Quick Reference Guide

Amputation Chart

Virginia Workers’ Compensation Commission

VirginiaWorkers’ Compensation Commission Claims Services Reference Material

A cess your claim onlin : webfile.workcomp.virginia.gov

Jurisdiction Claim Number (JCN)

Claim Administrator Number

Injured Worker Information

Patient’s Name

Date of Injury/Occupational Disease

Date of Amputation

Name of Company/Employer

Amputation Chart - Hand/Foot

The physician should complete this form with a straight line drawn at the exact point of amputation. Circles are not acceptable.

Middle (2nd)

Great Toe 2nd

Index (1st)

Ring (3rd)

3rd

4th

Little (4th)

Distal

5th

Phalanges

Middle

1 2 3 4

Proximal

5

Thumb Distal

Metatarsals

2 3 4

5

Proximal

1

Metacarpals

Which hand?

Which foot?

Attending Physician’s Name Attending Physician

City

State

Zip Code

Address

I certify that I personally examined and treated this patient.

SIGNATURE OF PHYSICIAN

DATE

6

Toll-Free: 877-664-2566 | Online: workcomp.virginia.gov | Mail: 333 E. Franklin St., Richmond, Virginia 23219

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