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Please TYPE or PRINT IN INK Rev. 9-3-2010 State of Connecticut Workers Compensation Commission WCC File Insurer Date filed in District Physician s Permanent Impairment Evaluation The Form 42 should be mailed to ALL parties employee insurer attorneys. For WCC use only EMPLOYEE Name D. O. B. required INJURY Date of Injury Address City/Town City/Town of Injury State Zip Code Tel. 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. LEFT. RIGHT Maximum Medical Improvement Exam Date HAND ARM or THUMB is. MASTER. MINOR Does the patient have a work capacity. EYE is. 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 Signature of Connecticut-Licensed Physician Print Name of Connecticut-Licensed Physician Date NO. Body Part Percentage of Permanent Loss or Loss of Use LIMB is. LEFT. RIGHT Maximum Medical Improvement Exam Date HAND ARM or THUMB is. MASTER. MINOR Does the patient have a work capacity. EYE is. 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 Signature of Connecticut-Licensed Physician Print Name of Connecticut-Licensed Physician Date NO..

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