Free FORM - Connecticut

State of Connecticut Workers Compensation Commission
Please TYPE or PRINT IN INK

WCC File # Insurer #

42
(for WCC use only)

Physicians Permanent Impairment Evaluation
The Form 42 should be mailed to ALL parties (employee, insurer, attorneys).

Rev. 4-30-2009

Date filed in District

EMPLOYEE
Name D.O.B. Address

EMPLOYER
Name

INJURY
Date of Injury

City/Town Zip Code Tel.#

State

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

Percentage of Permanent Loss (or Loss of Use)

LIMB is ..........................................

q q q

LEFT .................

q q q

RIGHT

Maximum Medical Improvement Exam Date

HAND, ARM, or THUMB is ...........

MASTER ...........

MINOR

Which standards were utilized in your evaluation? (AMA Edition # or Other Source)

EYE is ...........................................

LEFT * ..............

RIGHT *

* Indicate:

q

complete and permanent loss of sight

q

reduction of sight to one-tenth (1/10) or less of normal vision

CONNECTICUT-LICENSED PHYSICIAN SIGNATURE
Name Address City/Town State Zip Code Tel. #

Signature of Connecticut-Licensed Physician Print Name of Connecticut-Licensed Physician

Date