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06-01-1992'•�r'••�;�A''1 i �'�RS�' �' .t'r�.�e��tf2: • ��l..is .•l. . .��t . . � . . � .l' !!' . ' . et .1' .l• �' �. � .1' . ,., r�R•' . , ' . . e 1 i •�Sr�' ;�;. .r,. ^!�i . . " , ... , . � , ' . . . . ' � , f. ..i I � � ��' . •• , .: ( � .i r�� . . . . . . , . � . .. .F � � ii��. , .71 � .. . � � ' , � - � . . � . . . � . .. . . � � . � . � i '�=s , . :i � , ,t r� f . .. , • �� . ' � , �, ' . ' , " , , .� . . .�' , � � � . �'. :.''�� i .,�r � ' . .e. ' . . '� • ' , � 1 . . � � ' •' . , � . . .. . . . ' �� ,. jj7�',a::i{:,�.,.. i . ,. ,� ' ' . � , . .., . • ' ' ' . ' ' . . ir - ' � � .. , .. . . . . ,'.P�?, �i. � � .`t' :t �i� .. : '�. 1 , � . . . . .. . � . . � . . . . ` , , ' . t. �'.j.� �+�� .it E" . `'i .. , . � . . � f.. . � � .. . .s � ��[7 ` � . . . ` • ? .. . . i' � . • t , . . . _ � , � ; i � 1�{� � •,t • • 1J •' . e a �. ` .�� .i 1 � . . � ' . � � . . ' .' '}:i, " ' . . �. ``e,' �,. 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'+ � � . i . � . • . �., u 'k,SF�' �3L�ti'�3' ,f��,r� .:� �': . : . . <1,;,.�.� , . . . . , . . . - ' • . , ' I]' i.�•k�.t�.� �,a�.: 'p.��.� I � �� i31;f:..�y�,i•'F �� "'�, . . _ ti..� .�i�... i�..e,9 .i�;i'.:N: f•: �v�•.Y�{'~,7J:•i}:1s�" :�l'.�ia�s�b�.��YFR' S1"e ''�.�i�G��1r��a'�iii31..�. ?l�tYi!4`i4:�< ' �z. � 7l:" :i-:' '.ieA�-: .Rr.�!':;.�ra�: ;iP�a�/� .�� n� � �. .. . ) .. . ri�..G3a,i n. . ,.�...0•�1..8�p ct-,......y�l:., r ...s. .a�r.:.,:q•i.•..e}� _�r.;�;, ,�q.. v�.i:ra.a+ . 4��gr . . .. . � .�1.� . � . . .. ��'�i�ii,.Trs'..-1't•'�'?'�."'�C. t' , . . ' ' I • • , .5 •. � . � � , , , � ' ' . . ' . .. ' ; . . � . . , � . • . ' :1 r ' , � � , ' � . . • r ' . t . 1 � ' ' ' . ' . . . , ��;:� , �' " � � , � . . - . . , , .. qC3�NDA � � • ' . . � , � , , . . �'� s � ' ' ' �� .Boa�d of Trustees o! the �m�ic�yeas' Pensian Fund ' . � , . �� : � , . :,..Jur�e 1, � 992 � ' . �� . '. ' ' . �,. . . . . . : � : ,. � � ; � , . immsdia��y f�llawistg CRA meeting , . � ' • , . . : , � '..; .., .,'.., � . . , � . ., ` . . , '.:;` , ',, .' �� . , � - � , . , � . . , �`_ ,- . � . . , , , . _.... . � 1. Cati ta order . . � . • , � . . ' � , , �,'r �,; . . ,,, � . -� . ' �, , ' , � , , . , ', ' , . . =,�i; ` - , ,2. Approva) of Minutas • . � � , � , �' of 5/'� 8/92 . �.,��: , . � , .. � �,�. �. �. � . �. . �. . �, . , . � 3. Pension(s1 to he granted: . � � , � . � , . .F . ' , , • . .Job-Connected disability � � . � '' ` ' � �'� .. . , � , � . . i., , � . . , , , , � . , � . a� Paui .G. Jackson � � • . � . , . '. , � � , b)'Christap�er J..Tamczak � �° , ' F ' � . . � . . . . � . . , . .: � � ; , � � c1 Harry L. Norris, Jr. , ' ' . , . � . . - � � � . � ' 4. Pension{s) to be granted:. . , • � . . . , „ . . , �� j . Nar�-Job-Con�ected Disability , ' . . . . . . Rnbert C. Spitateri . � ' � , . , • � . . . . , , , . � .. - . � � 5. �ther Business: , � , � , . ' ' � ' . � � , B. Adjournment: ' : . . ' . , , � , , . . +, . . , � , , ,.` . . �.. , . . , . .. � ; .,� , ' � � ' , . , � • . .._._.. _ :. . _.� .. _ .: �. ' ` . ..... .�.. . . ___.-_ �.,., ..,.- - - - _ - —,_ - _._. . _ _ _ . _ _ I � ��'SE�� . - CL�ARWATER �1TY CONIMISSION � ==� � r emorandum n$,� �r � � , �, �;,� _ Age�d$ Cove N� ��'�fiER'��'�4 � Trustecs of tlic EmpZoyccs' Pcnsion Fund MeQ1Ing Data: Subject: ' Pcnsion{s) To Bc Grnntcd � Recammendatianlh/lotion: � Paul G, lacksart, Mech�tRic �I, General Serviccs De�rartment/F1eci M�inicnancc, be �runteti A jab-conncctr,d dis�bility pcnsaon undcr Scction(s) 26.3� nl' thc Enzplpyccs' Pcnsion Pl�n as rccommenacd by thc Pcnsio� Advisory Comrnictcc, ❑ and that the appropriate nHicials be authorEZed to executa same. BACKGR�UNQ: ►= � Pstul G. Sncksot�,' G�ner�tl Services DepartmentlFleet Muinte�ittnce, was cmplaycd by thc City as � Mcchanic II on Fcbruary 24, 1975. and be�un participating iri the ErnpIoyces' Pcnsion Pl�n on Scptembcr 8. 19'1S, His work as a mccH�nic for ma�y yc�rs lcad cn carpal tunncl syndrome of his wrists which resulied in his application For a job-coiinectcd disahility pension. Mr, J�cksan has submittcd �ettcrs front Dr. .1. S�d[cr Hood (d�tcd May 18, 1992); Dr. Thoma�s O. SchwAb (tlatcd Muy �, 1992}; and Dr. Charlcs Abrahamscn {datcci Aprii 30, 1992) in suppori of' his rcquest . for a�ob-conncctct� disnbility pcnsiou. The doctors rcport that Mr. .inckson has ctirp�l lunncl synciromc af bo�!? wrists us n result of inaurics sustainec� during his em�loymeii[ as a mcchanic with thc City af Clcarwater. A Naticc qf Injury Report datcd M�y 2, 1990, is on fi�c whic�� inciicates tiie injury suffcrcd wtts "carpa! tunue] syudromc of right wrist." Iv1r. 3�ckson I�as h�id s��rgcry �'or car�al 1F�nnc1 synciromc on both wrisis at�d has r�ached m�xicnum medical iis��ro�cn�cnt. He is unable ta perform thc du�ics of a Mcclianic II duc to permanenl intpairmcni af his wrists. Mr. Jacksan's disability pcnsioiz was approvcd by tfle Pci�sion Advfsory Caii�mittec ac its mccting �f May 20, 1992. Bascd on a�i avcra�c salary of ap�raximatcly $27,957 avcr thc pasl fivc ycars and tlic sevcnty-fivc perccnt {75%} u�inin�unt ciisAbility bencfit, Mr. ]�ckson's ncnsian will a}�praximate �2U,968 lnnually. Charls fron� Finaiicc wiiich take i�ito considcration mor�Ulity r�tcs t�nd agc reflect [hc "�resent value cost of financi��;" this pension will be ,��rproximalely $19�i,10U. Mr, Jackson ctaims iio children u�der tt�c a�c af 18; �nd, clicrcfarc, no supplcmcnt co thc pcnsian is to bc providcd for depcndcnl children. Revlewed by: Lagal �"' puciget PurchasfnA A' Rlsk Mgmt. � �� ACM —�� Othor_., ��' „�� Submitt�d by: City Manager Originating Dept.: Hum�tit Rcsou User Dept.: Advertised: Date: Pa�R r: l�l Nol required Aflected {�arties ❑ iVotified L?�Nol required Costs: ��L.,.�+-,bov� _ Tota� Current FY �unding Saurce: ❑ Capt. Imp. ❑ Operating ❑ Oiher Appropriatbn Code: Cpmmission Action: ❑ Approved ❑ Approved wlcondiilons � Dersfed ❑ Continued to: Attachtnents: ❑ Nnne Let[er{s} Rcyuest Farm I. � � . • � ' . ,, � . �� , , I ' � � � ` � � � i � � . �. . � � , . � � , . . . � • 1 . ' � . . It ".(' .1. ' • . m . � � : l�r' �.fr., . � ... , . , ... . . . �. . . ��. . . . . ., � � • . F'ersannel Oepenmanl 482�i}8i0 . , . . ' � , C I T Y 4 F C L�.A� . R W A T E R POST QFFiCE gOX �17i0 CiEARWA7ER, FLOi�IDA 3�A'818-a�aa 'iD: � Honarab[e Mayor �tnd Mcmbcrs of thc City Comrr�ission �s Trustecs of thc � Employces' Pcnsion Plan � FROM: Pension Advisory Committcc � ' CqPIES: Pa�l G. Jackson; Risk Ivianagcment; Dan Dcignan, Assistant Dir�ctor of , Administrutive •Scrvices/Finance Di�cctor; Employce's Filc . SUBJE�,`I': Pepsion for Paul Cr. Jacksan-7ob-Cannecicd Disability Pcnsian ' DATE: May 20, 1992 , , Ti2e Pcnsion Advisory Committcc (PAC) received an �pplication for c�isability pensian Trom Paul G. Jackson on March 27, t992. Mr. Jackson �as bcen determined by the Pension Advisory Committcc �o mcet the rcquirements of the Pcnsion Pl�n far �t job-connecieci cfisability pensian. He was employcd by Ehe � City on Fcbruary 24, 1975, and bcgan partici�ating in the Pc�sion Plan on Septembcr $, 1975. Fu:ther, hc has submitted mcdic�l documcntation, copics of wS�ict� arc attached, ccl�tive ta his disability wltich has bcen reviewcd and approved by the PAC. By mation made and duly carried at its meeting of May 2Q, 1992, the Pension Advisary Cnmmittce approved/recommcnded thc granling of a job-connectcd disability �cnsion ta Mr. 1�e�cson in accar��ncc with pravisions of Seciinn 26.35 of the City Coc�c. 1'his pcnsian is to be cffeclive an t� dAlc to 6e deter��i�ycd. Thc amount af Mr. Jackson's pcnsion wiil be calculatcd by the Financc Dcpartment accordin$ ta the formuia in the Pcnsion Ptan for ja�-connneccet� disabilicy pcnsion At such time as his iast five ycars of service and salary car� be computed. I hercby ccrtify th�t ihe Pcn,sion Advisory Cumrr�ittcc h�s approvcd the �rantin� of a job-conncctcd disabiliiy pensio� far Pt�u! G. 3acksan nnd tl�e �t�iovc daics are corrcct. � . C�la� "Equaf Employmenl and Alfirm�tive Actlon Employer" L ory�C8lmmittce ` . , .�:. ,r .. . �� • -'— ' ' . i' ' . f . � � � . ' . . • ' , . � ' � 1 � � . . ' '� . � ' ' . ' �� . • ' • • • ' � • ' ' � . ' • . ' 1 � ' � ' , � . . . ' . � �' _ � ` ,.i' . . .' � . � � � � • . � • �,' . .�j ' , • ' .' • . ' ' . . . ' + . . . . ' ' i �, . . . ' i . ' � ' . � � .. • . . . .. � �� . . � ..+ � ..:•��. ' ' ' ' ' Y. �� [ .. � , ' � . . ` 1 � 4 .. � ' . , , '� . ' ,. ' . '` • ! . • 1 - . � � , � � . . � . ' . ' , i . ' ... � .• � S . • ' . . . i . , . ' ' ' . . . . � ' � . p � � . . � . . . • 1 . ...... _�.. . . .._ . . . : �,.....�r........ , ..., . �:.... .., ._�..... ., .,�, . �,..�,r �r � . o �.... , `� • . . , ...... .� . . ,..... .. .. y . . , • � . � � . . � `. PENSION REQUEST FDRM � � ' � :. I. _ Paul G. Jacksan __ , do �ercby appiy for retiremcnt �, from thc City of CIearwater Gencr�t Employces' Per�sion Plan. � � -� ' � My benerts date is �`�-fl$-75 �� (Eritry date into pension plan) - My d�te �of hire is D2=24-75 � ' . � . � My birthcfay is ' ' 17-10'-33._ _ � . � � My.,�oh classificatior� is Mec�ranic II and I waric � �, � . � �1e �Gen�ra'!^5erv3ces � Departme�t, Flee� Maintenance Divisio,n. M y resignation date is,. -_ �o be _ de��rmine�,,,,.,,_, � � The ty�e of perision For which I am applying is (check only +ane): Reg�1r►r Peasiaa bascd on ye�rs Of SEiV1C8 • , � � XX � ,�4b-conaecied Disa6ility Pension � Moa•,�ab-ca�nected Disability Pension • My spnuse's name is: Jaann� Jacksor� , � Dependent ci�iidren vnder the �ge of 18 �and residing in my hoc�sehold �are: � � none . (Print Child's �ull Name) (Chiid's Datc of Birth) . s . I hereby Certify all of the above tq hc true anci ctirrect: � ' . (Signaturc) ,�r�h 27, �.99� /� � �Date} Q L � � {Notary Pubiic} , � - ' , ' � e,: r � �Ifi�T!` ' tIOTAP,Y Pl!�L ! � � .i �. Cr �,'� �Y C':`:.4�.'Si,;�; ' . ,'t.i��_ 's;' i:9; BOiiOtl� �I1hU {�ch�i;rlL lti�. '��0. , ' , r �.i. h. . . . e . ' . . . . . �. . . .,..� . � ; � : l � . ' � � , � �; . t . ' I �' I . � � � ' . . � . , � ' i . , . o . 1t � ' ' • ' . , � . . , ..�.. . . . - , . . � ' . . . . 1 , . � f ., r • . � 4 . . . . , . � ' . . . �' .. � ' . i. . � � . , r � .. � � , . . i i . . . j . . , � . .�' � ' 1 .. ' • ., ,r� . : ,r . 3 ` � , � e ` � • ' '. , ,5 ' .. , • . . , � , ' � , � . . .. • . , i . � . � � . 1 ' ; � . . f � ' .. � . . ' . . < . ' 1 � .( . . . 1 ,'` 1I, : . , ", ' ... " ' � ' � � � .. • . . ', '. ' � . . 1 A } , � . � r . i. � . i � � ' ' . � . . . � ' . ; ' ' ' . � '. ..r'.sa,.'"1^:l1i.'-:}`?r(;fsi'k-�''��?�'ji'.��a.�-1r1�.:o�...�'.:Y:r.e..�. h w i ..,� � � ' • ' •. . . . ...... . ... _�.., . . . . .. � . . .. ... ... ... . .. ... . � . . � . � �� ; . ' . ., �: . � • ' � CITY OF CL�ARWAT�R � . �, ,: ''' � ' GENERAL EMPLOY�ES' 1PENSYON' PLAN ,. . � . � , . . �� : � � . � � ' UPTIONS �-. GENERAL EMPLOYEES ' . �. � E. ' ' . i. . � � i . . . � � ;': ,� OP'TION #l.: Employecs can receivc a lump sum payment �or .. , �� ' vacation and . holiday pay and• 1/2 af �ccrued sick �eave � ; at �he time af separation; from ihe City. Tb,ere will be no ; ,� . 8% deduction far pension from shis lvrnp sum p�,ym�nt �. , � nvr will . this amount couat as earnings in the i,'� '. �..