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Colorado Lower Extremity Impairment Worksheet (DOWC)

Colorado Level II accredited physicians record lower extremity impairment for workers' compensation ratings on this two-part record. Part 2 covers the hind foot, knee and hip: angles of motion and ankylosis, diagnosis-based and amputation impairment, then combines foot, hind foot, knee and hip values with peripheral nerve and vascular impairment into total lower extremity and whole person ratings.

Who completes it

The Level II accredited physician performing the rating, either the authorized treating physician or a Division IME physician, completes both parts. The injured worker completes nothing.

Submitting and payment

How to submit it
Attach the completed worksheets to the impairment rating report; the Division's checklist asks raters to include their worksheets with the report.
Who pays
The worksheets carry no separate fee or billing code.

Good to know

  • Part 1, for the toes, is listed by the Division as optional; it records motion of each toe joint, amputation level and other disorders, and converts digit impairment to foot impairment.
  • Each joint section adds impairment from range of motion or uses the largest ankylosis value, then combines that with diagnosis-based impairment.
  • Rule 12 requires scheduled ratings to be converted to whole person impairment and final percentages reported in whole numbers.
  • For partial loss of use of a scheduled member, Rule 12 tells the physician to rate the most distal body part, such as the entire toe or whole foot.

Get the official form

Download the current version from the source each time; forms change without notice.

Lower Extremity Impairment Worksheet

Official pagePDF

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Is the Colorado toe worksheet required?

No. The Division lists the Part 1 toes worksheet as optional use. Part 2, covering the hind foot, knee and hip, carries the combined lower extremity calculation, including peripheral nerve and vascular impairment and conversion to whole person impairment.

Where does the lower extremity worksheet go?

It is attached to the impairment rating report. Treating physicians include it with their closing report, and Division IME physicians send it with the WC201 report and WC132 summary sheet to all parties and the DIME Unit.

Which AMA Guides edition does Colorado use for leg ratings?

Colorado Rule 12 requires the AMA Guides, Third Edition (Revised), and directs physicians to use the instructions and forms in the Guides, convert scheduled ratings to whole person impairment and report whole numbers.