Form WC132 "Division Ime Examiner's Summary Sheet" - Colorado

What Is Form WC132?

This is a legal form that was released by the Colorado Department of Labor and Employment - a government authority operating within Colorado. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2016;
  • The latest edition provided by the Colorado Department of Labor and Employment;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form WC132 by clicking the link below or browse more documents and templates provided by the Colorado Department of Labor and Employment.

ADVERTISEMENT
ADVERTISEMENT

Download Form WC132 "Division Ime Examiner's Summary Sheet" - Colorado

Download PDF

Fill PDF online

Rate (4.3 / 5) 14 votes
COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS’ COMPENSATION
INDEPENDENT MEDICAL EXAMINATION PROGRAM
DIVISION IME EXAMINER’S SUMMARY SHEET
1. Claimant Name
WC #
Date of Injury
2. DIME Physician
Appointment Date
3. Is the claimant at MMI for this injury?
Report Due Date
Yes, the claimant reached MMI on
No, the claimant is not at MMI
(date)
4. Physician’s Rating (Unapportioned Ratings)
Whole person impairment
Spine
% WP
Extremity Impairment
Left upper extremity
% UE Convert to WP
% WP
Right upper extremity
% UE Convert to WP
% WP
Left lower extremity
% LE Convert to WP
% WP
Right lower extremity
% LE Convert to WP
% WP
Psychological
% WP
Other
%
% WP
Final Combined Unapportioned Impairment Rating
% WP
5. To Determine Apportionment, Answer the Following Based On Prior Medical Records or Objective Findings:
Current Rating After Apportionment
No prior injury, no apportionment
A
Was the current date of injury before July 1, 2008?
Yes
Spine
% WP
P
P
Left upper extremity
No, after July 1,2008
% UE
% WP
O
Was the previous condition work-related?
Right upper extremity
Yes
% UE
% WP
R
No, not work-related
T
Left lower extremity
% LE
% WP
I
Right lower extremity
Was the previous condition independently disabling? Yes
% LE
% WP
O
N
No, not independently disabling
Psychological
% WP
Other
No apportionment can be done.
% WP
Use Combined Unapportioned rating (from Section 4 above)
Final Combined/Apportioned Rating
% WP
6. Signature
Date
REMEMBER TO ADDRESS ALL ISSUES ON THE DIME APPLICATION
This form, your narrative report, and applicable worksheets must be completed. Send the original report to the
Division with copies to both parties (or their attorneys) within 20 calendar days from the appointment date.
Division of Workers’ Compensation – IME Unit
633 17th Street, Suite 400, Denver, CO 80202
Telephone # (303) 318-8655 Fax # (303) 318-8659
WC132 Rev. 6/16
COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS’ COMPENSATION
INDEPENDENT MEDICAL EXAMINATION PROGRAM
DIVISION IME EXAMINER’S SUMMARY SHEET
1. Claimant Name
WC #
Date of Injury
2. DIME Physician
Appointment Date
3. Is the claimant at MMI for this injury?
Report Due Date
Yes, the claimant reached MMI on
No, the claimant is not at MMI
(date)
4. Physician’s Rating (Unapportioned Ratings)
Whole person impairment
Spine
% WP
Extremity Impairment
Left upper extremity
% UE Convert to WP
% WP
Right upper extremity
% UE Convert to WP
% WP
Left lower extremity
% LE Convert to WP
% WP
Right lower extremity
% LE Convert to WP
% WP
Psychological
% WP
Other
%
% WP
Final Combined Unapportioned Impairment Rating
% WP
5. To Determine Apportionment, Answer the Following Based On Prior Medical Records or Objective Findings:
Current Rating After Apportionment
No prior injury, no apportionment
A
Was the current date of injury before July 1, 2008?
Yes
Spine
% WP
P
P
Left upper extremity
No, after July 1,2008
% UE
% WP
O
Was the previous condition work-related?
Right upper extremity
Yes
% UE
% WP
R
No, not work-related
T
Left lower extremity
% LE
% WP
I
Right lower extremity
Was the previous condition independently disabling? Yes
% LE
% WP
O
N
No, not independently disabling
Psychological
% WP
Other
No apportionment can be done.
% WP
Use Combined Unapportioned rating (from Section 4 above)
Final Combined/Apportioned Rating
% WP
6. Signature
Date
REMEMBER TO ADDRESS ALL ISSUES ON THE DIME APPLICATION
This form, your narrative report, and applicable worksheets must be completed. Send the original report to the
Division with copies to both parties (or their attorneys) within 20 calendar days from the appointment date.
Division of Workers’ Compensation – IME Unit
633 17th Street, Suite 400, Denver, CO 80202
Telephone # (303) 318-8655 Fax # (303) 318-8659
WC132 Rev. 6/16