�. '� calculation of the pension. The last day of woric will be , ihe termination date a�d pcnsion beaefits will bcgin .. the. fo�Iowing d�y. � OPTYON #2: . Ernployec casi extcnd terminatior� date by the time due (Only �vaiEable to , far �vacation, haliday pay, and 1/2 oE accrued sick leavc. employees hired Terminatiaa date wi11 be ths �nal day of extcaded time. prior to Ip/1190j Pension benefits will begin the fo�lawing day. � ��*�«**��*******�***��**�� Paul G. 3ackson I, �� , an emplayee of che City of Cle3rwater, hcrGby a��ly far pcnsion benefits uader the Gencral Employees' Pension Plan. . i her�by certify t�at I fuZly understand the lwo options offercd to me. I choosc - to retire using Option # and wish my benefits to be calculated undcr this opiion. ' I underst�nd that nncc this forn� is sigr�ed, my decision is irrcvocable. , . EMPLOYEE'S SIGNATURE: _ SOCIAL SECURITY #: 126-26�G?�b . WITtvE5SE5: ADDRESS: _ 1710 Tawnsend � Clearwatez, FL 34615 , DATE: _' MaY , 1992 �� . , , ��.i:�iV� of it��ury R[ro�wa r�.strt ►�cwunt■ usT IND. �a�vsn�HO. �t�� I�tEO. - aa�r xa� rawrorwor ur� tir, run+� R�w�a� � � .�, • �xP. Repart al� daths by telephone ot �elegr�srs w'sthin Z4 houn. ' PLEASE TYP� EMPLUYEFt INFORMATION FIfIM'S NA�AE `� NAI�AE (Flrtf, htlddl4, L�teM ... � . _ _ � ..�. - -- — ` .. �I � 1�� -- -� ... �_ -`--- S l n I li ul� � la�lt��n DfzPAR7'MIiM' pi;1.J11f{�ft ANI) fiMPWYM[i?t'1' 5�CUftITY � 1'11vi�ion d Wn�ken' Gom(xyt+�dan ZTZi Cerr�errlaw lhira, Sul�� J00, Fnns�� f3u31d�n� �,�,., r.�.�.��, �a�a. 3zs�v•cx,a� , , �L� A�T�NTION: W,C, G�AlMS OFF1G� ; Pfione; t�q00�342�1i'�il :MPIOYE� tNFQFiMAT10N ' SOC1/�6SECVIIITY NUMp�R NAII.lNG ADCHE55 t►nclude Z+p Cods� ' HOM� A{SCA�55 ��ud� ,Zip Cod�1 P.O. BOec �4748 ��tlA�,tiMtiN ,� 171� Zb�ea:� ' --. .. �7.e�t,�r. F1. � ZD� GL�ARw�A A+ ,' If�. 34�15 � �l� e 3 51� p1ti� B°x • . - � � "8391 � TE�EPHONE _,��« � TEl.EPHONE DATE OF OIRTH SEK Arr� Cods� S�m� �s Mulinp 5Q7 Vine At�e�nxe C�e�ter � �'1 J 4515 NATURE Of 6V51fYE55 a pATE AND TIti1E 4F ACCfOEP1T ; �ty, Couniy, St�lr1 � ,.. Arr� Cad�7 Numh�r' M ❑ F How lonp MumE�r ol haur� p�� yyr�k Numb�r a diyt FIATE OF PAY •mp{qyrd7 warht@ worle�d pee w��M � P�r Ory ❑ P►r Hnu� 11 pi• � wa�k or commhtibn, mlat 1 baard, lodqinp ot othr� i� pM q�y •wra� ws�kly �mnunt +br�nl�p� furnhh�d, fnt�r wMkly �mounl P�r W�� WpRKEA'S COMPElVSATION CVVEI�A[3E OY ��ur�nc• Compsny Srlf•in�ur�d �1 VE NAME, A�QF1E55 ANI] P041CY NUMBE R OF INSIIHANCE �OMPAMY OR SELF•INSUHEDSERVICE COMPANY. GALLACHER BASSETT S�f�VICES, �NC. P.O. �ox 4$40 Clearwaler, Fi.. 34618-4840 ACCIDEN7 INFORMATION D TtM� FIAST FFEPOA7ED NAME,AUGHESS ANO PHONE NUMp�R OF rHY51Clf• tAST�ATE 6MPLOYEE WOR1GEp REZQiiFi�d tt1 V �� EF Y�S, ORTE R+n�orr a� �o. I o.�. si �� EMP�O'f�� M1S5El?Ot+1E SHIHT,ONF OAY pR MQ#iE) �Y�s Np wns i�+�unr FATA�� (�Y�t �Na II YM, b�ir o! p�;�h Yes Yn I 1No �MP�OYEE'S dESCRIPTION QF AC IDENT (Ci1v�d�Ta�l�tuch �s,Idl,w�silrutk,nc,) , � l Ye�rr� a� �vrkinq a� a paittt ��#iy r+�d�znLts to th.f.� pr�l�► � � . . ^. r.�. r EMpLOYEl�' 1 aq�e* w�Sh �h�� dHdlptlon� Y�i [] Np II no, *rplairt In cqmm�nl{. , COMMENTS: � • f/ t tiJ1�l �r►/ � ��9i3i' Z495 Uriva, b�.ii.b� 107. PHYSICIAN AU7HdSFl ZE o35eM LaVCii Ye� ❑f NAME, Ai]DRESS AND PHONE OF HdSPiTAL OESGF:I{�� INJUNY ptl C115�ASE AIJd INQICA7 PART dF OQDY AFFECTED Ii,q. Ampul�t4nn af elq• Ind�■ Itnqrr �1 f�eond �aEnl, Frwelui�d rlh�, t�• Pollonlnq, �Se.} O�xp�ni, ha��l �yr�dx�am °� ' i1�1t �I�"�Bt• m Any person who, knnwinyty and with fntent ta injure, dcfraud or'�eceiva any cmplqyer or �mployee, insurancc company, nr scll�insurrrl program, files a slatemenl of claim cor7taining any fat'se ar mEsldading in�ormation is guilty o�.a felony of the Ihird degrea. ~ P�.EASE FILL IN Ai.L SpAC�S ABOVE r, t; �,;�' "� '� �' t� � •r.r� � : ' � ' �� .,.4rs �MPLOYER tRead �nd Signi�'- • • , , . • sioyk� Fle: ' . � '. { . . � onTa '� ' � t' . �MPLDY�� (He.ci snd S�gni � N 7uA ,� owr�0--. . ., . \ ` tES �o��+ ar,� i IF�rv. 6 79i ' �MPLOYER COPY °y 4�:!';.'•.5b , t: •. .. . , . . . , . . - ,� ; . ..r. .<_r�:"�'i... • . , . . .. . :r . ' : S3C �;}^!, i, .{, . • . . , :rr':i � � ' .. ' ° ' . , �i .. �a: - . ;�'�` ,i' .;,�` , .'r � - , , .. . . , . �, � . . t.• , . • • .. . , , ' •, 5�: .s': ' � ,'a �'�, . ' . . . . . . sF . . : � i ' f . ' •?�'� i '' .'i. ., ' . ' ' . . . '� ., . ' � t . . . ' � ' . . ' ' . , te � .:; `. . t . . r .. . . r . .. , , . ,�' ' ; � +.' . . .. t , . ��'�� . , . . , �.' � .' • . ' • � . . . . . ' 1 �'� , � . 'i;�� . .., i , . 4 , '�!: � � ' • � , � , i i. , . . �� , , . � , ' . �° ��'�� ^;�] � .� i,� F s, . ., �� ' , . . . , . . . '. ,. . ' . . ' � . . . 'u, ," ;.,. .: . . , . .. ti�" .. • . . ,>�� .: , . . . , ; `:� ' ,' � °� . H�: ' . � � � ' '- ' ' , .i. . . �. 'k � • � , .� � .� . ' . ,' . . � . ; �:- o , . . . � � 3''� . . . �� . . . . . . . . . . . . . . . � ,i', � i'. .1J. _ . ' �,: . r ' . . . , , ' a - . . . . -1- . j�' �.;.t� , . .n�e � . . � � . � ' . � - ., . . ' ° . ' .. � � , � . . ' • . , ... "a� : t�l� '1.�� , � � . . � �r . . . . . , . � . . .,i P . . ��i� '+, :7�?•R s,�.' '� ` . ' '� , ' `Y ,il . ...' ' . . . � .. .. � � ... � � ' ' ' . .;.. .'�.,o-• '. �1 ..r�'�'�' . . . � .. . � � . . . �r fi . . . . . , � . � , ��'. . }.' ji _. fE' � 3. 'f�,� "r.,. ; `:� .. . . ili , . . . . . . � � :7; ,t. . ,• e �, };� .i>" '�i` . .. . �� '' >. , . , :.ti . "i, •:.''• � . � : .'� ' , 14' ,'s • .. •• � � i- - � , .. .i:. 1r1 ' � �t:�rx {f; �E'.� �l•'� �t , • � . . . . , � ' i'. � . �. , t� . ' ' �i ' " .. ' . Y , r,�. ' . , IS� ,rf 1 1� � , .. .. ' � ' 1 � . ii � ' . ' . . YI:t� , .. _�l :ii��,,,' ..�. _ f' . � '{k� ' � . � � .. . . " .. , '•! . . . . ; . . '.��. . , ..�^ t.•t�. :�..1. ' . .: ' � � . . � .i i . ' ' i . �^4'' ,!! ' ,4 S: .. . '•s:,' . .t. • . .. ' ,1� ' }. ' . . .��.�.:.:;.r'...,:»�drr�t��.'�,`�3:�'�fE's�`:�j;'s�i�': �C�f:.�!!��;, � : ',t, ; '.� � �,� . " . , � . 'I . � � . • , . ' ' . �'- � ry.....,.,� . .. ..: , ....., . ..... .U"..�.:.,. ;. , -..; w .—. .,:rnr�.•..�s�r... ... �..' � . . ... .. , .+,-�.:r., .. . i . . �.7 � � ,'• � ' � .� • ' . . � . . 1 ... , . � . ' r ' �. •.' �, . . . �,.5 , . !f� . ..i ; . , .. � 3 . ' ' , . . . �`r . .. . 1 .. � ' , .� • . • F. . , •'I . �, • � . � , . . ' ' . . ; . . . . . ` - . � . . � J, SUDLER. HOOO� M�D.� RA� • ' � � ' :�-s. � . . � . ��3; � , , . . ' � � .' ' � onT►+ari�soic su�a�aN . • , , , {`;i>. ' . . . � , � • 618 L.AKkYIEW ROAD. VILl.A Vltl . ' , �i{ F ; . .. � - . 'r , • , . . . . . . ' . , 4. j .: . : . , c�,t�w�rer�. FLdRIDA aae � s � . . , ��: , _ . , � � . . . .. — .. . - . . . `�. ;s, . . .:� � . . � . � . 7e�arNON�.�at31 aet-2ea7 •' , ' � � , . • , �'� , ' , •. . ' ` � , , �, , � ,. . . . ,' �i1�1 . � ' ' 1 . � ` `. ' , r , r. . ' , .. ' � ' � . � . � ' , . , ,� , � ` ' , ' ' r, .� � I ' . � ' . , . . . . , ' ' , � . . 1 ,. r ' . " .. � � i, . " � � �• ' � ' . � , ' , ' ' . • r � ' . ' . . i � . . � . . . .�� . .. ; i''idy �8� , �.�� ' , . . , , , ' , ' , . , • . . . ,,. � : � . . ,. , , ,� , . . . . , �' � T0 WHR�3� IT MAY •CO�NC�kh�:' . . � ' ,' .' , ' � �. . V�'� • , . � , � . . . . , . . � ' �E: Paul 'Jaclt54�i � � . • . . . � � �"• °�� .'3�e pa�s.ent �uas ex�amin�d by' n�e on May 18, 1�32. • Th� p��ien� , . , I,. .�. ' h�s perroan�nt i.mpai•��jent iti� both ha�7d5 as a re5u1� �nf a�i , • � � � ' o'n=�h�-;job inj�tiry to bath h�nds. The patient is u��able i:n , �'.. ,� � . � re�u•rn to , wark as � mQChanir iI d�►e tn th 'is pern�aneti�� '' � , impairmen�. � � '� � � . � ' � - • , � . Sinr�relY, � , , : �� . , � ' � ' - , , � • . . �,-r. Sudl�er Hoad, �I. D. . . . , < � , , . , . � � 35Mlgw, � . � � ' ' � �41. .` ... . . ; ' ' 1 � ' � ,. . � ,. . . . , , r. " . . . . � . . � � F � . . . ' , ' � � i ' ` ' . . . . . ' ' . f. . � . . . . ,� . > r , , ' . . . . f , � ' ' . � ' � • . ' � .S - , " � i � �, . . � . . . � � . . � . � . � " , i ,. . � � . � � � . � � � . ' � . . � � , { ' . . . . y . ' . . . . � � , r` .I . .. � . ! , r r , � .i �� . . � . � . . . . , . . , ,. . � i'. . . . , . .. '. � i . . . . f , . , � , . , , � , ' ' . < , , . . . � ' . ' ', . ' ' ' . ' . ' ��i�J' �.Ja� :'`,�,•Y�i � � . . . . . , r ' ., ...�a vlSt!f�l ��f�'�. �' , . -. . .!i':.1� .t _. .� .�.5.- . . � . ... . . . ...,. " . . " ..� .. . .. .. .� .. ' . . ,.. . � ' � ' . S � . • r � ' � . . . . ZACKSEINs Piul G. ' � ' Page 1., . • , i. May 18� I9�2 � . 5ECOHD OPYNYO�i � .. ' Pa�i��it� co�aes ir� for 3rd opinin�t for di5ability. � He �as� a prablem that da�es back �a � May of 19�0� when he pre5ented �n Ar. A�rahaatisen with 5 e�nnths of numbness and �itigl�ng in �� his ri��t upper extremity. Ne had nerve COT1dtlC��e11, S�LLdi�s da�i� by Dr. Leb�r which wer� pasi�ive iar rarpal �u�nel syndrome, He underwent derompression with epineu•rolyaia later �� ha� �a�ue mon�h. lie subaequently, in la�e JuZy of the same year he un�erwen� decampr�55inn an tfie 3e'tt. The pa�ient however� has had nngoing difficul�y with both hatiids. .He rotes �� hands are weafc� he r�ates the finqe�s are s�iffy I�e �iotes the fingers are 5amewt�at �es�aitive ev�n tn �ight pressure. Fie T1Q�L5 �he digi�s are aomewtiat cool and he daes nnt occa5i�nal � �di`@S�I1�5�d5 in �hQm. i�ecen�ly he has been having snm� Swelling av�r the dorsum nf �he � carpus. �3�e patient has bger evaluated by rheumatol.aqist and evid�ntly nn�hing defini,ti�e . was ' no�ed. I had revi�r�ed �he offl�e nnted from � Dr. fl6rahamser. The pa�ie�i� has , classificatian of �a�chanic II which requires him to wark an heavy eqttipmeni� surh as � dump �TLl�I�S� au�on�ahilea etc. I had the last dQfinition al,so in his rhar� and I have reviewed .. th�t. The patiet�t has been given d'zsabi.lity by Dr. Abrahamsen far his re5idual , syn�p�amatology. He has al.ao be��i given disabi].iicy by�Dr. Schwab bu� sinee they are both part �- of.�he same graup on the same l�tterh�ad, the second lette•r evidpntly was disallnwed and the patien� cam�� in ta se� me today. RHYSICAL EXAM�i�ATiON: � Qf �l�e patien�'s hand5 shows milt! di�iuse swelling over ��e dorsuni af �he carpus bila��rally. 7h� fit�gers arQ all very�slightly swol�en. �x�ension is full at aI], jnirita but fisxiori is limi�ed to abo�,tt 'rotighly E�0 degrees � a� ail the �tCP jointa a��d roc�ghly �0 deg�rees a� a12 th� PI� j�117�5. Whet� he �'ries to make � a fis� this puts hi.� finge�r�ips abou� I 1/2 cm. sway fran7 his palm. 7her� is same n�ild � hypersen�i�ivity �o palpatinn aver bo�h sca•rs. 7he•r� may he same Slight wastitiig oi the . �heiza•r emirience but nathing niar�Ced. Fadial. pulse is in�ac�. 7f:�AihI��IT PLAW: I agree wi�h �he •re5itival that he l�as h� is unable ta func�ian as a mechanic II ard wa•rrants a let�er to �ha� effec� which we will dictate. � �. 5udler Hood, M.b, JSH/gw � TRANSCAIBED BUT NOm �b�'TED �,i . , . � , . � ' , ' ' � � . � . . � � - , , ' , �. .; . �� •. � . . � . . � , - ' . ° �° '. . . . ' � . ' . : , � . ' " - . ` , . � ' � , . � , . . ' r . ` . . � , . ' , 1 � .�, 1, . , i ' .. . .' � �: , • � ' .� � . , � . . . � '� • . . , . . - . . . .... ....... . � , . _ .. . , .. . . . �i ' . . .. . . � . . . . . ,. 1 , ... . . ', � . • � r , � . 'ORTH�PA�DiC,SU.ItGERY CENTER oFCt.�nxwA�r�� P.A. , . � � 15Z8 (.AKEVIEW 1i0Ab, CI.EARWATFR. FLOa�nA 34Gj6 • ($J3) d��-{N12G . � � � , �si3� ab�-ta�z {�Ax� . Jo�N M. Mce�.vRE IIr, M.D. � , ' TE�oMns 0. ScHw�n, M.D. ' ' • � HAftRY 5i'ElyMAN, M.D, ' . . � � � . CHARL�S E. ABRAFiAMSEN, M.D. , • , � � May 4,1992 . v , . To Whom it May Conc�rn: � Paul Jackson is seen zn �second opinion in regards �valuation for,' , permanent i,mpairrnent in regards to an injury he susta.