Fillable DIME Examiner's Summary Sheet (Colorado DORA)

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DIME Examiner's Summary Sheet (Colorado DORA)

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COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS' COMPENSATION
DIME Examiner's Summary Sheet
WC #: 1. Claimant Name:
2. DIME Physician:
3. Is the claimant at MMI for this injury?
Date of Injury:
Appointment Date:
Report Due Date:
Ye s, the claimant reached MMI on
(date)
No, the claimant is not at MMI
4. DIME Examiner's Impairment Rating
Spine
% WP
Extremities
Right upper
extremity % WP
Left upper extremity
% WP
Right lower extremity
% WP
Left lower extremity
% UE Convert to WP
% UE Convert to WP
% LE Convert to WP
% LE Convert to WP
% WP
Psychological
% WP
Other
%
% WP
Final Combined Unapportioned Impairment Rating
% WP
6. Signature
Date
REMEMBER TO ADDRESS ALL ISSUES ON THE DIME APPLICATION
This form, your narrative report, and applicable worksheets must be completed. Send the report to the
Division
with copies to both parties (or their attorneys) within 20 calendar days from the appointment date.
Page 1 of 2
WC132 Rev 01/20
5. DIME Examiner's Apportioned Impairment Rating (if applicable)
If apportionment is performed, attach Desk Aid #14 Apportionment Calculation Worksheet (required)
Final Combined Apportioned Impairment Rating
% WP
Issued October 2008
APPORTIONMENT OF IMPAIRMENT
Guideline for Accredited Physicians – Injuries pre-and post- 7/1/2008
Changes per Senate Bill 08-241 and Workers’ Compensation Rule 12-3
MEDICAL RECORDS OR OTHER OBJECTIVE EVIDENCE SUBSTANTIATES PRE-EXISTING IMPAIRMENT
(1) ‘Disabled’ requires information that the prior injury was identified, treated, and independently disabling at the time of the current
injury. ‘Disability’ is expected to include conditions which adversely impact the claimant’s ability to perform his job, or limits the
claimant’s access to other jobs. Permanent work restrictions would generally fall in this category.
Previous Work-related injury Previous Non-work-
related injury
identified & treated
Patient was
disabled prior
to and at time
of current
injury (1)
Patient not
disabled
Calculate
impairment for this
work-related injury
(no apportionment)
Current Injury After July 1, 2008
Current Injury Before July 1, 2008
Deduct past impairment
from current total
Apportioned rating
Calculate and clearly state
current total impairment rating
including past impairment
Page 2 of 2
WC132 Rev 01/20
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DIME Examiner's Summary Sheet (Colorado DORA)

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Completed 27 January 2021

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