prox Ring Dist Mid Prox Little Dist Mid Prox CIRCLE HAND INVOLVED : Right Left DOMINANT HAND : Right Lef t See DW D 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 fingert ip 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. Middle Joint Distal Joint Little Finger Ring Finger Index Finger Middle Finger Thumb Proximal Joint