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11-02-1992?4.?1, ?}.? „?. r-?3 ? '?; '.e ? • •1 is 4Nr•?.;f .£... ?+f .I°. 'Itf!` !tt"2', •`{' 1 .[t•;" .•5 _ ?b. a. .:'+: .:f 'a1 1 ,., 'i ; ?? • ,'I,. r:i. Yap `. e. " .{ •' t. ? + •1? ?, ? t ,. s cd ?,'r?+ .i -T': 1•. tf•?, ift;:..y. i. Y'r? rt.i' s5 ?<. :i '3:'.'?'4i 'fl' :•??!r. , a'. tl.i'"°s?i`iipr[•'-?' ?4?3?ttn 9 ;yrY?.c.4 5..rtG Y.>. ,},1'4"?. ?€'{,?•';'•.e.??' ,,?,:.:' .} P'+..?. "[ (??? "S'. §9?') <i' ..t?'? •? J1 :1 i ? ?.N' r 7....ati ,,,c• rLS..li?x. °'r <<'?'? ?I. ?'{3. ., ?j .?[s:E .s: of :1,:'? {':s 1?$"`al, ''Si: :;el,{r ,. ,.t: .,.r 1 • •;,;:5: "r?'' '''7; :ll:s ?` ?*F + ef4'' .,,,,7?? ! ,i r'? }. o??' Gy r.F. +}. ? ',:.:3•?i .} r?.,y,•t r,<., i?? ie ..?, ; :e.,.1 ?<?, t.?? ?' 1a1' -'r; aa, .. "?F'fi?;•6.,?t?'•?•.t+ ^'' ' ,:!9t, -0(°f'?? r ;,,,y? s-.f, i ,?,5? ,??_ 1., .F. r,[ ;r {,,..?i,;'- ?.y,ql.;,, Y '"'. ?`.5:• rtr' .;?_,.. „{,?;} ,n .,s r <f.. T •pF:r ".fir.` ;;'..1 I•r;., `t:,?'.?iG1i;:..,?,: ?'t ?{''r3.3'., [ ? ".'l. w?'i :f.3 {:. rt .5 ?? ?t ? di, ?1 i't ,•t? .:1'•it rj;',?: P,. ???',:??` ??.?., ?.A,.. "k •1. r ? ??'r. 7; r '.fi"`.tr??,V '?: a'''?;?r11,'.? ;{r: ..?, .x :I: !?.r:' r°?" t< '.3:, +I'; ?,.y-I.s . lf[:,rF,` .I: ?? y t ' I•i ?':;.. .Q',3:'.. y.';,..,.°r„5?'...?..,°;;F ,??•'-,'?>y. til l„ r- ..5 `!: +t r' ,?=5'. a`. ..iii e ? 2'' ' , 3 e`: YI' f', '• l': Irr •- i,' r?r •/•.I .'' ,• '` .. r .. ]. r'v' MIN .:...'? . :.a.: _J_.a. .. - . . :3. , t - '.f. y... ? i.?,' ', ?. :J• ,k: ,•,, '#'r$?:ih{•>n£K'.rF`-''yA?.'?..??`.:::t`,y'wro3gfs .?a. : t'? K`-3ryY'fy' „yri r.;' ? ''•;{',r .. .f.. ?'t.: . ,z•. n. ,•;v•,: :.i .L?'" .,a. Jc.,. .. ... '._.' ,2,f L'x,:"'!;. *.:v7:N''!. t "7" .. .:r. AGENDA Board'of Trustees of the Employees'' Pension Fund November 2; 1992 Approximately 10:30 A.M. 1. Call to order 2. Approval of Minutes of 9/28/92 3. Request for acceptance into membership: a). Charles Howard', b) David Pletcher c) Charles Charity d) Norma Mathews e) Veronica Hunt f) Wayman Pearson 11 g) Ronnie White h) Dina L. Ayres ; i) Phillip D. Hughes a).Vincent.R. Booker k) Richard A. Carroll l) Steven M. Sears m) Donald E. Main 4. Pension(s) to be granted: Regular Richard D. McManus 5. Pension(s) to be granted: Job-Connected Disability a) Arthur Carpentieri b) Shirley Mobley . c) Caleb Winston 6. Pension(s) to be granted: Non-Job-Connected Disability Ray Brock 7., Temporary Amendment to the PAC Policies & Procedures Manual [-419 to allow a quorum of the PAC to vote, on disability pensions ' a,`1'' I, ,:?s.i '}? ?{•[`? ? ?4'• •: S, rr' ,. xy.' ?1 tip ?i , ! .i. o !' "??, I.? •fa ?.f Yr ICY Ft ?'tr,], `ll, ••+' ,. , '? ? , r . ,i F, ..f 1'. ??`? •}. S• ':.i .'4 ,t?:. ?•t.'