Physicians Permanent Impairment Evaluation {42}

State of Connecticut Workers' Compensation Commission Please TYPE or PRINT IN INK 42 Date filed in District (for WCC use only) Physician's Permanent Impairment Evaluation The Form 42 should be mailed to ALL parties (employee, insurer, attorneys). EMPLOYEE Name D.O.B. (required) Address City/Town Zip Code Tel.# State EMPLOYER Name INJURY Date of Injury City/Town of Injury State Zip Code EVALUATION -- IMPORTANT! Use a separate Form 42 for EACH body part! Connecticut Statutes do NOT recognize whole person ratings [Section 31-308(b)]. Body Part LIMB is .......................................... HAND, ARM, or THUMB is ........... EYE is ........................................... LEFT ................. MASTER ........... LEFT * .............. RIGHT MINOR RIGHT * Percentage of Permanent Loss (or Loss of Use) Maximum Medical Improvement Exam Date Does the patient have a work capacity? .......... YES ........... NO If the patient DOES have a work capacity, please list any physical restriction(s): * Indicate: complete and permanent loss of sight reduction of sight to one-tenth (1/10) or less of normal vision Which standards were utilized in your evaluation (AMA Edition # or Other Source): CONNECTICUT-LICENSED PHYSICIAN -- SIGNATURE Name Address City/Town State Zip Code Tel. # Signature of Connecticut-Licensed Physician Print Name of Connecticut-Licensed Physician Rev. 9-3-2010 WCC File # Insurer # Date . www.FormsWorkFlow.com