Indiana's Worker's Compensation Board provides this two-part report for an attending physician or independent medical examiner to document an injured worker's examination. Page 1 records the examination findings and page 2 the permanent partial impairment (PPI) rating. The employer or insurer receives it, and it is filed with the Board when needed to support an agreement to compensation or a PPI dispute.
The attending physician or the independent medical examiner completes both pages. The employer and insurer use it alongside their own filings, such as State Form 1043, Agreement to Compensation.
Download the current version from the source each time; forms change without notice.
Physician's Report
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Either the attending physician or an independent medical examiner. Page 1 records the examination findings and page 2 the permanent partial impairment rating, so the same form works for a treating report or for an IME report that includes a PPI rating.
Usually the report goes to the employer or insurer. It is filed with the Board when needed, for example to support an Agreement to Compensation on State Form 1043 or when a permanent partial impairment rating is disputed.