Exam Forms and Templates
The IC report templates and instructions are intended to provide streamlined information regarding our report standards and legal requirements
needed to help guide examiners effectively through the permanent total disability (PTD) independent medical examination
(IME) report publishing process.
If you need additional assistance with the below forms and templates, please contact us at medical.services@ic.ohio.gov.
- Musculoskeletal Examination Report Template (Word Document)
- Musculoskeletal File Review Template (Word Document)
- Musculoskeletal Report Template Instructions (PDF)
- Mental Status Examination Template (Word Document)
- Cranial Nerve Examination Template (Word Document)
- Cranial Nerve Examination Guide (PDF)
- Physical Strength Rating (PSR) form (PDF)
- Dental Examination Report Template (Word Document)
- Dental File Review Template (Word Document)
- Dental Report Template Instructions (PDF)
- Residual Function Assessment (RFA) form (PDF)
- Impairment Guidelines (PDF)
- ENT Examination Report Template (Word Document)
- ENT File Review Template (Word Document)
- ENT Report Template Instructions (PDF)
- Residual Function Assessment (RFA) form (PDF)
- Vision Examination Report Template (Word Document)
- Vision File Review Template (Word Document)
- Vision Report Template Instructions (PDF)
- Residual Function Assessment (RFA) form (PDF)