Form IME-4.3B "Attachment for Report of Independent Medical Examination Non-scheduled Permanent Partial Disability" - New York

What Is Form IME-4.3B?

This is a legal form that was released by the New York State Workers' Compensation Board - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2018;
  • The latest edition provided by the New York State Workers' Compensation Board;
  • 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 IME-4.3B by clicking the link below or browse more documents and templates provided by the New York State Workers' Compensation Board.

ADVERTISEMENT
ADVERTISEMENT

Download Form IME-4.3B "Attachment for Report of Independent Medical Examination Non-scheduled Permanent Partial Disability" - New York

Download PDF

Fill PDF online

Rate (4.6 / 5) 10 votes
Page background image
PO Box 5205
Binghamton, NY 13902-5205
Customer Service Toll-Free Line: (877) 632-4996
Statewide Fax Line: (877) 533-0337
www.wcb.ny.gov
ATTACHMENT FOR REPORT OF INDEPENDENT MEDICAL EXAMINATION
NON-SCHEDULED PERMANENT PARTIAL DISABILITY
Please utilize this form as an attachment to the IME report, where there is an injury to a non-scheduled body part. These
attachments will be considered part of the IME report, and must be served together with the IME-4.
Claimant's Name
:
Social Security No.:
(LAST, FIRST, MI)
WCB Case No.:
Date of Injury/Illness:
Date of Examination:
Permanent Partial Disability
Non-Schedule Award (Classification)
1. Non-Schedule Permanent Partial Disability:
(Identify impairment class according to the latest Workers' Compensation Guidelines for Determining Impairment. Attach separate sheet for
additional body parts.)
Body Part:
Impairment Table:
Severity Ranking:
Body Part:
Impairment Table:
Severity Ranking:
Body Part:
Impairment Table:
Severity Ranking:
State the basis for the impairment classification (attach additional narrative, if necessary):
History:
Physical Findings:
Diagnostic Test Results:
2. Patient's Work Status:
At the pre-injury job
At other employment
Not working
3. Functional Capabilities/Exertion Abilities:
a. Please describe claimant's residual functional capacities for any work at this time (not limited to the at-injury job activities):
Never
Occasionally
Frequently
Constantly
Lifting/carrying
lbs.
lbs.
lbs.
Pulling/pushing
lbs.
lbs.
lbs.
Sitting
Claimant's Residual Functional Capacities
n Occasionally: can perform activity up to
Standing
1/3 of the time.
Walking
n Frequently: can perform activity from
1/3 to 2/3 of the time.
Climbing
n Constantly: can perform activity more
Kneeling
than 2/3 of the time.
Bending/stooping/squatting
Simple grasping
Fine manipulation
Reaching overhead
Reaching at/or below shoulder level
Driving a vehicle
Operating machinery
Temp extremes/high humidity
Environmental
Specify:
Psychiatric/neuro-behavioral (attach documentation describing functional limitations)
IME-4.3B (5-18) Page 1
IME-4.3B 5-18
PO Box 5205
Binghamton, NY 13902-5205
Customer Service Toll-Free Line: (877) 632-4996
Statewide Fax Line: (877) 533-0337
www.wcb.ny.gov
ATTACHMENT FOR REPORT OF INDEPENDENT MEDICAL EXAMINATION
NON-SCHEDULED PERMANENT PARTIAL DISABILITY
Please utilize this form as an attachment to the IME report, where there is an injury to a non-scheduled body part. These
attachments will be considered part of the IME report, and must be served together with the IME-4.
Claimant's Name
:
Social Security No.:
(LAST, FIRST, MI)
WCB Case No.:
Date of Injury/Illness:
Date of Examination:
Permanent Partial Disability
Non-Schedule Award (Classification)
1. Non-Schedule Permanent Partial Disability:
(Identify impairment class according to the latest Workers' Compensation Guidelines for Determining Impairment. Attach separate sheet for
additional body parts.)
Body Part:
Impairment Table:
Severity Ranking:
Body Part:
Impairment Table:
Severity Ranking:
Body Part:
Impairment Table:
Severity Ranking:
State the basis for the impairment classification (attach additional narrative, if necessary):
History:
Physical Findings:
Diagnostic Test Results:
2. Patient's Work Status:
At the pre-injury job
At other employment
Not working
3. Functional Capabilities/Exertion Abilities:
a. Please describe claimant's residual functional capacities for any work at this time (not limited to the at-injury job activities):
Never
Occasionally
Frequently
Constantly
Lifting/carrying
lbs.
lbs.
lbs.
Pulling/pushing
lbs.
lbs.
lbs.
Sitting
Claimant's Residual Functional Capacities
n Occasionally: can perform activity up to
Standing
1/3 of the time.
Walking
n Frequently: can perform activity from
1/3 to 2/3 of the time.
Climbing
n Constantly: can perform activity more
Kneeling
than 2/3 of the time.
Bending/stooping/squatting
Simple grasping
Fine manipulation
Reaching overhead
Reaching at/or below shoulder level
Driving a vehicle
Operating machinery
Temp extremes/high humidity
Environmental
Specify:
Psychiatric/neuro-behavioral (attach documentation describing functional limitations)
IME-4.3B (5-18) Page 1
IME-4.3B 5-18
Claimant's Name
:
Date of Injury/Illness:
(LAST, FIRST, MI)
Functional Capabilities/Exertion Abilities (continued):
b. Please check the applicable category for the claimant's exertional ability:
Very Heavy Work - Exerting in excess of 100 pounds of force occasionally, and/or in excess of 50 pounds of force frequently, and/or in excess
of 20 pounds of force constantly to move objects. Physical demand requirements are in excess of those for Heavy Work.
Heavy Work - Exerting 50 to 100 pounds of force occasionally, and/or 25 to 50 pounds of force frequently, and/or 10 to 20 pounds of force
constantly to move objects. Physical demand requirements are in excess of those for Medium Work.
Medium Work - Exerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to
10 pounds of force constantly to move objects. Physical demand requirements are in excess of those for Light Work.
Light Work - Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently and/or negligible amount of force
constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Even though the weight lifted may only
be a negligible amount, a job should be rated Light Work: (1) when it requires walking or standing to a significant degree; or (2) when it requires
sitting most of the time but entails pushing and/or pulling of arm or leg controls; and/or (3) when the job requires working at a production rate
pace entailing the constant pushing and/or pulling of materials even though the weight of those materials is negligible. NOTE: The constant
stress of maintaining a production rate pace, especially in an industrial setting, can be and is physically demanding of a worker even though the
amount of force exerted is negligible.
Sedentary Work - Exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull or
otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for
brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.
c. Other medical considerations which arise from this work related injury (including the use of pain medication such as narcotics):
d. Could this claimant perform his/her at-injury work activities with restrictions?
Yes
No
If Yes, specify:
e. Could this claimant perform any work activities with or without restrictions?
Yes
No
Explain:
4. Has the claimant had an injury/illness since the date of injury which impacts residual functional capacity?
Yes
No
If Yes, explain. Attach additional sheets if necessary.
5. Would the claimant benefit from vocational rehabilitation?
Yes
No
If Yes, explain
IME-4.3B (5-18) Page 2
IME-4.3B 5-18
Page of 2