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Workers' Compensation Division (WCD)
Department of Consumer and Business Services

Worker Independent Medical Exam (IME) Survey

The Worker’s Compensation Division would like to hear about your independent medical examination (IME) experience. Your feedback will help us determine how well the IME program is working and what we might improve. Your survey will be kept private and will not influence the outcome of your workers’ compensation claim.

We hope your IME experience was a positive one, however, if it was not and you would like to file a complaint you will have an opportunity after you submit the survey. If you have any questions, please contact the IME coordinator at 503-947-7606. Thank you for your assistance.

  1. Your name: (first and last)

  2. Your date of birth: (MM/DD/YYYY)

  3. Your date of injury: (MM/DD/YYYY)

  4. Your workers' compensation insurance company:

  5. Date of this IME: (MM/DD/YYYY)

  6. Name of the health care provider(s) performing the IME:

  7. How many IMEs have you attended in the past 12 months, including this one?
    1
    2
    3
    4
    5 or more

  8. How far did you have to travel, one-way to this IME?
    10 miles or less
    11-25 miles
    26-50 miles
    51-100 miles
    More than 100 miles

  9. Did the letter notifying you of the IME satisfactorily explain the purpose of the exam?
    Yes
    No

  10. Did you receive the brochure called "Important Information about IMEs" with your appointment letter?
    Yes
    No

  11. Please rate how satisfied you were with the following:
    Very
    Satisfied
    Satisfied
    Dissatisfied     		Very
    Dissatisfied
    The IME health care provider's explanation of the purpose of the IME
    The distance you had to travel to the exam
    The level of professionalism shown to you by the IME health care provider
    Your overall IME experience


  12. Did you have an invasive procedure during the IME? (See IME brochure for definition)
    Yes
    No

  13. Were you informed of your rights in advance of any invasive procedure?
    Yes
    No

  14. Was this a psychiatric exam?
    Yes
    No

  15. Did you know that you could have an observer present during the IME?
    Yes
    No

  16. Did you have an observer present?
    Yes
    No

Please review your answers before submitting;
they will be final.





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