�ned in his employment for the City of C],earwater. . Mr. Paul Jackson sustained bi].aterai�carpal�tunnel.syndrvmes as a resul.t .of his empl.ayment for the City o� C�.earwa��r in the capacity o� a master mechani.c . . � Patient underwent surgery for carpal tunnel syndr�me rel.ated �o this '3.n�ury on 5-94 0� the right wrist and 7-26-90 for the I.e�t w�ist. ��Patient on examinati,on still has evidence o£ persa.stent carpal tu��nel syndrome, He has decreased grip sirength o� 16 Kg af � bd�h hands and the pa�.ient has marked stiffness and sweiling of the MP, PIP and DxP �oints of both hands. I teei the patient has a permanent S.mpairment o� 10� o� �he body as a whole according to the AMA guidelines ot physica� .i.mpazrm�nt. z � f ee]. that he has reached maxi,mum m�dica]. improv�ment as of 9-3-9Q. ' He is unabie to return ta work as a mechanic I� d�e io permanen� impaa.rment in both hands. . ' z� you have any �urther questions please feel �ree to call us. . , Since�ely, ToS/t�k � , � � � � �� . Thomas 0. Schwab, M.D. � � � � a[PLqMATESOFTHEAMERICANSOARpOF'ORTNUPAEq�C5lfAGEltY , FELLOW5 pF 7HE AMERICAN ACAOEMY OF OR�HOPAE�IC SURGEONS �....' . .,. , . • � , � , . � • ! • ,. :" .�'. ,�. ' '� �, '" . ' ,. : , :.' ' � ; �' �� '. ' ;'r t , � ' ; • , . �' • • , : � � � . "' � " � , • . � , ' ' , , . , . , F, � ' . , • ' . • . , . , . „ � '. . . . . . . , . . . • ' • . . . . , . ; , ; ., .. i , , , . , ' .. . � .; . .. . . . . . . • , . .. , ,' . ., , � . : ,� � ' , �� . . � � . � 1 �� .. , .� �, `r� .:.� �. : . �, , , ' ' . .'.,. .. , ' ': �� . ,. ' ;' � , ' � ' : , t ... . : .� . , ' . ;,. , `, ` ' � ' . . , , ' , , .: . .' . .�' . � � ,. . ` � � i . , -� `. � , .. � . � '. . . 3 ' � . .' '' . , : . . � - �;1•<':<'.-�„•Kts ':F'�•';<��t �; , , , , . ..�-:in1-,F :t ...fr,. .. . ,;f�.-^.!," i,., :i�� ,•'A`��.. ig','!, ' . ' , . � ' ' � . , , ' • ' � . `�:� ... � .�.. . .. .. . , � . . . . .... . .. . . ... �..' .. .. � . , . . , , .r .. f ' ' . .. � ► � ' . , . ' ' � . ?�� '. �'RTHC?PA�DiC SURG�RY. CENT�R aFCz�naw��r�a, P.A. ' �F � � - � � �.... � � � , iSZ$ UIKEVIEW RO�d, Ci,EAAWAiEa, F�.oRii�� 3dbi6 .� (813} 4b[-G026 s' � ' � � � , ' {813) 461-1�t91(�AX) � . Jo�tN M. �YICCLLFRE I�I, M.D. ' � � ' � �� r . THOMns C?. Sc��wn». M.D. . . � � � , . . H�RxY Sr��rtiin��, M.D. . � . ' . � , � CHARLES E. A�RANAMS�N, M,D. ` � ` ' • . � ' ' � � ; . Apx'].1 30 r 1992 - . . To Whom a.t May Concern : � � . � , , � ' �T am writing this l.etter ,at the '.reque'st ot my patient Pau]. � �ac�:son. He has been a patient of mi.ne since 5--15--90. ' Carpal tunnel synd�ome uras caused by,r�pe�z�ive on the job in�ury to both hands. . � He und��went surgery foz carpa� tunne]. syndrome rel.a�ed �o his occupation on 5-�.e-90 �o� ri.c�ht and '7-26-90 far his le�t hand. Due to the carpal tunnel syndrome and surgery he has some permanent impairment af 7.D� of �h� body as a whol.e due to loss af mat�on, strength and functzon in hzs hands. Maximum m�dxcal ' improvement date i.s 9-3--90 , He i.s unab�e ta return to work as a "mechan�.c Iz", due �a permanent �.mpairm�nt.in his hands. . � Sincerely,. � . , . - Charles Abrahamsen, M.D, ' CA/t3.k , � , . pIPLOMATES OF TNE AMERICAN 8(1A3ip Op QiiTNUi'A�U�C Sl}KGERY • F[LLOWS OF THE AI�SERICAN ACAO$MY Op.QItTHUPAEpIC SLtftGEONS � �: .'.. . . . . . ., . ' , i....�.__._.. _.� �..._, � � . _ _._..__�_...�._.�� ...�_ Subject: CLEaRWATER �ITY CAMMiSSl01� Agenda Cover Memorand�um Trustccs of thc Empl�yccs' Pcnsia» Fund Pcnsion(s} To Bc Grt�ntcd ltem N Meoting ❑ata: Racommendatio�lMa�fon: Chris�to�hcr 3. Tomczak, Te�hnica� Equipmcnt Operatar, PubJic Works DcpsrimGnt/�'ubic 5�rvicc, bc grAntcd ��ob-cannected ciis�bility pensian under Section(s) 26,35 of thc Empinyces' Pcnsion Plan a§ rccommendcd by t�c Pcnsian Advisary Cnmmictec, ❑ end that the approprlate atiicials he aulhorized to exec�te same. BACKGROUND: ►=.�s Christopher J. Tomcxak, Public WarEcs DepartmentlP�biic Service, w�s cmploycd by the City As u Tcchnical Equiprr�ent Operator an August 30, 1985, And bcgnn pt�riicipAiing in the �mplayces' Pcnsion PIAn on that date. An injury to his shoulder which hc incurred wf�ilc employed with the City ttas resultcd in his �pplication for a job-connectcd disability pension. Mr. Tamczak h�s submittcd Ietters from Dr, Richard F. Lystcr {�3ted A�rit 30, 1992); Dr. Danald C. Sullivan (datcd Janut�ry 27, I992}; and Dr. �ivscpli M. Scna (datcd M�rcti 4, I991) in support of i�is requcst for a job-cannected disabiliiy pensioii. The . repart fram Dr. Lyster stAtes that Mr. Tainc•r.ak has "1n injury to liic bracliial plexus, possibly from infectinn And�or thc originul blust fr�n� tiic high pressurc hose." The repor[ from Dr. Sullivttn statcs tl�at he "did �ave � permancnt soft tissuc injury to liis axitlary urc� of tlzc righi arm." A Noticc of Injury Report dateci Septcmber S, 19�9, is on filc which indicatcs trie i�jury suffcrcd was "skin torn right �rmpit." Thc Report A150 indicutcs thac thc "cmplc�ycc was flnshing oat mant�olc w�th �i�h pressure jet �ase, �hc' nozzlc came u}� aui n�' thc manhaie unci up under his �rm. Thc wt�tcr pressure torc 3 ar 4 holes in thc skin." Mr. Tomczak IlAS reaci�cd n�aximum medical improvemcnt �Rd is �ermanently unublc to perform i}�c dutics ar � Tcchnical Eq�ipment Operaior. Mr. Tamczalc's disability pensian was �tpprovcd by thc PcnsiaFy Advisory Committec at its mccting of May 20, 199Z. Ss��cd on �n �verage saiary of approximAtcty $18,2SS avcr [hc �ast �vc ycars and thc sevcnty-fivc perccnt (75%} minir�unt disabili�y benefit, Mr. Tamczak's pension will approxim�te $13,691 7nnually, Cl3arts fran� FinAnce wliich take ii►to ca�isiderulion mort�lily s�tes and agc rcflect the "preseni vAluc cost of financing" this pcnsion will b� up�roximately $178,8�1, Mr. Tamcxak claims no children �ndcr the a�c oi' 18; and, thercforc, no supplcment ta the pensian is to be grovidcd for dcpenctent children. Raviewed by: L�ga! . _ �11-� Budget _ �� !'urchasing +�A` _ . Risk Mgmt. N/�-- D15 ACM Olher ��' ,....� Submitt�d by: City Manager ariginating Dept.: Humun Rcsou User Dept.: aavertised: Date: �aper: � NaE required Afiectad parties ❑ Notifiad it� Not required Costs: .]�� a Total � Current FY �undiizg 5ource: ❑ Capt. Imp. ❑ Operating ❑ Other Appropriation Gode: Commission Actian: ❑ Appraved ❑ Appraved wlcanditions � Denied L7 Cornin�ed lo: Attachtnents: � Nane Lctter(s) Rcqucst Farm :, � � , • . F • � � ' � . I . � � � .� } .. . ii , ' , . ' . � , t�� [ ..i.a, � . . , � r .l! � . �.{ %'•� , n.P.�- r'I . � . . . , �. . . ,..� . ' , ' ' e . , �, � , ' . �� paraonnei Oep�monl �82-8670 ��w a C I T.'Y � Q F C L E A R W A T E R ' POST OFFICE BQX 4748 ' • CL�ARWA�ER, FLORIDA 314'{i18-a7A8 � • 'IL): Hanorab[c Mnyor And McmUcrs t�f thc City Commission as Tr�stGes af thc � � Employces' Pension Pl�n � � � FR�M: PenssvR Advisory CommRttee � COPiE5: Christophcr 1. Tomczak; Risk Management; Dan Dci�nan, Assistant Dircctor of Administrative S�rviceslFinancc Director; EFnployee's File • � �� SUB}ECT: Pe�sian for Christogt�cr J. Tomczak—Job-Connccicd Disability Pcnsion , DATE: May 20, 1992 . The Pcnsian Ac�visory Committcc (PAC} reccivcd an Ap{�licaiian fnr disability �ension frnm . Christopher I. Tomcxak on March 9, 1991, Mr. Tamczak has i�ecn dctermined by the �'ensian Advisary Committec to mcct the rcquirements of the Pension Plan far u job-canncctcd disabitity pensian. �c w�s emptoyed by the City on August 30, 1985, and be�un �articipaiin� in the Pension PIAn on A�gust 30, �985. Ft�rt�cr, he htts submiticd medical documentation, copics of which are A[�AC�1C�, relativc to his disability which has becn revicwcd and approved by tt�e PAC, By motion m�dc and duly carricd at ils mccting of May 2U, i992, thc Pcnsion Advisory Commitlec approved/recommended the granting nf a job-conncctcd disabilily pension to Mr. Tpmczak in Accordancc witH prpvisior�s of Scctian 26.35 af the City Cadc, This pcnsian is ta be eFfective on a datc to 6c �etermined. The amour�t of Mr. Tomczak's pension will bc calculatcd by thc Fint�ncc Dcparlmcnt according to thc forn�ula in thc Pensior� Plan for job-connnectcd c�is��tbility pension �t s�ch timc as his last fivc ycars af servicc and salary can bc computcd. I hereby certit'y that the Pens'son Advisory C:nmmiltec has approved the granting of a job-connected disability pensian for Christ�pher d. Tomczak and the ab ve dates arc c�rrcct. . � �� n � � \ �-�. . ChA�rman. vi5d�+ �ommiticc "EqUal �mplayment and Aftlrmative Actian Emplayer" '�'' , � '. . , E � , .. �• , • � � , � . . . �� . . '. . , � • � ' . . �,r • . . , . d. ' � . � . ' � ? . � �1 � . ' • . ' . , . � ' � ' � . . . • � � " ' . • . , � � � ' � • . ' . ' . . i � . . ' ! - . � ' J . . . 't�� ' � .• . ( _J, , ' . j , . ' . ' . � ' . . . �; •1:.• . .�� . . ' � ��:'3'. ^i.'. r .;� . eSe{... .r�r... �� _ � .. . . . i. .. „ . '. .' • . ,� " • ,, •. . ' ' . . , . . ' ' . � �ct�szatt t«:qut�.s� �v�ut •� . � � ' - � . � . ' � . . ' . � � . . . . . ' ' . . . � ��, C. o1�.r r� , r� t z,,/� � do h�reUy n��ly for ra�ireMent �rom tlia ' ' . (pxin� N�meJ ' �, City oE Clenxwnt�r Cenern� Emplayees' Pena�on P3.�n. ' .- . T�[y Uenef �.te date. i� � �� ` $ � (Er�try datQ �itta pens�on p�an) . . ^--� ' ', Ny c�ata oE i�ire ie � . �3� � v'�� . � �sy b�rtl� date i� , �-}-� — �� " . � . riy �ob clas��.f�cat�.vn J.e ]_ �r� F � (' nrid I work i.n . . � � . . - ��.}� . �-l�� _ �C be��srtmenC, � 11U r�y� �-4-I'��i �C��-vis%on. ' • 1�ty..resigr�ntivn r�ate �� "��-�.-rn�.,�3en . ,� • �'Ije� type aE pens�.an fvr wts3cZc I a�r tt��lying is (c��eck anZy one) ; • � Re�ul,ar Yen�ivn I3:��ed on. Years o� Serv�.ce ��'� Jo6-Cannected Uis�bi�lity �'esisivn ' Nan-JoU Cannected, A.lsab�lity Pension � � � iiy spause's�� narne is u P o-M . L• . � ' peretide�� cl��ldren under the a�e oF. 1.� and res�.ding, iri my l�vu�eliol�! arc: • (P�f.n� Eull. n�rne) � (bat� of ��.zt1t) ' w � � ytereby cert�.Fy ml.l oE tl�e ��ove to. be tru� and correct: , . . � r C� `"-� �. � �� ' ,T ��(/�' �iOTI��'f PUE�_IC STAT"c OF FLOREOA Signaturn) "' _ � FtY CC��tt 55 f�N E XP JU�iE 30, � 944 , BDl;UED THRU G�i�ERAL I��S. UNO. • , , `L� � "� 1� . � `.., (Un� � � � . � � .L�rr��. ; ctlar��y �ru�x�r) . . . � mmt- , ., . . . . . �: .. � � .. ' r .. .. . ,�, r . �-. • � " 5TAT5 c]F FL,ORIDA . V�c��r�� of ln�ury �� '•T �� u�R DEPARiMENT..r LABOR ANC� EMPLQYMENT SECURtTY ,�d, �n».,�nh�.o. ].3�l� Dlri�ian of Warkers' Compens�tion 1321 Executive Center 1]�iye, East 1�D• a.�r .a� . r.�rnrwor ,�w,+ ,�s. Masuxc Talla�nssrsc, Florida 32341 �EHae. «1 � ��'• ATl'��lTION: Y�►.C, CLAIMS OFF1C� ,epart al) de�ths !sy telephnne or trleg�am with;n 24 haurs. PL�AS� TfPE Phare: 1•B00•342•1741' EMPLOYEFt 1N�ORMATiDN �MPLC3YEE IlVFORMATION FiRM'S NAME NAMQ �Flrst, M�ddl�, Laitl 50CiAL.5�CURtTY NVMBEfl � C��y. a� C1ea�raC�c , Chcistopher J. Taarz•�k Of7--56�50].� 1vIA3L,INO ADDRE5$ llnC�ud� 2ip �adrl �{pME ADORESS 1lnclud� Zip Codel OCCUPATION �f�,Qpz� p' o. �a _.�4'7 3�fi18 $� $ 1`�9 125 N. Aigh�and Tech. F,�uip. O�er.atar C�.e�arxa er. Clea�uate�� k'� 3�5�5 SUPHFiV150R'S NAME �r �nts4�L"'r' -{ r �i. Ft�,C�]ie�'. �r. R;��` �~ � ��{S C� DEPAHTMEN7 NAME • 1 O�r ��'�`''R� eub. Wks./Pub. service T��PWONE � � ��;�� /` Tr�8r� etfONE OATH OF S1R7ii S�X • J1ria Cod�: a�� Numbrr: � "� �� A r� C tl�: a}.� tJumbv. �63.'�QrJ' �/ �l.�r]� � M Q F r LQCATiON gy ��l�Q 3iow fong Numbrr of hour� py� yy*�k Numhir a� d�y1 FiflTE OF AAY fr+� 1pV�CT work�d work�O p�r w��k � : �.ZZ $. 03C�0.�21 'i �3C5 �iQ ❑?�r Dsv � ❑ P�r Hpur ;(,'"I�g�yj�tta=� �'� �� P;k� wa�k oc tomm��y�on, mte� II boa�C, loe7q+nq or ath�r ��%�.2� ❑ pH p�y � � w*r�Q� �Nkl� �mqunt �avafit�qrs furnich�d, �nt�r w��kly � amaun� ].�WQ�CI�C] par W��k WORK�R'5 C�MP@Dt5A710N CqV�RAGE BY ❑In�ur�nc� Cmm�snY 5�11•Insur�d GIVE NAME, A�OAESS ANO NOLICY NUM6flli OF 1NSURANCE CpMPANY ' NAiLJF1E OF 6LSlN@SS aR 5E�F•1T1511HE4 SEFiVICE CQMPAfVY. ' t•�una.cipality C'.,-�ALLACzHER BASSETT S�RV�GES� �NC. ��a�aa�. er�n�+�oveq i.o. NUMB�R 2953 �.5. 