Ohio BWC uses this two-page diagram to set scheduled-loss awards for fingers and thumbs under ORC 4123.57(B). The physician marks the exact point of amputation and any ankylosed joints on dorsal views of the right and left hand, initials each mark and signs a certification. BWC staff then apply the loss schedule printed in the box reserved for BWC use.
The physician completes the markings, initials them and signs and dates the certification on the page for the affected hand. The injured worker's name and claim number go at the top; the weeks schedule is for BWC use only.
Download the current version from the source each time; forms change without notice.
Amputation/Loss of Use Diagram
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Circle the affected joint on the hand diagram rather than drawing a line, and initial the marking. Amputations are shown differently, with a single line at the exact point of amputation. Use the right-hand page or the left-hand page depending on the injured side, then sign and date the certification on that page.
The current C-196 (BWC-1326, Rev. Feb. 19, 2026) shows only the posterior (dorsal) view of the right hand on page one and the left hand on page two. Its notes and weeks schedule address the thumb and fingers, including the extra weeks added for loss of a metacarpal bone.