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Colorado Upper Extremity Impairment Worksheet (DOWC)

Colorado Level II accredited physicians record upper extremity impairment for workers' compensation ratings on this two-part AMA worksheet. Part 2 covers the wrist, elbow and shoulder: flexion, extension, deviation, rotation and ankylosis, then combines hand, wrist, elbow and shoulder impairment with amputation, nerve, vascular and other disorders into total upper extremity and whole person impairment.

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 names the UE worksheet among those to include.
Who pays
The worksheets carry no separate fee or billing code.

Good to know

  • Record the side, dominant hand, age, occupation and diagnosis at the top; the digits are rated on the separate Part 1 worksheet.
  • If both limbs are involved, calculate whole person impairment for each arm on separate charts and combine them using the Combined Values Chart.
  • For cumulative trauma disorders, Rule 12 sets a staged rating method, preferred over grip strength; the two cannot both be used, and each extremity needs its own worksheet.
  • The Division posts the worksheets with the AMA's permission, and Rule 12 requires the AMA Guides, Third Edition (Revised).

Get the official form

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

Upper Extremity Impairment Worksheet

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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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

How is bilateral upper extremity impairment rated in Colorado?

Complete a separate worksheet for each arm and convert each upper extremity impairment to whole person impairment. Then combine the two whole person values with the Combined Values Chart, as the worksheet and Rule 12 both direct.

Can grip strength be used in a Colorado upper extremity rating?

Rule 12 prefers its cumulative trauma disorder rating system over impairment based on decreased grip strength. If grip strength is used, the CTD system cannot be, because that would duplicate the rating, and care is needed to avoid duplicating neurovascular or range of motion ratings.

What does Part 2 of the UE worksheet cover?

The wrist, elbow and shoulder: flexion and extension, radial and ulnar deviation, pronation and supination, abduction and adduction, internal and external rotation, and ankylosis. It then totals amputation, regional, nerve, vascular and other impairments and converts the result to whole person using Table 3.