18 iJorth, 5ukte 301 ��GZ89 � Ciearwater, �iorida 3462'� �ccio�nrr i�vFaRM�r�o�v OA7E AlVD TtM� OF ACC�flE►JT DAT$ AND 71M� FIqS7 REPOFiTED 09/07/89 -1�:3,5 �.m. 09/0?/$9 -- 1�•15 a.m. PLi1C� OF A��{OENi' IStr��t, Gi[v. Gounty, Stat�i LAS7 OAiE E41A1.OY�E WORK@D Seaum�nt C�. & �o�th�i�e Dr. �9/�7/�g CI�c�l.Ydt�= (Pxn�].�as }� F'�OCZC�3 RETtiRNEp Yq WORK Yes � IF YES, DA7E � mniorts ra�a+or �-- ^-- IVAIAE. AOOAESS AND PWpNE NUMB@R OF AHYStCiAN M�ase Coun�tyside Hagpi�al 323� i�cMul�en Bvoth Rd. Safety Ei�rbv�, E`L 34695 (813-7�5-�111} PNYSICIAN At1TNOfii2EQ BY £lv<ALQY�A �Yes �Na NAM�, AOf]RESS AND PMONE �F 1-l05PITAL Et+RPLOYEE Mt55E0 ONE SHIFT, ONE �AY DR MORE7 �Ye� �No YYAS INIURY FA7At,3 []Yef NO I! Yef, Oare af De�th � EMPLpYEE'S OESCRIPTIOlV OF ACCIOENT {Civs d�i�ifs tuch as, fell, was ssruck, etc.� �@&CRlBE INJLIRY �R OISEASE ANO 1N�IGATE �layee �aS ��.LL`3rilil� QU� IIki.i2flp�� vith hi�h pres�urQ �� PART OF�r�Qt srcandTjoDntf pFr�csu �d=�� t �u�tlS irG��e tin 1'10.58� �LL nozzZe came up aut o� �h� �ElOa.Q and 1IT] lIL1deL' Aoitan�nq, etc.l his a.t�n, The va�e� p�essure tia�� 3 0� 4 hales in the skin. Skin torrt �igh.0 ara�i�_ ! EA�tPLOYER: 1�qr�� with thil tlhSriUt�an7 � Yri � No I) na, expl�in in cohrm�nts� GOMMENTS; � A�y person wl�o, knowinqEy and with intent to injure, defraud ar deceive any emp�oyer nr emplayce, +nsurance campar►y, ar selt•insured prngrarxt, fites a statemenr of cfaim cantaining arry false or mislEading inforRiation is guilty of a fcVony oi the third degree. PLEASE FIL.L IN A�L SFACES ABOV� ;1� � __ Q��Q8�8g EMPLOY�R (Read and 5ign1 , �, , _ _ _ . oAT� SIGNATURH . �� .�'�� EMPLDY�E (t�ead and S+gni SiGNATIlAE flASE tE5 Form 8CL•1 {Ft�v. 6•79! .� 1' � � ' - . . •'+ . �.I�ft�i..�Y�r' �OPY � r S I { � i a _ I i , . . , ,. � .•. , � , . . . � . ' • ' � � , � , . � , , � . ,s' • . • . ' � � � � . � � � " . � � , , , . � �.�... :.-�:..> � � a, � . � �. .. .. :"-_•: =e..,.� .. . , � � . . . , . „' ! ' . �� ,. � RICHARD F. LYSTER, M.l�, P.A. ., DIPLOINATE OF 7ilE AMEAIGt+i EW1RD OF OR77;QpAEI)IC 5UROERY , FT.LLD4V AMEFtICAN /4CJ►DEMY OF OR?ilQPAF�SC SURGERY .. l2d1 FlFtH AV�NUE NOR'Ii�, SUiiE 30U • . • 5T. PEf�RSiitlxtU� FLARIDA 33A5 � 0 �� 3a April. i �92 ■ . .� , , . , „ ; �._ r � � r��,� TEL�PHONE (8t3) 822•3110 � Ms. Nancy �egner , . City af Clearwater , , . P.O. Box 4748. ' � ' Clear�vater, F�. , 34618 , • . � RE: Ch�istopher Tamczak � DA: 09-07-89 INS: Clty of Clearwater . ' �ear Ms. Degner: I examined Mr. Christopher Tomczak .in my off�ce on �4-29-92. My radiolac�y technician, Rt�onda was present during t1�� examination, Mr. Tomczak states . that � he was cleaning a storm . drair� with a pressure hose that was pushing out treated waste water to clean the drain. On 09-07--89, th� hqse apparently .slipped out af the cirain and the high pressure water struck nim in the right shaulder si�ea, particul�rly in the region of the rfght axilla. He was takent to Meas� Haspit�! wY�ere he had a d�brfdement. Because of t�e contaminatian of the wound, the wound was left open for ti�ree to four days and then a secondary closure was r�ade. The patfent states t��t he retU�ned to �vork around Christmas af 1989, and shortly thereaft�r had a re-operation of th� sho�lder in early i990, fvr an Infectfon c�f the rfg�t axfZla. He ret�rned ta work and the pain intensified along with increasing numbness in t�e shoulder. The patient has continued on original. job far fIve to six manth5 anci Gvas tY�er� tra�sferred to a light duty jc�b .until C�ctob�r 01 , 1991. At that point, he 4vas taken off work by ths personei d�partrnent. Since October Ol , 199i , the patient has been looking for work. � ' Thts is a 33 year old white male who has a high 5chaal dtploma. He stands 6' without shoes and weighs 193 po�nds. H� was seen by Dr. S�na and Qr. Sullivan. At, the present time, he cloes not havQ any problems with the cervical spine, but has weaknes5 and pain in the rzght shoulder with radiation down the right arm .to the forearm. The past history daes nat revea! any history of any MRI scans of the s�houlder ta checic th� soft tissue of the shoulder, nor has F�e had any nerve conduct�orr tests ta checfc the damage �done to the brachial plex�s. He h�s been doing some hom� stretchi�g �xercises. The patient has had a mitral, valve pralapse since age 18. This is nc�t related to his pres�nt injury. ca�tinued...,... . . , , . � ' 3 � • � • r ' . • . . ' ' . . . ' � . . . • . . , . , . � , � � . ' . . .. ' ' � r . . � • > � . . . � ,i . • r " � , �.. ' , • � t ' , ' . . ' j 1 � . , ' , i , . , , , ,' �, ,. � . ' , . , , ' ' " • I� .. ' , �. , ' , . ' .'.:.,,...�.:��..:.,a� ,.�; r.<Z.e•c�:.. . r'r:t�:S:�t';•rf.. �.. ',. .o, ' , . � ' ., ' , � . .— . .. . . .i � � . . . . .. . . . . � . . . . ' . .. ,. � - � , .. . . , . � • , � , , ' . ` , � � . • � .. ' , • ' ... , . . ' . . � � City of Clearwater ' � �, �> , � � � Page Two � � � ' ' � , � � 30 April 1992 . � � , . ' RE: Christopher- iomczak . ' T�e physical examir�atfon was dor�e �+vith the patient In the s#��tiinc� , • � `position. He had a full range of motipn 4f tt�e cervical spine.' �He . � • was �able � ta rafse the right arrrr. overh�ad �35° iR forward elevatlon. The left arm . elevated to � 80° . He ca�ld abr�uct to 95° on th� right '� side, The ieft side abducted to 160°. � in pasteriar elevatf�n, he was , able to e'levate the . 3.�ft arm 85° and the right 45° . He had pain and. , ,� crepitus with internai external rotatian of �the rfght shoulder. Ne cvuid ��'. externally rotate and put his hands in ,.back of his neck. He coukd• .� �lsa reach his hip packet i.n the back. The patient had wesk biceps on �the left and the ' absent biceps reflex • an the right. He haci +l to � , �2 , radial and triceps reflexes. The hand dynomnrr�et�r showed grip strength on the right of 20° and tl�e left of� 60°. A� manual examination . of muscie streng#h 'showed that the right hand has a much weaker grip � and the patient has vs+eakness nf pronatiar� supfnation as weli as bice�s � and shoulder abductor muscles. � ' . 7he impression is that the patient F�as had an injury to the . ' , br�ach�a� plexus, possfb�y fram ir�fectian and ar the original blast from °. the h,igh pressur� hase. I have recommended that we send him in tor an MRi scan of #he s�nulder and also a nerve condc�ction test of tne � right arm. The�e tests were authorized by Nancy Degner, however, wlien MRI called for their� own autharization thes� �ests were denied. ' � in view �f #he denial for a nerve conduction test and an MR� scan of the shoulder, I would have to state that the patient has a brachial plexus inj�ry, as weli ,as lass of shaulder motion fn forward exter�sian, flexion, as well as abduction, From a conservative stand point, I believe ' that he is at Mh4I. The loss of . shoulder motion �aould give him an . estimat�d f34° fmpairment of the �uhole person. • A nerve cande�ctfon test ar�d rating by a r�eurologist mighi be • able to add or, chang� the relative im�airment. value for the nerve damage to the right arm. ,. No r�tur�n visit was r�ade. If th�re ar� further� question�, pleas� . f�el fr�e ta contact my afflce. � � Sincerely, � ` � �� . `/•�� %�J � . � % ��'% . � � , Richard F. L.yst�r, M.D. � � RFL/bdd - DBNR , ' ; � „.;.�.. � � :. �: ; � � , � ' ', � , • , ' . .. �• ”' , . ..;. , � , , . , . . . .. ! � , . , �S' . . � � . � . . . . . . .. �. . , i f . �. . Y ' ' . . . �1 . i . . ' . �' , �i� . � � , r, ' . . . . � l , ' ' � ' '. . . 1 f � ' � ., � • ' ' . � •. e r ' ' •• • ' � � . e � . � . � " . ' . . .i � ' � , • � � ' � . � 1 ' r . � � . .. � � . . ..j � � . . � . . ' • . . . . . . . . , � ' . . • .. , ' . , . ,' i , . . . ' i , .,��ra.�,,,�:�i 'r{..�::�;��ik�,;�s�:i��.':r� �y'. ' , . ' . . s.t .t� �sc. ,::1'., rti.. . ..... . .....s �.� .. .. . , � ., . . . . . . .. . .. . . .. . • • . .. , . , . .� :.�.�,. .; � ;� � � � ` , �� . � w � . . . :, ' ' V ��01212��,i C.�L.ICLLSJQl2� GLOh'IhQ CT �L� CJV�. ...U.1 �.C�. ;• . . ' OERMOT J. D'CONNOFI, tvt,D. � � nIpLOMAT�S OF []OM11Al0 C. SULLIVAN� IVI.D. • J�ortz artd r inE cSu cee 'fHE AM�RICAf�i BOAF�O aF . . MICHAQL �. 5LOMKA, M.p. . . ' . ' , � � .1 df1iH�PE01C SURG�FIY � HOGAN G. Y�. M.a. ,� 81'EVEN �. WARREN� M,p. �ainE t�taCar_cmtnE rSuu�ct� , ' ' c��iwsco�ic �-Sulycu� . • P�ease repiy to: � � cS�totls.d�iu�iclrs� .. _ � try w. �l �E� �`r `7;�: {��,;'= i �; ,�� r� f ��;tjt�� r i � �� • �r.. :��,l.:r.. �a.. ..a5� �' �r' ^ � i ; � i`�• ; ..FEB - 3 . i � : }�� y� ' •'•..r-.-+�..�..,...-w.,,,,.��....._ � � ' , .y.....,�..�r�,+_�'t�•� �:F'-'.-...�J Janua�y 27, J.992 To Whom It�May Concern: � Ae: ChrisGcaptier '�amczu4c Dur, �I].e �! 24452 Cf�ristoph�r Tomr_z�k was seen i.t� our o��ice on Janu�ry 22� ].992. i , � . � I �his ger�tleman was :,een in regasd to an acciden� whe�e he sustai�ed � an injury to his rfght arm on 5epte�ber 7eh, i.989. � xhis gentleman did have a permanent soft t�.ssue �.njury to h�s axillary I , azea qE kkte r�.g�tt a�rt. He continues ta complain of pair� and weak�es� . , f.n the arm. $ecause of� his compla�nts of pain, I recommended he ].imi.t the use of h�.s arm tcr those ac[iviCies wttich t�e ieels �re com#ortab.le. � His sofC tissue 3.n�uri.es are permanenC. Sfncere�.y yoe�rs, �' CONNOR, SULLIVAN, SL�riKl� & XI, M. D. , P. A. .. ' Don� , DCS: 0 � � I , : r�-�2" �" V � , 4pQ0 PARK STREET NORTH • ST. PEiER58URG, FLOFiIC�A 337�9 � ■ PNOM�: {8�3� 9d7•t2flG ' 112a4SEMINOLEHdUL�1/ARQ • SUlTEH1Q3,�l1RGO,FL�R1�A�464B • AFiOP�E: (B1�»97•11�1 6350 C�NTRALAVENUE • SUI7� C, ST. PEi'ER58UI�G. FLORIDA 33707 • PF{OIdE: {813� �45•�442 . � �,.�, �� D- .� . � � .�, . t.'�i,t's�•'>�h�:et 4}�','3; , ' , � . • . . . . . - . . , ,. . � . .' . .' - � '. ' ' ' ', � ' ; . t'��.=.' '. ..E . ,. r, �.i,i.: ' ., ., , : s � . . ' , . ' r. , . ' ' ' . . ' . .. � �, � , ' . � , ' �� , ' . . • � ri�,! , , � . . ' .. .l ' .� , � � . , , � � , � . + . �. . ' ' �. . i � � , ,. � . . • . _ . . • . E�� .. , , . ' •S , � � • ' • .. . ' � �. ' , . . . ' ' . .� . . . � ' ' , � ' y . , . . � , . .� � � i ' . . � � .. . . ,. ' . , E.. � ' .. , . � , . � . . � ... ' � ' .. ! , � • i'. . � , ' z'i . .� � ' E �� ',( ' `�F: ' . ' . � . .. . ,. , . ' . ' ' . ,� . � '. � � ' . . � . rt ' , � . � . .1` .i' ' '. .� . , � � � I . � . , . . i • . .l . . • . , ' . ' 'f� �"A�� ' . � ' ' ' ' ' ' . . , �� ' , i � �, • I�� •��.�. ,i� ' .� .r �: � ... . '.1�.'.; . . , iy, ' .. �' ...�. ' . , ' . ; . � .. , .. ' . _ ' ' . I'�• .✓" �� . • : .. , U' ..i� � � � . , + .. . . '� � . . . ' . . . , ' �' . ; . ` • '1 •�� . ' � , ' ' .. •'y. , � � � � � , � . � . , ' � F !- � . ' . , . �' ' ,'� . . . - .' .. ' ' � �' ' i . .. I� Y,,'•' ,. . , . f', . . . . ' ' , • � .� . � � .. . . ' . . ' ' . . '. ' ' . ! .� ', '.. �sj.�...�.t...s,.'-,..ayi:a{.�. etiliRJ:itii��{,�'t�2w��"IS�"'.-u..�.... . ,. .5.�.. . , , ,,. . �r.,. ,. •, ,..,. • . ..' . ,... , ' . . � . . ...y>. ,e . .. , � . ., � . ... . �i. �1� ,f' i.ia� 'J�.r..:.i,...n '��'�. i�. i� � r ' . . . . . • . . , � � � . . ' . ' � ' � . i . x • � r ' . ' . � � � ", ' . ' . ' . ' ✓��. Orl�eo�ac�ie �anfar o� �/�%3f ��oric�a ' . ' , , . : . � . � . . J�SEPH M. S�NA, M.D • , . • 4 ' � . f' '' 9806 9EMtNOLE l70ULEVARD, SUiTB S OI • ' ; ' �. � � � S�MINdt.B: FIdFiIDA 34!!42 , . . ' . ' • • , ' 7�ttKrr�ar+[ 1813i 393•2T32 • • • ' � ' ' Is13) 323•1350 . ' . , , �" . , ., • , ' ' , � , , „ � , . , � � �. � � MAitCH k, 1991 ." � � PENSION ADVTSQRY COMMITTEE ' � ;` � � �� . CITY OF CLEARWATER . ' , ' � , � . ' � � . � , � P .0. . BOX G748: , ' ' . � ,� � , � CLE,AAWATER, FL . 