Colorado Level II accredited physicians use this one-page worksheet to compute hearing loss for a workers' compensation permanent impairment rating. Thresholds at 500, 1000, 2000 and 3000 Hz are summed for each ear, converted to binaural impairment with tinnitus added, then to whole person impairment, with a separate monaural result for each ear.
The Level II accredited physician performing the rating, whether the authorized treating physician or a Division IME physician, completes it from audiometry. There is no section for the injured worker.
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Hearing Impairment Rating Worksheet
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A Level II accredited physician who is rating permanent impairment on a Colorado workers' compensation claim, typically the authorized treating physician at maximum medical improvement or a Division IME physician. The worksheet turns audiometric thresholds into binaural, monaural and whole person percentages.
Section 2 has a line for tinnitus, added to the total binaural hearing impairment taken from Table 3. The combined total hearing impairment is then converted to whole person impairment in Section 3 using Table 4.
Colorado Rule 12 requires every permanent impairment rating to be based on the AMA Guides to the Evaluation of Permanent Impairment, Third Edition (Revised), as in effect on July 1, 1991. The worksheet points the rater to the specific table and page for each step.