Missouri requires this four-page report for every work-related eye injury that leaves any degree of permanent disability, so the loss can be evaluated and compensation computed accurately. The examiner records central visual acuity with and without correction, field of vision on a standard perimeter, binocular vision and diplopia, secondary ocular disabilities, pre-existing subnormal vision, and conditions that call for a delayed final examination.
The treating physician completes all four pages and signs item 24 in their own handwriting. Item 5 records the patient's account of how the accident happened, in the patient's own words.
Download the current version from the source each time; forms change without notice.
Physician's Report on Eye Injuries
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.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
In each case of eye injury resulting in any degree of permanent disability. Eye injuries that heal without permanent disability are reported on the Medical Treatment Form, WC-9. The form warns that all requested data must be provided for it to serve its purpose.
For certain conditions, including extrinsic ocular muscle disturbance, optic nerve atrophy, retained intraocular foreign body, retinal injury, sympathetic ophthalmia and traumatic cataract, at least six months and preferably no more than 12 to 16 months must pass before the final examination the report is based on.
Section I asks for distance and near acuity for each eye twice: without any corrective lenses, and with correction only for natural presbyopia and other conditions clearly not caused by the injury.