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Permanent Work Related Mental Impairment Rating Report Work Sheet Form. This is a Nevada form and can be use in Workers Comp.This is a Colorado form and can be use in Workers Comp. Permanent Work Related Mental Impairment Rating Report Work Sheet {WCM3PSYCH}. Guidelines for Assessing and Rating Areas of Function on the Mental Impairment Rating Worksheet. PERMANENT WORK-RELATED MENTAL IMPAIRMENT RATING. Form EE-11A contains information explaining impairment benefits and that the employee may be eligible for an award based on permanent impairment. For a non-schedule award (classification), complete Attachment B. Sign below and submit to the Board only the pages of the form that apply to this report. Items 5 - 24 — 20. 6 Step Four: Determine the Final Rating of Mental Health Impairment .