COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT DIVISION OF WORKERS’ COMPENSATION INDEPENDENT MEDICAL EXAMINATION PROGRAM IME EXAMINER'S SUMMARY SHEET 1. Claimant Name WC# 2. IME Physician Date of Injury Appointment Date Report Due Date 3. MMI Information Yes, the claimant reached MMI on Date No, the claimant is not at MMI 4. Previous Physician’s Rating 5. IME Physician’s Rating (Use all appropriate spaces) Unapportioned Extremity Ratings: Right upper extremity % Left upper extremity % Converted to whole person WP Converted to whole person WP Combined upper right & left extremity % in WP Right lower extremity % Left lower extremity % Converted to whole person WP Converted to whole person WP Combined lower right & left extremity % in WP Unapportioned Whole Person Ratings: % WP extremity % WP psychological % WP other physical (digestive, visual, etc.) % WP additional physical (spinal) Final/combined % in WP (UNAPPORTIONED) 6. Apportionment Information No, Apportionment is not applicable (skip to #7) Yes, Apportionment is applicable IME Physician’s Rating Apportioned to This Injury (when applicable): Right upper extremity % UE % WP Left upper extremity % UE % WP Right lower extremity % LE % WP Left lower extremity % LE % WP % WP extremity % WP psychological % WP other physical (digestive,visual, etc.) % WP additional physical (spinal) Final/combined 7. Signature % in WP (APPORTIONED) Date REMEMBER TO ADDRESS ALL ISSUES ON THE APPLICATION FOR DIVISION IME FORM. This form, your narrative report, and applicable worksheets must be completed for every IME and the original sent 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 WC 132 Rev 01//07 American LegalNet, Inc. www.FormsWorkflow.com