AMPUTATION CHART Michigan Department of Labor & Economic Growth Workers’ Compensation Agency P O Box 30016, Lansing, MI 48909 Employee Name (Last, First, MI) Social Security Number Employer Date of Injury Insurance Carrier or Service Agent Date of Birth In all cases of amputation, the diagram below should be used to designate the exact point of amputation, which must be marked and certified by the operating surgeon only. In cases of amputation of arm or leg, surgeon must state exact distance below elbow or knee of such amputation. I hereby certify that I marked the above diagram on ______________________ and that said marking correctly indicates (Date of marking) the amputation(s) made upon _____________________________________ on ______________________ and that the (Name of injured employee) (Date of amputation) remarks above, if any, are in my handwriting. ___________________________________________ (Signature of Operating Surgeon) The Department of Labor & Economic Growth will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status, disability, or political beliefs. If you need assistance with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this agency. WC-728 (8/05) Authority: Workers’ Disability Compensation Act, R408.31 American LegalNet, Inc. www.USCourtForms.com