3461$—G748 � �� : , , . AE: CHKISTOPHER TOMCZAK , � ' � , � . DEAR COI�iITTEE; � ' ' � , � � , ,, , , . . ,. , . , .� , THE PATY�NZ � MENTIONED ABOVE HAS BEEN DETERI�tINEA �AT MMI, WITH �� . '• � PERMAN�NT PART�AL DYSABILITY.AT APPROXIMATE�Y F�FTEEH YERCEHT ' � QF THE UPPEA EXTREMI'TY AS IT P�RTAINS TO TH� BODY A5 A WHOLE. , • , . � , , T'HZS WA5 DET�i�'IZNED ON 2I27f 9I AT WHICH TIME HE� WAS G�VEN THE � � �� RES'SRICTYON OF NO Hr.AVY' LZFT�HG HO GREATER THAN 20 LBS. � ' . � THIS PATIEN� HAS ��EN R�T�EASED ON A�'RN BASIS. Tf�ANK YOU � .TOSE M ENA, M. D . ;, � , 1 � I . I' . . ' r � ��M+ CLEARWATER CITY C�MMISSION � � i�, � :.�. . �. =��.j � Agenda Co�sr Memorandum it�m k ��v ��4��°� ' Trustces of thc Ernpioyecs' Pensian �Fund Meeting pate: SubJect: . � Pcnsinn(s) Ta S� Grantcd RecommendatioMMotion: Narry L. Norris, Jr.. Firefightcr. Firc Dcpartmcnt, be grantcc# u job-cor�ncctcd disability pcnsian �ndex Scction(s) 26.35 of thc Employces' Pension Plan as recammcndcd by thc Pcnsiun Advisory Committcc. . ❑ and that S�e appra�riata ofilcigls be auihorized to axecute samo. BACKGRDUNQ: ' � N.a n� e Hurry L. Norris� Jr., Fire Department, was cmplayed by thc City as a Fircfi�hter an August 28, 1978, And bcgan participating in thc Employccs' Pension Plan on ihat datc. Mr. Norris was inj�red geiting out nf �re truck when he fcll and pullec� �is right shoulder ai�d t�it his back which resulted in his applic�ttion for a job-connccicd disAbiiity pcnsion. � Mr. Norris has svbmittcd lcttcrs from Dr. O. Wecros Hollowcll (dalcd May 4, 1992) and Dr. Robert Harris (datcd May 3�, 1992) in suppnr� of his requcst #'nr � job-cnnnccicd disahiliiy pcnsion. The doctors rcport that Mr, Norris hns c�cgcnerativc disk discasc which was aggrav�tcd by �he inj�ry sustaincd during his employment as � FircCghtcr with tlie City of Clearwater, A Notice of Injury R�pnrt daicd Fcbrvary 13, 1992, .,is �on filc which indicates' hc s�fE'ereci an injury to his "�ight shovldcr and towcr back." flis injury "rc�ders him panicul�rly vUlnerablc tn law back injury. The activities of a fircfigl�ter wauld cnr�sidcrably enlarge the prvbability of occurrence." Iv�r. Norris is permancntly clisabicd fram thc performing thc duties af a Fircfi�hter. . Mr. Norris' disability pcnsion was approved by ihc Pcnsian Advisary Cammittcc at ils mcciit�g of May 20, 1992. Bascd on An a�cragc salary of appraximatc�y �29,23Q ovcr �hc past fivc ycars and the scventy-five perccnt (75%} minimum disability bcncfit, Mr. Norris' pensian will appraximatc $21,922 annuaily. Charts from Finstncc which take into consicicratiom m�rtality rs�tcs und agc rcficct the ."present valuc cost of financing" this pension will bc a�proximately $272,912. Mr. Norris i�as �wo CIlIIC�CCil undcr the a�c nf �8 and, thercforc, will rcccive �!S% supplement for cach degendenE child. R��tewed Legal Budget .r Purchasing Risk Mgmt. bIS ACM � Other � Submittod by: City Managor Or�inating Dept.: uman RC50U User Dept.: Advertised: Date: Pape : �Noi requlrecf Affected partios L� Notified G� Not requfred ��sts: s � � � Talal Current FY Funding 5ource: ❑ Capt. Imp. ❑ Operating ❑ Other Appropriation Code: Commissinn Actlon: ❑ Appraved ❑ Approved wlcondiilans ❑ penisd � Contlnued ta: Attaohments: ❑ None Lcticr(s) Rcyuest Farm � ' � ' 1 . . , . , ' � . � , i ' .i .. ' . . ' . ' . , ' . , . . . � ' . � • . ' �� . . ' r, ' ' � � , ' • i' � ' , . , . � ' ' � . . ' 1 � � . � � � � • � a i � � � . �'�1. . •.S��fi�; i�ri . ' I�a � • , � • < - ' i^• , i ry��i: � � . i . . • � .. . . . .. . ' • , . � . ' . . . � � e . �. � . � . . � . � � � � . . . ; � � ' . � �'�fCa�,�1� � �, ' � . ` �� .C� � . �:::��_ � C I T 7�' U F� C L E A � W A'� E�i. ; . , � • �''p�r."`-- t��,�� . • , P05T OFFiGE BaX 4748 � �,��+ ��l�f �,r,d+ CLEAFiWATER, F'LOFlIDA 314B�8-4746 ' � Perao�nel pepprtrnent . � . 462-687Q � . �. 'IY?: Hvnorablc Mayor and Mcrrzbers of the Ci[y �ommission t3S • TR35[CC5 oi thc , Emglayccs' Pcnsion Plan � � • FRQM; Pension . Advisory Gommittee ' • C�PIES: Harry L.. Narris, Jr.; .Risk Management; Dan Dcignan, AssislAnt Dircctor o1' ' bdministrative Serviccs/Finance Director; Emp�oyee's File � � . SUBJECT; Pension for Harry L. Norris, )r.-1ob-Connectcd Disability Pension . DATE: May 2D� 1932 , � Tlnc Pcnsion Advisory Committec {PAC} rcccivcd an� application %r ciisability pcnsion fraFn Harry L. Norris, Jr., on May 4, 199i. Mr. Norris has becn dctcrmined by the Pcnsion Advisary Cammittce to mcet the . requirements of the Pcnsion Plan E'or a job-connected disability gension. Hc was ctn�loycd � by the City on August 28, 1978, and bcgan participating in thc Pcnsian Plan nn August. 2$, 197$. Furthcr, hc has submittcd mcdicat , documcntution, copics of whi�h �rc �ttached, relativc t� his disability which has becn rcvicwcd �r�d approvcd by thc PAC. By mption made and duly carricd at its mceting of May 20, 1992, thc Pcnsion Ad�isory Committce appro�edlrccommended the grantin� of a job-connccted disability pension to Mr. Norris in accvrdancc witl� provisians of Scction 26.35 oF the City Codc. T�is pcnsian is to ' be cf�'�etivc on a c�ate tn be determfned. The amount of Mr. Norris' pensian will bc caleUl�ted by thc Fin�nce Department �ccardin� to the formula in the Pcnsion Plan for ' job-cannncctcd disability pcnsion at such tirnc ns his lASt �vc ycars of scrvice �nd sa[ary ca�n bc camp�tcd. ' I hereby certiiy that thc Pension Advisory Committce has appraved thc granting af a job-cvn�ectcd tfisabili[y pcnsian Tor Harry L. Narris, 3r„ and thc ttbo�c dates c corrcct. . `� � � �. Chairman, n ion Advis r mmittcc "Equal Employmont �nd AZlirmatfve Action Employer" � ... , , . .. ._ , ' . , , • ; , . . . . . � � ' ' ' - ., , , � , , , „ . : 3 . . .. , . , , . . , ,, . , � , . , . , t7 . . � � . . _ . . ' � � � . . . . . . � ' ' ' . 4 . � .. . ' ' • � • . .. . . ` li � . . . . � ' . � � . . �' ' . ' . , i�' • • � . . � ' - . . . � � . � . • . ' � � ' . � � � . � . 1 � .. � ' 1 � � � � � � � � � � � • 1 ' . •� ' t 1• • . ' . r .� i . , � � , . . .i ' ': , ' .. . .��.. rex... �±�,:5��. r�j:Y.?I7� �, � , . � ' . . . � . ' � . , . , �-• • .. ... � . .. . 1� . .:.t. .. . _. . .., �. . ..... . . .. . � . . � < . . , . � ' , PENSION REQUF,ST FORM � ' �r Narry L, Narris, Jr. � r�n hercby a�Qly for retircmcn� �'rom t�e . City of Clea�rwater Gencral Employess' Pensian Plan. , My befiefits dttte is Avgust 28, I978 ' '{Eetry date. �uta �ensioe �l�n? • My date af hire ix Au ,�us� 28, 1978 �, �. My bi�'thday is � Novesabez. �24 Z956 � � My job' Classification i5 Fire�� hte � and I work. . in thc� F�'�� Department.� Di�is�an. � M y � r�sig�natio� t�ate �s„ to be determi,ned Thc type of pension for which Y am applying is (chcck only one): . Regular Peasion b�se� on years af servlce • x � ' � 1ob-co�nected Disabiltty Pe�sfoa -F , Non-job-coanected Disab[iity Pension � My spouse's name is: Yvonne � � � ' � Depeudent childre�a �nder the age ui 18 nnd resid�ng in my ho�ssehold are: Andrea `� June ib, 1983 � (Princ Chiid's i�ull Narrte} (Chi}d's Dat� of Birth) Alexandra `� January 4, Z988 I hereby certify all of tt�e above to bn true and correct: � IiY COl�IS5i9H E7fP7�0EC,z0aRS�� &Ol{OEU FFiRU GFHERAL I�S. �NO. I� � � � 45i�ayt��e11 2 (D�te) � 1 . . < <, ' ; ' , , , . . � , `- . . , • . • �_ , � � , � � � ' � � ' . , � , , �. ' �. - � , , � � � • , � � � , • . ' � . . . � . i " ' . . . . � f , ' � r � .. . �, i , t ' � . j � � � r .r � • •I � . � ' . i � . j , . . . ,� . � . .• � � r �. , - ' . ' � , � E . � � � 1 . . . . � I . , ` . . . . , .�, �.� ..L�'YY:y �. . ...=i�:j�1•� -...is. ... .. . . . . • ... ,.. . . ' . '. " .. , a.. .. . ' . � �•• . • . . . .. ,: � , � � CITY 4F CL�ARWATER � ' � � � � ' � GENERAL�,EMPLOYEES' PENSIQN PLAN � . , � � � � OPTIONS - FIREFiGHTERS ' ' �. O�''TION #1: �mgioyces can rec�ivc a lurnp sum p�aymcat for ' � � � � vacation aad haliday �ay and 112 of accrued sick leavc '. � ai tt�e timc of scparation from thc City. Thcre will bc nt� � ' €% dcduction for pcnsio� fram this lump sum paymeat � � , . '. ,. nar ' will this amount count � as earniags in thc , � ,calculation af ti�e pcnsion. The last day of work will bc , ' , ihe icrxnination datc and pcnsion bcnefits v�rill begin � • thc following day. �, , � OPTXON #2: Ernployec can, extend termination d��e by thc time due � , ' (Qnlq �vaiinbte � ta far vacatian, ho�iday pay, and �f2 of accrued sick 2eavc. � , . employees hired Termination date wil! be the final day of extc�ded tima. . prior . ta 1011/88) Pension benefits wiil begin thc following day. � �;. � � ��*�*�*****�*+�***�*k*��*�� . � Harry L. Norris, Jr. T, � � __,�,�___„�, an cmpioyee of the City of Ciearwater, hercby apply far pcnsion bencfits under thc General Employccs' , Pensian Pian. � � � . I hereby certify that I fully understaad tise lwo options offered to me. I choose ta retire using Option # 1 and wish my benefits io bc calculaced under [h15 OQ[IOR. � I uaderstand that a�ce shis forrn is signcd, my decision is irrevaca�le. EMPLOYEE'S SIGNATLfI� � SO AL SECLTRITY #: 261-29-8206 . . . _ DD SS: _ Z042 };igh Ri.dge Drive � `p Glearwacer, FL 34623 � DATE: _ May G, 1442 . i � , � .� . � .�,��.^, oansiar tiu:r�� . FLORPaA D�pARTMENT �� LABdR AND �ElAPLQYM€Ni S�CURITY gISK MAN,�G�rdEN7 o�vrs�aN o� wo�KERS' COMP�NSAT{ON f•80Q•3�2•t7« �or) cor�tact yvur bca� otlice far assfstartr,o City� ot C�earwatar � NOTiCE qF lN.1URY P. �. Box 4748 Fleport alt de�ths wilhin 24 hours (904� 48B-3044. °arwat�r, FZ 346�8 F�B I 4 �941 , H�rrv L. �o�ri s , Jr, 7l�R A b (knduCe p� 8QA2FNac�h1 R�d��r�efV L pHON �� Q�� ' u�'s' " F� refi ahter � � 11 � 2�4 ; 56 2Gi-29-ti206 earwater, �L 2�63Q� ieA Amputet�on oi � ht intlex 1��qor at f Fil h� S�IOIl�der $� LOWE oia v�ou R�ouesY M�oicr�. c�A�a F IF YES, b!0 �MPtf7Y�R PFIOVIDE ME EMPLOY�R lPlFORMA7lON � FQA CA�iRIER'S [7ATE STAMP REC'D BY CAFiRI�R SEt�T i0 DIVISI0�1 i �1�21�� 11 an r�ar, a, nu�lit�a �Ai'E PAFiT a B�Oti dCjClrecturod dua� t� 7tES a Na .? �1j6'�5 p I �.400 hrs. hile fal�in nht sroUlde ECTEp �ja U eC� `'°�°°`�i�W��ed ack FIRM'S NAME AND A�DR�SS FEO�FAL i,p. Pil1MBER OA7� ANO TIM� FIRST REPORTED . City of C'�earwa��r, Dep�. a22Q 56-60000289 2/12/92 �40� hr5. P. �?. 8oX 47�8 w.c. coveR�E ar PatIC17MEMBER NUMBER Cl earivat�:r, F�. 34fi18 ❑ iNSUH�r�cE co. s�tF.�NSVREo NAME. ADDf}E$S, 7ELE HONE QF TELEPHQNE _ IN5URANC� CQ. C}R SEFiVICE COMPANY WILL YOU CQr�iNUE TO PAY '^'`°°' "'""�' Johrss Eastern Compeny, Inc. SAUIRY? C�YES ❑No PLACE OF ISCCtQE�lT (SUoat, City, Caunty, Stntej Pp;} Q#{'�ce Box 3318 i.kS7 bAY PAI� THFiC?UGH Er►��r�ri se �� MCMt�Z ��n Boath 5araso�a, F�. ��230 ! ! Ci e�rwate�-. FL ��t i14�; �S � �- S��' �'49-30�i fiAT�L��AY7� ��iR O WiC NAME. AD�HESS AHD 7ELEPHONE QF PHYSICIAN Of� H05pITAL Numbar al hours �y��+�'�y DIU 7HE Ei4lPLOY�E Kt3pWtNGLY RE��SE TO US� A SAF�i'Y �fease Dunedi n�05 1�d� Ter day �_ {� Number a! hours ,�{} APPLIANCE PHOViDED BY YOIf, l'HE EMPLOYER7 C] Y�S � NO r wnek 601 Nai n Street N� °,,,�, q, d0ys C1ATE EMPlqYEO LAST DATE �MPLOYE� WORK�D ��nQ�i n, F� p8 Z8 i8 OZ 12 92 ., a�� flk r r r � ��_�� Z 1 � PAIO FflFi OATE OF 1NJURY FlETURI��4 TO WCRK ❑ YES C�NO AUiHQAIZ�p BY EMSPLQYER L!�Y�S ❑ N� YE5 � ND ❑ IF YES, GtVE DATE! 1 LRCATION Ap�R�SS WA5 INJtJRY FATAL? p Y�5 [�`Np �F YES. G11�E DAT� OF D�ATH 1 � (LOCATION x , 1F APPi.ICA6tE) A�GHEE WEiki DESCRIP710N OF ACCIa�i�T7 NAiUEiE aF E3USINE55 L,�YES C7 NO IF A!O ATTACN �}fALANA7iDN My person wha, knawingly and wilh intgnt to injure, delreud 4r dacerva any employer or emplvyee, insurance tomparry or sell•inSured program, tdes arty 51alament of cleim caMainirq any falso or mislsadinq in[armaf�on is gwlty o1 a laiony ai the thirC dagroa. i have prwiaed Ihe em�layea thair capy oi th�s not�co: . ❑ ln�rson p By M� ��vt ��aila5l� for �iar,ature 2,�i3/92 � .