(3)
Item 19. Check if this injury/illness resulted in permanent total or partial disability.
(i)
“Permanent total disability.” The classification for any injury or illness other than death which permanently and totally incapacitates an employee from following any gainful occupation or which results in the loss, or the complete loss of use, of any of the following in one accident injury or illness:
(B)
One eye and one hand, or arm, or leg, or foot;
(C)
Any two of the following not on the same limb— hand, arm, foot, or leg.
(ii)
“Permanent partial disability.” The classification for any injury or illness other than death or permanent total disability which results in the loss, or complete loss of use, of any member or part of a member of the body, or any permanent impairment of functions of the body or part thereof, regardless of any preexisting disability of the affected member or impaired body function.
(5)
Item 21. Nature of injury or illness. For injuries, use commonly used medical terms to answer this question such as puncture wound, third degree burn, fracture, dislocation, amputation. For multiple injuries, enter the injury which was the most serious. For illness, name the illness, such as pneumoconiosis, silicosis. Avoid general terms such as “hurt”, “sore”, “sick”.
(7)
Item 23. Occupational Illness. Circle the code from the list below which most accurately describes the illness. These are typical examples and are not to be considered the complete listing of the types of illnesses and disorders that should be included under each category. In cases where the time of onset of illness is in doubt, the day of diagnosis of illness will be considered as the first day of illness.
(i)
Code 21— Occupational Skin Diseases or Disorders. Examples: Contact dermatitis, eczema, or rash caused by primary irritants and sensitizers or poisonous plants; oil acne; chrome ulcers; chemical burns or inflammations.
(ii)
Code 22— Dust Diseases of the Lungs (Pneumoconioses). Examples: Silicosis, asbestosis, coal worker's pneumoconiosis, and other pneumoconioses.
(iii)
Code 23— Respiratory Conditions due to Toxic Agents. Examples: Pneumonitis, pharyngitis, rhinitis, or acute congestion due to chemicals, dusts, gases, or fumes.
(iv)
Code 24— Poisoning (Systemic Effects of Toxic Materials). Examples: Poisoning by lead, mercury, cadmium, arsenic, or other metals, poisoning by carbon monoxide, hydrogen sulfide or other gases; poisoning by benzol, carbon tetrachloride, or other organic solvents; poisoning by insecticide sprays such as parathion, lead arsenate; poisoning by other chemicals such as formaldehyde, plastics and resins.
(v)
Code 25— Disorders Due to Physical Agents (Other than Toxic Materials). Examples: Heatstroke, sunstroke, heat exhaustion and other effects of environmental heat; freezing, frostbite and effects of exposure to low temperatures; caisson disease; effects of ionizing radiation (radon daughters, non-medical, non-therapeutic X-rays, radium); effects of nonionizing radiation (welding flash, ultra-violet rays, micro-waves, sunburn).
(vi)
Code 26— Disorders Associated with Repeated Trauma. Examples: Noise-induced hearing loss; synovitis, tenosynovitis, and bursitis; Raynaud's phenomena; and other conditions due to repeated motion, vibration or pressure.
(vii)
Code 29— All Other Occupational Illnesses. Examples: Infectious hepatitis, malignant and benign tumors, any form of cancer, kidney diseases, food poisoning, histoplasmosis.