AMPUTATION CHART Michigan Department of Licensing and Regulatory Affairs Workers' Compensation Agency P O Box 30016, Lansing, MI 48909 Employee Name (Last, First, MI) Employer Insurance Carrier or Service Agent Social Security Number Date of Injury 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) LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. WC-728 (12/11) Authority: Workers' Disability Compensation Act, R408.31 American LegalNet, Inc. www.FormsWorkFlow.com