��/ 7 --�, � %�' �� EIAPtOYEE 51Gt�ATUftE (�f an�iablr ta aqn) DATE ! EMPLpYE3i SiG11A7UR8 OAT� CARFiEEfi �fVFORMA�ION Carrier Audii � Lxalion �+ Service Co. � CaRiar File � p 1. Contrcrrerting Case—DWC-12, NOTIC� OF a�NIAL'ATCACK�D p 2. l.ost Tlm� Case--[?ar� of Firsi P�yment � % AYVW Camp Ralo First day q! disability r � —Date ol First Cantac! with Claimant � � ❑(n Persvn ❑ Telephone ❑ Mail ' —f�latica Fited aue to Mukipla Aeriads of Disabitity, pases Covared by First Paym�nl 0 T.T,D. Cj �P.A. �atn Forrn Fiec'd.! � 0 Catastraphic p p,7D. p Daath p 3. Medicaf C3nfy whfch kecame a Lvst Time Casa. (Compiete aN �rtformation in ilem 2 abovej R�MARlCS: ADJUSTER NIAAAE: CAFtRi�R fYAAdE, AQ{?R�SS 8 7EE�PHQh1�: . OAT�: ! 1 Afl,fUSTER SIGNATURE: l.ES Fvr�r+ CNYC•1 i1Nt1 y �a =1 /�1 P1��n �"�"' •^t• �r��l�,Cr��b�r'�i�.<z��. �'�_�. �'' . . . ��, .. . .. - . . ' . . � . . , � . . . • � ': " < f :�i: - � .. . ,:e � � � , "l�'i:j�s, t3�Y, .'c ... ��y,' . ' . ' ° .. . � ' . l � � ' 1' " . �� '�'�' f"{+�,li�}il_l: :l�. '.i "�ni :" ..''r<�.'• ;Ir. . � . .� � � . . 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' , I • . 1 . ` • . . . { • . . . .• . ' .' , � ' � . ' . � . . . ' ' '� . , � ' . . � � . . . . . ' �{' .� . , � 'r . . . . , . ' . � . , '. ' , . .. �. , ' • r v . , ' DATE : .'May. 4� 19 9 � . � , �. . . � , • ' , �+ � . . ' . . ' . � CITY UF CLEAAWATER • ' � . . � . � ', . � . . -;� .'.. ATTN: Pension Advisory Committee . � �� , : , . C�TY HALL � . . � � ' . . . . . . ' �. �� P.�O.. BOX 9:748 . - , . , � � ., , ' - ' � , . � ' CLEARWATER, FL 34 G ]. E , . ' . � , :, � - � ' .. RE i Ha=ry Norris ' �, , DATE OF ACCIDENT:- February 12, 1.992 �� • . �_ . ' � � ` ' . , . . . . • . . , . , , . •. j , . . , .. , , , . . . � � � � . � . . ' ' r . � � , ` ' �. . I ' , ' � ' � . . . ' � i, f ' . . . .� , , . , ' . � . . ' It ' � � ' ,. . • � • , � ' � • • i , �� •• , , , . ' i.. . . . • ' . � '1 ' , . , ` . 1 ' . ' • ' I .. . . � , ' ' , ' ' ` � '' � ' . . . � • � . _�.. .,-!ti`� . ; ��"• . .� -��i. ..� . � �. �,�. . ' ; � r .' . , • ' ' ' , .' � . � � „ . � . � .. . � `. � . . . , _,:.._�.... ,._ �._.. , ....,. �. ��. ..... . .. May� 4, 1992 ° .. CZTY 4F CLEARWATER. � • ' ATTN: Pension Advisory Commi.ttee � '� CITY HALL� � � - P.4. B�X 4748 . �CLEARWATER, FL 346I8 RE: Harry Norris � � DATE OF ACC�DENT: F'ebruary 32, �.492 l�ensioner is a 35 year old white ma3,e fire�ighter empl.ayed by the City o� C].earvaater who sustained �n on-the--jo� injury �on February 12, ].99�. He tell'heavily onto his buttocks exiting a fire truck., He �lso wrenched his right shoulder in att�mpting i:o arrest his falJ.. Ini.tiall.y, he � had low back gain radiating bil.atera].ly, ].e�t, more than right. Thzs suhsequent].y has become canstant 1,ow back pain with radiation to the l�ft buttock and upper postez-ior tha.gh.• Low back pain is constant. The left-sided buttock and upper thigh pain is in�e=znittEnt, being preci,pitated by long s�anding, walkinc� and range o� motion of the �.aw back. He was evaluated by Rob Harris, M.D., a Cl�arwa�er ne�rosurg�on, on March 3, 1992. This exam revealed rest.ricted low back �uncti.an without evidence o� radiculopathy. He was bEgun in physica� therapy at Mgrton P].an� Hospi.t�1.. Reeval.uated by Dr. Harris on Maxch 24, 1992. His candition was no� �mproved. MRI imaging was requested and ob�:ained on Apri1. 2, x9 92 , imaging of both the �.umbosacral. spi,ne and the cervical spine. The patient's s�atus was nat �avorably influenced by physical.therapy. His condition remained static. He has li�ita�ian af range o� motion. He has the symptoms as outlxned above. iae was unabl.e �o progzess to higher level.s o� therapy loecause of the static nature o� his problems . zt was the opi.n�.on oi the physica], therapist as expressed in a let�ez o� April, 20, ].942 that he saouid have to improve his overa�.l acti,vities by at least 300� to� resume his occupation as a fire�i.ghter. The physical therapist was pessim�.sta.c abou� his prospects for recov�ry ta the goint of func�ionzng zn h�.s capaci.ty as a f�refighter. m f • � ` ' � r1lR' ' � -_...� I � � , . r . . . .. . . �. . .... •:rt ::i''�� . .� a ' � R�: Harry No=ris Page 2 MRZ a�. the lumbasacral spine r.eveal.ed dessication of the disc between L5�and S1 1.evel. There is" bulging and/or buak].a.ng o� the anulu� to the ].eft of the mid-�lin�. Sagitta7. views of th� lumbar , spa.ne indicate straight�ning � o� the .normal curve. We have no plane spine x-rays to compare. The conus medul.Zaris is visua3.ized on sagittal va.�ws and is normal. With reference to the cervical area and right shoulder,' sy�pto�s exacerbated as a sequel to the accident o� February. 12 � 1992. His comp3,ain�s �re a� neck� stitfness, particularly in the ].ower third Qf the cervical area posterior�.y. He has i].1-defined radia�ion involv�.ng the right shouZder which does not descer�d b��Qw �he shoc�Zdez 1,eve1, Neurological �xam referabl.e t4 the upper extrem9.ties is nax-ma].. MR� ot the cervi.cai spine revealed osteoarthrosis, particu�ariy at cervical. 5-fi right side. Pa�enth�tical.l.y, h� had h�d cer�riaal QrobZems previousl.y and had a pr�vious MR�. The MRIs were comparal�le. Wi�h r��ezence to the pensi.oner's prnb].ems, his low back probl.ems tar outw�igh the cervi.cal. probl.ems . PAST HISTORY: Seventeen years psoriasi.s tr�ated for the past 4 man�hs �by PUVA with gvod resu.lts. Psoriasa.s i.nvol.ved knees bilateraliy, scapular areas, bu�tocks and waistline. He ktas no history r�£ d�.abetes I17E].�.1t1]5 � arthritis, �iver or kidney p�obl.ems. His opera�ions include a vas�ctomy and subsequen��.y a reanastomosis and subsequently a vasectomy. Other si.gniticant problems incl.ude the episode af necic pain evalua�ed some �wo years ago, which cl.eared with conserva�ive care. FAMZLY HYSTORY: His maternal gzandfather, diab�tEs mel�.itus, adult onset. His father and maternal unc�.e have psoriasis. REVIEW OF SYSTEMS: �IEENT -� No chan�e in headache pattern, no visual. probl�:ms, Cazdiorespira�ory - denies chest pain, anqina, dyspnea an exertion and praductive cough. Gastrointestinal - denies jaundi.ce, meZena, cliange in bawel, pattern or abdnmina3. pain. Gen.itourinary - no camplaints. Muscul.oskel.etal � see history ahove and, in 9 �� . . 1 . ' .. ,, � . � � � . . � . . � RE: Harry Norris . . Page 3 ' s �.. � addition� cvmplains af "=ath�r marked A.M. s�.iffness," which lasts �ox� 1-2 hours a�te� arising. Denies �oint �welling. i��ni�s �oint rednes� or limi�ation o� motian other than as described above. EXAM�NAT�QN: B1ood pressu�te is �.40/80. Pul.se is 80 and regular. Respira�ion is 20 and normaZ. S�nsorium --, th� patient is alert. Mentatian a.s normal. Speech is �ree o� dysphasia and dysarthria. Pa�ient a.s right--handed. �Iead is norntocephal.�c . Eyes show the ratations and �a.e�.d3 to be gross�.y :�u],]., no nys�agmus . Pupi�s equal. Crania�. nexves intact 2-12. Neck -.supp�.e, full range o� motion. Aeart - regttlar sinus rliy�h�, no murmurs . Lung3 -� cl.eaz tn percussa.on and auscultation. Abdomen -- fzee o� abnormal tenderness and masses. Recta� - not done, Oropharynx , beniqn. ., MUSCU�,OSKELETAL: Low back range of motion - he cvmes within 8 inches o�•thE tloor an ��.exion at the waist. The fulcrum of motion is at �he upper lumbar regi.on. Upon latera�. bending of the lumbar spine, he is limi.ted some 25--30� bilatera].ly. Extension is ].imited some 3a$. With r�ferenc� to the thoracic sp�.ne, the ranqE of mota.on is norma�, and inspirat�.on and exp.iration tharax is normal.. I�eck xange af motivn is noz�nal. NEUROS��GiCAL: Examination of the extremiti,es is intact to mo�o� rcflex and sensory exa�. Individual m�tscle group , strength testi�xg is norma�.. Gait is normal. Pa�ient is able �a bear weight on his hee�.s and toe� arid squat and .r�.se wri.thout abnarmality. 5t=ai.ght ].eg �aising is about 80$ o� expected norrnal. No fasciculations ar wasting of the musculature is noted. Pl.an�ar responses are downgoing. IMPRESS��N: xsol,ated disc resorption at the lumbosacral 1,�vel without radiculopaihy; a pre--exa.s�ing condition aggravated hy the acciden� a� February 12, 1992. Cervica�. osteoarthrosis without radiculopa�hy or myelopath� , aggravat�d by �he accident af February 12, 1992, now essentia�.ly qttiescent. The psoriasis unrelated to the accident of February Y2, 1992. ,'f.. ;f� .� '• ''1 ` ' .' . F. � . �. � �. ' . . . '; . . , ' � . . . . , � � e ,;�; .. . � ; ..9 , � ' � . ' 1.t ' �.. . i . � • • . , � .' � .' r. � • � 17�. . ` � ' � � � � . . ' ' ' .' � �. • , s � '1 ' i[• "��••� , e �''• (. , . • V� ' .• ' .. 1 • , -, � . . , ` �� . ' ' .� ' . ' • ,• ' ' . '• ' .. ;1 . . . �. r',�^ � . • . � ` . • . , ' • �° � � a , ., ,� . 1 . . .1 ' . . . . � , . . .. ' �,le ''S�. , ' �.. . X,e , . '- � ` ,� . `' , � � � ' � '' . ' . ' • ' . . ' • . , .. .. � ' ' • � � ' ' ' t i' ,� t i ' . �. i � s , �. � ' ' . . � ' . . • � . � . . . , ' � • . ' .' .. ' . . i . . ' . , ' . , . . . � ' ;f: . , . • , i . • 1� • a % . . � .. . , . � . . . ! ' , ' 1. . , r . . ' . :i' .' ii �l. . . . . 1 . . . .. � . � ' . ' ' . � � .. � ' , , � . ' ' ' �� ' � e `t .��' ' , ' � . . . . . ' . . , . � . . " . ' �. , ' � , �.�:,�3....,.R.�,�.ti•..�..yw,�a`iS#:�L','i�J�'>^�'��,r.frf..y� i;w�i.r{:kt,�.:J.. � , � , f�A , . . .. , . �� ... . .. � . .� ..,... , o-.. i«. ,.� e . . . �. � i� .. ..� . ... . � r. -. � . . , _�^k ' ' . .r , ' • � ' . . ' � ' . � . . . ' . � . � ; . . + , ' � � ' � . . . 5; . � � , . . . . , . , � _ . • ' � . ' . . ' � . ' � �, � . :.' .. . RE.� • HarrY Norris, ' . , • , � � � , � , Page 4 ' . ' . . � , - , . � '�COM1►iENT & ANALYSIS: This 35 year o1d man•ha� isolated . , diBC resarptxon at , lumbosacral level. , This 'is .�lso. referxed tv as desiccated d'isc or degenerated disc. �He is. young for this� condition, although it does,�occur. Tt •,represents a pre�existing condition aggravated by'. the acr.ident of Eebruary 12,�].942. This condiZion renders him. �, particu�arly vuln�rable ta low back injury. The �� aativities of a� firefighter wauld aonsiderab�.y en�.arge th'e � , probability o� occurrence. � •�With r��ererice� to specifics, the, pensianer's condition is � p�=manent. His condition i.s �ob-re].ated. 4��stian ot � maximum medical. improvement �is not pe�ti.nent since this , tends�to bQ a pezsisting conda.tion which caaxes and wanes : depending upon'th� demands imposed on,tha low back. Sincer�ly, �� . , . ' ' / . ' � t/ L/� ��' / ` � ✓�'-� � ' � . � , O. Weems' Hal,lowell, M�. D. � � ,OWH/n7F . ' . , aew . .. , ' , ,. . ��1 . . , � � . . � � , . � . , . • �'. . . , . , , , � � ' r 'l •.1 , . � �� i ' 1. 1 i � . . ' . . � . . � ' ' ' . � r i , , 1 '�, f. • � ' ` ' � . • , � � ' � . i . . . , . , . ,..... . �... ...i,.....+..ci"w.v'�1 a�V. 1(:R `, ��t i.ti__.. .. � . � e . . . . .. . . . . , [• . . . . . ... • .. � . . � Rob Hatris, M.D., Ph,D., F.A.C.S. , . � . � ' .� Diptomate; Ameriran Board of Neurvdogical 5urgery � ' . � lp] ] Jeffords Street ' �(8 � 3) q42-7153 ,' ' � � Cle�rwater, FL 34b�6 . , � . � FAX .# .44G-4336 � ' , � � May 14, 1992 � . ' • City of Clearwater . , � ' � Pension Advisory,Comm�ttee . � . City Ha]. Z � � . ` . �P:Q. 'Box �74$ • , • . . � C�.earwater, FL 3457.8 � . ' .. �. Re: Harry No=�is, D/A 2/Z2/92 � � . 