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Colorado Vision Impairment Rating Worksheet (DOWC)

Colorado Level II accredited physicians use this two-page worksheet to compute visual system impairment for a workers' compensation rating. One page handles monocular visual fields: corrected acuity, degrees lost in eight field sectors, motility and other ocular impairments for each eye. The other handles binocular fields without motility loss. Both end with visual system and whole person impairment.

Who completes it

The Level II accredited physician performing the rating completes it from the eye examination, whether that is the authorized treating physician or a Division IME physician.

Submitting and payment

How to submit it
Attach the completed worksheet to the impairment rating report, which goes to the insurer or, in a DIME, to all parties and the DIME Unit.
Who pays
The worksheet carries no separate fee or billing code.

Good to know

  • Acuity is recorded near and far, uncorrected and corrected, but the impairment value comes from corrected acuity using Table 2.
  • Up to 5 to 10 percent of the involved eye can be added for other ocular impairments, such as vitreous opacities, a non-reactive pupil or light scattering disturbances.
  • Eye loss values are combined with the Combined Values Chart, then converted to visual system impairment (Table 5) and whole person impairment (Table 6).
  • Colorado Rule 12 requires ratings based on the AMA Guides, Third Edition (Revised), reported in whole numbers.

Get the official form

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

Vision Impairment Rating 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

Which page of the Colorado vision worksheet should I use?

Use the monocular visual fields page when field loss is measured eye by eye, with sector degrees lost and motility. Use the binocular visual fields without motility loss page when a binocular field value is used, from Figures 2A and 2B, combined with the acuity impairment.

How are visual field losses recorded?

On the monocular page, degrees lost are entered for eight sectors (temporal, down temporal, direct down, down nasal, nasal, up nasal, direct up and up temporal) for each eye. The total degrees lost is converted to impairment using Table 4.

Who completes the Colorado vision impairment worksheet?

A Level II accredited physician performing the permanent impairment rating, based on an eye examination. It is used by authorized treating physicians at maximum medical improvement and by Division IME physicians.