2042 High Ridge Drz*.re � Clearwatez, FL 34b23 . � . . ,� Dear Sirs: . � � . Per our letter of April Z8, ].992, let me reiterate that this' � gentleman has cErvica'1 arthritis and degenErative disc disease of' ,� the� ltunbar sQine. He is not a. surgical candidate at �hxs time. I believe these conda.tians are permanent and h� cannot be expected � �o work as a fireman where heavy 7.ifting, benda.ng, and stooping are the order of the day, i.e. he can't carry packs, OBA, etc. �ie ' has reached 2�iT effective 22 April 1992 with �a rating of 'i$ for dQgenerative di.sc disease o�' th� spa.ne without dQficit and i.t a.s � non-surgical. His conda.ti.on was aggravated as a result of the ' ' a�cident dated 2/�2/92 when he �el.l iour f�et irom the back compartFnent o� a fir� truck onto the ground. H� wrenched his � sight shoulder and his back. , . If you have any further questions with regard to ��2i5 pat�ient, please contact me at the above address. Sin e e � Robert .D., Ph.n. RH/LR ,._.: � ! . � S�� *� „ CLEARWATEF� C1TY COMMISSI�N � �-:� � Agenda �o�er Memorandum ��$m r� ••, ��f"' ` Maating T}ate: �q� r��t°4 Tr�stcc� of ihc Empl�yccs' Pcnsivn Fun� Subject: Pensian(s) Tn Bc Crantcd Reaommendatiar�lMotion: Robcrt C. Sp'sttticri, Palicc Qi'ficcr, Policc hcpartmcnt, bc grantcci a non-3ob-conncctecl disability pension undcr Scccion(s} 26.3a of the Employecs' �cnsion Plan as rccammcncicd by tlie Pcnsion Advisory Committcc. � ❑ and that ihe approprlate atiicfals be authorized to execute same. BACKGROUND: ►. � u Robert C. Spit�feri, Pofice De�na�tment, was cmploycd by thc Ci�y as � Police Officcr an July 12. 1982, und bcgan par�icipatin� in ihc Employccs' Pcnsion Plan on that dalc, Hc suffers from mt�ltiple scicrosis which resulted in his applic�tion for u non-job-conncctcd disability pc;nsion. Mr. Spitaleri has submitted lcttcrs from Dr. Barry Lee Lcber (dated Daccmbcr ll, 199I); Dr. Wi1liAni L. Taldnnc (dated Novembcr 1S, 1991); Dr. Rogcr D, Hazelbt�kcr (datcd Fcbr�ary 5, 1992) and Dr. Roy W. Bcck (dnted May, 1992) in supporl ai his rcqucst for a non-job-canncctcci disability pension. T'hc doctors repori th�t Mr. Sp�tulcri has m��tiple scicrosis witli aptic nc�rriiis. The repori irorn Dr. Bcck indicaics "he wus diagnnsed witiy muttiplc sclerosis in May 1991, afler dcvclaping nnmbness on thc rig�t sig}�t of his body. Hc t�ad somc, but incamplctc rccovcry...The dcficits i� optic ncrve function that he c�irrcntly has arc permancnt,.,wii� his visual impairmcnt, I do noL beiieve it is safe for him ta bc piaccd in potcntially dangcravs situatians." Tlzc Icttcr �'rom Dr, T�ldone states "I believe thc deer�ase in vision is real and I Uelicve that lic coufd have visuai f�uctuation corresponding ta temperaturc chungc and cxcrcise....I bclicve thal these factors cQn be t3ken inco eonsic�er�tion wlic:n one evAluates his �bility to peri'orm �s a golicc officer." Mr. 5�italeri is disabled iram �crforming t�is duties as a Police Officer wit�y tlic Ciiy of Cleanvater. Mr. S�ituleri's disability pcnsian was ApProved by tlic Pcnsion Advisary Cnmmittce �t its meeting aF Muy 20, 1992, Bascd on nr� averagc salary of appraximatcly �32,5 l�E ovcr ti�c past �vc ycars and using thc farmul� far comQutis�g a non-job-canncctcd disability pcnsion, Mr. Spitalcri's pcnsian will upprnximalc �8,12$ annualiy. Cii�rts from Financc which takc into considcration mortaliiy r�ics and agc rcficct ihe "prescnt valuc cast aF iinancing" this pension wili bc appraximatcly $8�,56Z. Revl$wed by: l,egal � �' Budget N �� Purchasing �-�� Rlslc Mgmt. � DIS ACM ._.. Other_.. Nf1" _ — Submltteci by: City Manager �rlgInating Dept.: Human Rcsa U�er 17ept.: Advertised: Date: Paper: �1 Not required Aifected panlas L] Nouned GSl Not requirad Cosls: � a ba vC'_. Tatal Curreni FY Funding Source: L� Capt. Imp, �� Operaling ❑ Other Appropriatian Code: Commisslon Action: � Appraved � Rppraved wlcondiUans Cl Deniod ❑ Conlinued to: Attachmente: [] None Lctter{s) Rcqucst Form , � • • � � , � ' .r. . • :f'', � ;:z.�:"l�i,;i .,�. .;r... � . . . � .. . , .i , � I ° . C I T.Y 4 g' C L� E A R W A T E R. ' � POST OFFICE BpX piAO . , CLEARWAfi�Fi, FLDRIE]A 346� 8-A748 TO: � Hanarable Mayor and Members of the City Commission as Trustees of the , Emplayees' Pension plan � FRQM: � pension Advisory Cornmittee COPIES: Robert C. Spitaleri; Rtsk Management; Dan Dsi�r�an, Assistant Dlreotor o� Administratfve ServlceslFtnance Dir�ctor; Emp�ayee's Fife � SUBJECT: Penslon far Robert C. Spitalsri—Non-job-cann�cted Disabilfiy Penslon nl a n DATE: A��i --�; i 992 �� The Pension Advisory Cammittee (PAC) received an a�pllcatinn ior dfsab�lity pension irom Rabert C. Spitaleri on January 8, 1992. Mr. Spitaleri has been determir�ed by the P�ns�an Advlsary Commiltse ta meet ihe requiremonts ot��the ' Pension Pian for a non-job-cor�nected disab�liiy pension. He was employed by the Ci1y on July '�2, . 1982, and bec��,n parilcipati�g in the pension plan on .1uiy i 2, 1982 Further, he has submitled medical dacumentaiEon, copies of which are atlach��, r�laiive to his disability which has �een review�d and approved by ihe PAC. . a o �� By motion made and duly carried at its meeiing of��, i992, 1he Pension Advisory Committee ap}arovedlrecommended ihs granting of a non-job-conr�ected disabi�iiy pensEo� to Mr. Spitaleri in accordance with pravisfons of SectEon 26.34 of 1�e Ciiy Code. This pension is io bo effeative on a date to be detarmined. . The amaunt of Mr. Spitaleri's pensio� wi11 be cafcufated by the Finance Depariment according to the formula in the PensEon P�an tar nan-job-cor�nnected disablllty pension at s�ch t�me as his last iive years of service and salary can be camputed. �f i�ereby certi€y t�at tna Asnsion Advisory Commlttee has approved the granting of a nan-jab-connected disabil�ty �ansior� for Robert C. Spltaleri ar�d thai ihe above dates are carrect. .. �'�, n n . � Chairm nsjon Advisory �o�hmit "�qual �mployment and Afifrrnative Actinn Employer" k�"' ' � ._ . � , . . , . � . �r . . � � . ,' . .. . . . � ' . �� ' , . , � ' .. ' . ' . . . . i . . . ' . . . , ' . . . � � , � � � � . , . . , � ' � � . . � � .�. ' . • . � , . , � . ' • . , . ' " ' � � � � . ' . . � t � . . . �...<... ...fi.� ...�.�ft..... �......�,, �,.�..` ., . �. .. ...,.�. . 1 ' ' ' � ' � , . ' • � � � � ' , � - � r � , i � � . �.. , , ' , .� . � PENSION REQUEST FORM , � ` �;� �, � ' � , j': �'� � I�� toberc C. 5pitaleri do hereby apply for retiremcnt' . � fram tbc City 4f Clcarwatcr Gcncral Employccs' Pcnsion Plan. • . My beneFts date ts ��12�8� (E�try date into , pensio� ptan) - , My date oi hire is ��$� , My birthday is 5I3Z/57 � � , • My jo� classificatian is Police Of�icer �nd I work • � ' in the �Q��Ce Department. Fa�rol D i v i s i o r�. ' ., M y resignatioa dg�� is_ tn be determi.ned ' , The type of pcnsion for which I am applying is (chccic only onc}: � Reguis�� I'ensiou � based on years �df service : Job-co�nected Dis�biEity Pension , � X Non-jab-connected Disabtlity Peusion . My spoyse's name is: Laura � Dependent children uncier the age aC 18 and residin� i� my household are: , i (Print Child's Ful1 Narne) (Chi;d's Datc of Birth) I � , , I hereby certify ail of the above to be wc a�nd correc�: G `�c.�.�e,c.�. . (Signaturc} 1�g2 Januar fi, ��` /� {Dasc) , t. (I�Iot�:y Public) �� ,� �'• •� � � OF FLORIOA , � � Puetlt SrtA�E ,, �G�g , � 1biARY h €XP. �h5; i.tiD. . 1iY CO�T1 �U Grt;E.AAL , 94tioED , , . . � '� .'. . ;.' .3 . . '. . , � I . . ! , .l. .. n�.� . . . .. .. . . � . .._......_ . >. . .. . � r.• .'i�.�... , . . . . . '� ' i ' � � � .� , , � CITY 0� CLEARY�'ATER � � ' � �GENERAL EMP�.QYEES' P�NSiON PLAN � � OPTIONS � POLICE �k"FICEitS - . .� OPTiON #1: , Emplayees ca.n receive a lump sucn payruent� for vacation and haiid3y pay and Z/2 of accr�te� sick �cavc at the tiaie of � . separatian from the City. Therc w'sl! be nn 890 deductifln for . pcnsion [rom this lump sum paymenc nor will this amouat� caunt �s earnings in �he calcuiation of the Pension. The Iast . � day of wnrk wit! be the termination date and pension be�e�ts � � � will begin the foilowing day. � DPTI4N #Z: �mpioyee � can �xtend tcrmination d�te by the time duc for � �. {Q��y s�va41ab1e to vac�tinn. hc�li�ay pny, and ' 11? of •, accr�ed si�ic leave. cmploye�s hired Terminncion datc � wil! bc the final d�y �of extended time. prinr to 1011l9U) Pension beaefics wili begin the following day. . . OPTTON #3: Employees can spiit their, accumulated sick time at (Ottly availaktle to nae-quarter pay and ane-quaxter early re[ircruent tima. That employees• hired portion received as onc-quarter �ay will not have 8°fo prior to 10f1/9f?j deducted for pension nor wi�i. ii couni as e;�rnings in t}te - calculation af the pension. The • portiop applied tawaid early retirement time will bc subjecc to the 89'a pension dcduction . �. and wiIj count as earnings for pcnsion calculations. ' . Termina[ion datc wi11 bc the final day af extencied time: ' pensian benefits wili begin thc fofiowing day, � x�;�,�x*�**��.��w�**��W � I� Robert C. Spitaleri , an employce of the City of Clearwater, hereby apply for pensior� bcncfits under che General �inpioyees' Pensian Plan. I h�reby certi�y that I fulty u�tderstancE the threc options offered to mc. I ct�oase tc� retire ��sing Option # � and wis� my bcnefits ta be ca�cula.ted under this option, ' I understa.nd that onee this form is signed, my decis'an is irrevocable. �MPL4YEE'S SIGNATURE: � � �` , , ' SOCIAL SECURITY #: _ 093-46-4580 WI'�'1YE5 ADI7R�SS: I1725 85th Avenu� North 5emino�e, FL 34bG2 � DATE• � J3n�ary b, i 992 f� ' � ..— _ - �.. . , . ... ' . . '... : �., . .: ,, � -,�°f•• . : , � . i „ . . . . ,, ti . , �' . ' I� , ' ' • � �, t' ��ARR.Y LEE�LEBER, M.D., P,A:. . � �;.; NEtJfiOtOGY ' � , � ,1� 1011 )cifcrds St„ Clt�rwater. Florida ad616 , , . � � • Rj3•A43�3Zh5 k'11X 811•A4Sw1��G ' � AlpJouw�r—,Ininlr�npmrir�/Nn�nAu� ,December 3.7�, 1991 ' . . • ' • . � Dr.' HazQlbaker , � ; 7�95 Cntezpr�.se Dr. � �� • Clearwa�L•er; Fi,• 39fi23 � � . , , 12e: 'Rob�r�. Spitaleri '' . . • .. , • . . �. Dear��Dr:�Haxelbak�r: ' � � I saw Mr. Rob�rt Sgita3�ri a.n �h� offi.ce an 12/�.1/91. Z had seen ;, this ,�34 , year old gentl�man b�,ck in May antt �t tha� tim� I�e1.t . �hat,'�he had�probable MS. He was h�re b�cause of an epxsode of ;� right bvdy n�ar�bness. �reviously he had right optic neu�itis nne � year :ago . � . . ' � • �, A��the time aF my examination 7 months ago x�ound na � neurologic�3 d�t'icits exc�p� for a very slight zight Mazcus-Giznn .;. punil.. �T.he. patient's vxsion re�ur�ie3 almost entirel.y to L-l�e � right eye'. �`• He . is actual�y �•20/2d irk both eyes, although he i.s , sometah�at', better on the �7.eft eye th<�,n �he xzght; accord�ng to Dr. � •��, William•Taldorie's eye exar� oi' �.1/S/91. : �.. �n CXAMINATIDN today r find no neu�o�ogica]. impa�,�ments. The � _ ric�ht pupil aceacts norma3.�y to 1ic�ht b�t does not �onstxa.ct quite ,;� as fa� as the lef'� one. There was no probl.em w�.th cooxdina�ion, ;`' strength vx zefl�xes at thi.s time. z cnu].d not find aiiy cranial ' n�rv� d�iici�s other than th� minimal pupil�.ary asymmetry. �•. . . , , �� The pa�ient is here today because he was concerned ahout his '� abil�.ty�to.per�arm as a police a�ficer. He w�s worki.ng as a E�, �� , patrol.m�n unt�l he was put on disabil.i.ty a month ago. He xs naw �'• s��ki.ng� long terr� disabili�y bec�u�e he feel� that he canno'� (' functa.on in �hat rol.e and he feels that he wouZd be a].xabi3.ity. `�� . . .. , . H� sta�es•that the heat is �he biggest com�l.ai,n�. This seems �to �� make:numbness ascend up the right arm. It makes his �ata.g�e ,�' worse. He also feel�s thati his vision is wors� when i� is , , �articular�.y hot outs�de. He says tha� he has diffi.culty reading out o� his ra.ght eye on th� computF_r sc�eens becaus� of g7.are a� � the briyhtness of the �ights. Somc: days he �eels "dixzy". He • s�ys �•�hai h� ura.nates o�ten but he r]o�s not have ir►con�i.nence or urgericy, . ' , ! . ; , ..� . . . � . �;. , . < , }.. i � I'' . ��l� ' `.'jt. • ,. f' .. 4 � ' � I ' ' r � � 1. ' ' � - 'S ' ' .. . !/' l ' . � ' ' � .q ' � e . . 1 . ' . .. ' ` ' � . . ' I.� ' 1 }. � - � . . ' 1 '' .. ' • 1 , I . . . . 1 ' . ' ' .. ; ,, :'. � • ' :f�' , ' .1 '�;.j�. ' r � . , . . � ' ' � � ' . ` • ' ,. ' , ,. 'F;�:•' . �. L . • , .. . , i; . 'v . .e. s' . ,'� : ,. � , � .. � . . - ., ' . .. . � . ��'s.� .... , . . ,'�1�� ' _' i. . ..... .I, , . . ' ., j ' .�' e ' .. ,' ' � ' 1 • ' ' .. . � �� . �E: • � . .IF . . � � . . . ' � " � . . . , � � . ' E�' � .` .� , ' ' ,t,'�' � `r � .,•. •�t.''(�'�' . ' ' .'4. '' , r' . ..�j' � . ' � • . •S � . '. � ��k.'}'}��Y�3:�f. �.`Itir`.`l'�' J;'.1Ia�;2.1 .�� x��v 1) I��i"� 1�w�4�,,�+s.�w• � .. . . .. , � . '... ., . �. "' . ..� . " F � . .. � , . . , ... ,r. . . . ' . � . , , n . . . � � , . � . . , ' . . . . • � . � . � � � r. ' ' • . . . . . � . . • � ' . 5 . � .. l� 1 , . • � ' . . . . , ' • . .. ' k4'• '� � . � i I � 5 • . . ��,, ' � 1 • � , � � . ' ; . � 1� � � . ,, `:i. ;''r , - ' � ' , , , . ' � �; { , � . .� . . . � , . : Robert 'Spi.taleri ' � ' -2- • , D�cember 1,1, �.991 ' � ,. � , . . . ' ' , ., , ,' . � , ' . ' , ' . . ` , ti .. . . � . . � • , �� . �� . iMPRESSZON: �'' The pat�.er�t �probably does have MS, although we have '_ �not' proved- that com�lefiely.. �,HP pzabably shou3.d have a].umbar �� ' �, i i • .punct,urE. ;and visual• evoked potential.s .. For . now, � assum3.ng that � he ,. E,,, ', i �. has.�MS� ;he `probab]:y would not be ab7.e to function as a police �.i�' � � officer �although I think he couI..d peirform other .occupations. , �s, � � Sincere]:y, � � , ' ' ' . � � ' ' ,l � , ' . , . 4 � , . . •:4• .r . . . , \ . LL [. � . - , ' , � , ' � . � • i , � ._, � � . „ , � . . , • BARAY; L` EBER, M. D. � , . ' , , , �;. .'. . , . . - ��. � . . , BLL/psa : . . . , ' ,. i: � ,. � - � . � ,. , . . , • . ;.�, � ; , cc: � . Patient � , �� : . ; ° • . . • . ; • . . ; , � � � �. .:, � • � '�,' �� ;., '� � .: � , . . ..� . .. ' ' � � ,. . . . ; . � ' � , � � � � . ; � � . i , , `, ' . . ' . : , � ' . , . i i� 'I . , , . . . � ;• � �� 1.. � . . ' ' °��' ; , . 1'' . , ', � ; ,; ' , , � - . . t I, .' , .;; , .. � • � ` , . , � - . I' � � ,.� , ' . ' ' �; i , �� . �.. - � . � - . , :�1r;. � I •. •t • ' •.1', I. • , • , ' . . '� .. ' �•1� � '. . � �',1�, � �j � ' ' 's . • �. . �.�� . ' '. •• . � ' i. . . . � ., I , . ' ' ' • ' � . `� ��•, • ; � , ��: , , ; ;. • .. ,. � . • • ' � �•r . � , • � . , �� • , , , , . • • , 1 ' ' , ' �I, . , • . . , ��, ,. , .. , , , . � , ' ' ' : � . 1 ' �. : ' ; •i , . ' , ' . �� • . . , .� i• , ' • , , ' • ' . ' . _ ' 1 � . • . • , � . , • ' • 1 � • � . � ' � , � � ' 1• • , . �'•,, � i 1. ' • , � ' ' , ' • . �, ' 1 �'.� , ' . �� . ' � • i, r � .. . . .. . . • P • '• ' � , i 1 " . . � � . � � ; . . � / � � ,� � � �w `� • m r�'. ;�•�1 f'!l •+.' 1; � j '' . J' ��,,, ; �,�4� = ' � � • , Vllifli�m L. T�Idone, N�.D., .A. � Oipfomato Amerlcan �oard of Oplhamolagy Mt. Vernon Profess. Ctr. 2?.16 U.S. Highway 19 Haliday, FL 3d691 (813y942-2273 Eye Sur�eo� 8,� C'hysician November i 5, 1991 Roger HazelBaksr, M.D. 2995 Enterprise Raad C].�arwa�er, � F1 34623 RE: SP�TALERI, ROHERT Dear Ar. Hazel.Baker, EX�M: 1 � /$/9'� i00p Lakev(ew Ro�d Sulte 2 Clearwater, FL 3d618 (813� 447-191Q Mr. 5pita].eri a:eturns today. He states �hat he has be�n diagnosed as having MS. He states �ha� he has b1.u'rred v�.s�.on in hot �empera�urss. H� alsa ha� per�.ocular or retrobu].bar eye p�in. He has si.m��.ar compXa�.nts in the �.ef� eye. He a],so stat�s that he has uniacular decrease �.n depti�j percep�3.on but th�.s �.s phys�.oZog�.ca�.ly impossibl�. He also stat�s that he has uniocul.ar dovbie v�.�3.on wh�.ch is al.so phys�.o].og�.cally parietal impvssible. A� you note we had a MFt2 scan p�r�vrmed on i 2/� 8/90 wh�.ch showed arr ar�a o� demyeJ.inat�on i.n �he ri.ghi: pa�raetaZ lobe along with opti.c nerve s��telxing. There£ore � am nat surprised �hat he �.s d3.agriosed as having MS at this point. I discusaed this wi.th the• pat�.en�,.as a passibil.i.ty in the past. The. pa�ient is consid�ring res�.gn�.ng ��rom �he po��.ce �orce. My examination taday is cons�.�tent c�=xtih pr�.or exams. ��The vzszvn 3.n the ri,ght eye is 24/20-3 and �he left eye 20/20 a� distance w�th gl.asses. There is a Marcvs-GUnn pupil �n �he ri,ght �ye. The ocular moti�ity is norma�.. There i.a no I.N.O. Th�ze a.s no nys�agmus. Th�re 3.s pa].�or. of �he right v�Eic nerve. Contrast sensitivi.ty tes�ing was 20%70 in bo�h eyes. Computer v3sua�. E�.eids w�th thresholds show�d an enlarged bZind consis�ent wi.th prior v�sual ��e�.ds and inferior arcuat� de�ec�. �pt�.c atraphy right eye �.s secondary to retrobul.ar op��c d�.agnosed on 12/i &/90. I be�.ieve �he decrease in visi.on real. and I bel�.eve �hat ha could have visua� i�.uctuation corresponding to temperature changes and exercise. A].so retrobular ache is cans�.stent with multiple �cleros�.s. that the�e factoxs can be taken into consid�ration when eva�.uates h�.s ab�.l.�.�.y �o pex�orm as a police officer. Please ca�]. �.� you have any ques�ions . � � � � � ,�� t�t,��' � . � / �� . W. L. Taldone, . �� WT/ap � CC: Mir.haP1 anr7*.a.�.� •• •• •• ne�ritis is I be].�,ev� one � , S'v,t _ 1 • . � . tc�'1N � . '! e� I� � � .. ' . ' , . � , , . . ' , . , ' ' �i � � � . . , , , til� .. � ' . � ' � ' , ., ' � � � . � ' � . . . � ' .. '. ' . ' `! . . . , ' . ' . .,� � . . , � � � , , . . . • . � , � , � :.r�. . . � ,� ., - � . ' . '�� . � � � . . , .. - . . . . . I�r . ... . .. � .. � . , � ' . ' ' . � ' . , , c . � , . .. ' . . - . 1 , , • ' ' � , , � . , . ' � .. � . . � , . , , ��. , � . . ' �i '� �F. � .. � , �. . 'i, t. . � • . ..� .. � r ' . ,.' ' ��, ' ' ' � 1 ' , '. ''��','�.. ' ., . �'. '�,1�. . ;,, . ` . , : ; . � . I � ' . � . ; . � 'I.. ' � . ' ..� � . . � . '' � , t . ' , ;� '. �� ,� .� ' • :!I . . . � ', . " ' . . ' �r. . , , � . i. . '�. . - . • �.� . . . ' • . ' ' v�.. ' , r . ' ' . ' . . . . ' . , . r . rr { n . + ' t .,', . , t, . 4 , • . ' ' ', ' ' ' ' . - ' . ' ' , • ' . , I , . . . . �� , . . ' . . , . , . . , , . . , . '.�` ., ,' . ° l • �� ' . . � � ' . � ' . . , ' � � • ._... . . . .....,. .-...r.{.s� nf.:i.(...��.. �-..a , r . . �e��L < � . . ....{>i . . . � . . .� . .�...r .. .. �I r.. i. . � . . ,. . .. .. •. . . .i ' . . CIGNA Heollhplcan �1 Fiorlda. Inc. � , . , ' • ' ' � , . . �495 Enlerprbe Orkve � ' • ' � . � � . � , Su110 �01 � � . r , � • . . Cfecrwnter. F1. 335�5 � ' � . • . . . � � (913} T91-�04i • � , , . . . • ' •" ., ' ; . � � �. � � . � . .. , . . ., . . :. ' Februsry 5, �99� . ' : . . . . . . � �,�: • �: . � ' . � . � � �• ' � ''� To Whom It May Can�ern; " , .' Raber� Spitaleri is a. patient of' umi.ne xho , has 'g presum�i.ve ' .'� �.diagnoais of. multiple scl.erosis. He has problems with vi�ian ., . � and. a�so some pare�thesi�s to ��his point.. Future GDUTS� �.s : �, � uripredictabie, � however it cauld involve ep�sodes of vario�xs, � ' • �� fair�y si�nificant disabi.3.�.ties. This shou�d be te,ken into • ' � „ consideratic�n xheri det�r�ning�his abilit�es �o perform the � , I �; � duties of a police of�fcer. , �� . ' • � � � Sincerel.y, � � � , . !'�� • , . Roger D. Haz�lbaker, M.D. ' , � � � ' . � . .. , cc. Medica], ftecord � � ' . , 1� . � I �_� � � �' � t � ' � . E' ' . ' � �a�a�a � r . , , . , . . _ . , .. . ........ ,.... {I�it° . . .. . . , , ; , �, . ■„�-. , �. �', ..��.�,. „ 1' , DPd7T STIiAY �iEAD(11�AP.i�f?5-813-97q-2995 i` .� May 19,92 12:?7 ��0.043 P.03 �._.._ . . .. .._ _ . _ . D�t� � CLfNiCAL RECORD . PRO�RE3S NDTES �l�/9�%� �.., ._.__ � .__ NEURO-OpFCTNI►LMGLOflY CLxNYC CON8VLml�m�ON � exemina4 Robart �3pizm].erl. an May �.2th, 1.992, x t�ed �sen him onc� �r��iou�I�y 3�s Maroh, �991. He �ut;CaraQ en epi�od• af apt�La neuritiQ in J�nuary, 1�Q,k. Initia��y, vie�.on rv�o maxkedly ac�duo4d. Yti subsoquar�tly imp�o�od, but ha h�a baan ic+�t uith ai�nifiaent vi�unl dOiSC�te. Ho raport� thet he��'and humi.�ity laad to a mexkad b].urring o# V��30R. He also oaaaeivna�3y oxDarionoe� doubie v��ion which i� vertica� end oo�s� or► Wi�hout warninq�. He oan cZoae hi�a eyes for a per�.ad o� iime an� rBetor� �+inpl� vi�ian. He al�a ha� not�d devxeaee� aoior vision in tho rfght eye. Vi�ion i� wor�e iz� bright r�un l,iph�. N• xaa di�gnvs�d tv hnu� muitipls eaiHroei� in May, 1991, nftsr dnvelap�ng �umbnovo on the x�i�h� oi�o af his body. Ha had �om�, but incompla�4 reaovn�y. ��her Problom� ho ha� oxyarienoed inoluds �ix�incsr�e� veeknas�, fatiiQu� nnd humtaneesa. LXAMINATION: ❑n exnm�naxi.ori, viai.on wae 7Q/25 in the r�flht eyo, enG 20/20 in the left eye With g�.aeees. Color vie3,on �a� m�rkedly raauosa �.n �ha ri4ht ey�, and wes noxmai in tha lef� eye. , V�.euai �1�a�.4s �howad modera�a qsneral con�cx�ct],on o� th� iield 3n tho r�gh� ayo x3th a nara,oz #iel�l in the le�� e�o. A rfqht Yolntivo a��orant pupiilary dofAC� waa prp�on�. Hi� lide, orDiti� end motiXity were nprmdi. On iundusovpY, xher� w�a mil� di�P�ae pellar of �he righ� op�ic �liek. Tho lq�t eye eppanred normal. �►I,thouQh ha haa had oifln3l�.oan� vtscsal r000very trom Ap�to nauari.ti8, he etl,11 hae exist�nQ optiic nerva dama�a esnd CONTINUEb a . _._,.^�..._ .... . . . _._ ..._ SP�TJ��+�Rx, Robart �538965 rqw �s�a� p+cr. �mM) PFi00R�SS NOT�S U�Iveroltr o! South �larld� Callapa af M�dlcln• Medic�l Cfinice 12901 9ru�e 8, Dawn� Bivd. Ti�mpR. ��arid� 33d1? , � t .. . , .., � � . .. .. . ... . ..:� .. . -.�: `; � . . � . , _.. . � �� . �N1'T S1'�DY FiEADOUARi'�i?5-813-97�-2995 � � r - �. , , ' , � Date May 19�92 l.'?:28 No,003 p.03 V � . ,,.........�, _..»... , _,— - CE.l1ViCA�.� REC�RD PRAQRES3 NOTE9 ....�._. _P7��'W6'•. ,.__w.. _� rea�,�ual � da�iQit�. Th3.a io appsxar►� ir► th� raduard pup�Z re�pvn�� to zi�ht �.n th� ri�ht eye no w�l]. e� tt�e p�c�e�noa of pailor o! ths siyht optia diek. l�rom Ai� functional atanC�oint, �tlare Sa ma.�a aocr�a�o in vi�uei aoui�ty, mnrkod iass vf colos v3.��on, nnd moderate � conetr�,ction o! tho viQU�7. fimld in �h� rigY�t �y�. �� His oomp3.aint or w�re�enir►Q o� v3eion whon hv �a in a hot tampns�aturn ia cg1�Qd U'htho�!'s phenomanon. Tt i�e r�lntod ,� to en im�eirmsnt of oonduotion a1onQ the optia nexve with ohatiQe,� i,n tampesnture. Nie de�crip�3�on o! tha prablam �,� quits conois�en� with What �.s knawn �bou� tha� phenomerion. � ��ind no evidar�aa aP d�plop3a vr en vauiar motiiity di�tu�benoa at tho pra�ent e�me. liowsver, theee 8ymp�oms o! o�ciilopa�a and dip�.oD3a that t�o Qs�porianoad 3n tha pa4t are oonais�ant With neuroloQ3a �.nvazv�ament �rom multipls �ciero�i�. . The detiaito �n op�tc narve func�ian that ho aurrahti�y h�o � nre permanar�t. �aeeQ on tho wer�snin� of H�e �ymptom� whan ho ia f.n warm tamparatu�roe, = believe �ha� it it� u�t�a�e �or �3m to ba emD].oyed n� � poliaeman worktnQ ou�ddor�. I beliave �chat he aould parform �unct�.an� inaiaa •t a dcok without.too muah di�'licuity. Ko�r o�, with is v3�ua1 imp�irment, i do not ba].iev� 3.t tg �a�tor him be p}.aced in potsntielZy denfleroug ai at��ne. _ ' R Y W. ECFt�, ,M.n. RW /T5 037 � D! S/x /92 T: S/1�/92 �D8 ao: Rabert 6piteleri 11726 8bth Ava. North Saminola, F� 3a642 -- �---��—• �. ... . . ... .. . . �-- -- ---. .__.. . .. , BpI,TALBRT, Robarti PROORESS NO�i'E3 1�598866 ' �lr�}v��lty oI 8au�h Florld� Calla9� o! MQdlclna M�a�cel �Ilnlcr 1�801 6tut,� 8. C�owne B�rd. . Tampi. Flotld# �3617 ro�w tst+cw Psir. �ia �+w� iulQ�' ' .