#! +.. fix ??v ' . , , ?.. ? ' '1 j :t' ,,'. 'A.," .1.'°??{ ?',`e le?' .ro :, ,+? j?•? Elf .,1 ,- .?f ? ? s ` ., .. ? ` .rh yt. .l','{`..'ir.. c.J? '?.' ,)• 'tF° s.., f? ., . Ir :L' , x'e ?1'.Yi'l?,y'.PV ?.' +.la ?x f. •,eE ^e '?l„??Y!;• ;esr ? •, x'.: ,1.?' :°cs.i,: '.rry,r.: ?T?', L.' ? Vii: `-`•+,.:,'n-:: '..• ,??r q.?'?. 1, ?.1 ` 1' 4 F.? 1,. iii h`; •1,'{?«r ? r '' ,?t ??,J';r.?7,'-3:.. ,.. ," r x' ?-ia:,, E e7,.?fi !?;r?.._':'S: =i• .r?d,.,.•?y. Li7VON, ,t 'wa•?xe,r.; r, f'', n : 1. .. .Y., ,.. ° 'i i,..}.^`•: ., ?^-..;1•. , °,...., ..xw -Medical Standards for ?. Pension. I inr? PAO\je, - (l 301 ' Physical Examinations Purchase'of Pension Service Credit >'.. Lois Maroon Other Business.. . Adjournrrient: . I ? 1 PFA 1112192 CLEARWATER CITY COMMISSION 3 Agenda Costar Memorandum Item # Trustees of the Employces' Pension' Fund Meeting Date: Subject: Membership ' in Employees' Pension Plan Recommendation/Motion: Employee(s) listed below be accepted into the Employees' Pension Plan as recommended by the Pension Advisory Committee. ? and that the appropriate officials he authorized to execute same. BACKGROUND: Date Seniority eniority Pension and Job Class Dcot,JDiv. Date Effective Charles Howard, Police Officer Police 8-18-82 9-12-92 David Fletcher, Maint. Worker I Parks & Rec. 10-19-92 10-19-92 Charles Charity, Com. Dev. Mousing Spec. Planning 9-21-92 9-21-92 Norma Mathews, Library Asst. I Libraries 9-21-92 9-21-92 Veronica Hunt, Staff Asst. I Pub. Wks./Water 12-6-85 9-28-92 Wayman Pearson 11, Solid Waste Wkr. I Pub. Wks./Solid Waste 5-4-92 9-25-92 Ronnie White, Solid Waste Worker I Pub. Wks./Solid Waste 5-4-92 9-25-92 Dina L. Ayres, Data Entry Oper. I Planning 10-9-92 10-9-92 Phillip D. Hughes, Mechanic 11 Gen. Ser./Fleet Maint. 10-19-92 10-19-92 Vincent, R.. Booker, Firefighter. Fi rc 11-2-92 i 1 -2-92 Richard A. Carroll, Firefighter Fire 11-2-92 11-2-92 Steven M. Sears, Police Recruit I Police 10-19-92 .10-19-92 Donald E. Main, Sanitation Worker Pub. Wks./Solid Waste 5-4-92 9-28-92 Reviewed by: Originating Dept.; Costs: _ A6±-- Commission Action: Legal Nk Human Resources Total ? Approved A - ?. Budget ?SG ? Approved w/conditions Purchasing A- User Dept.: Current FY ? Denied Risk Mgmt. ? Continued to: DIS Fundin Source: g ACM Advertised: ? Capt. imp. Other- N - Date: ? Operating Attachments; Letter(s) Paper: ? Other Submitted by: V- Not required Affected parties Approprialion Code: ? Notified City Manager Not required ? None CITY OF CLEARWATER i' EMPLOYEES' PENSION PLAN PENSION ADVISORY COMMITTEE TO: Pension Trustees FROM : Pension Advisory Committee SUBJECT: Recommendation for Accept ce into Pension Plan DATE: October 7, 1992 As Trustees of the City' of Clearwater Employees' Pension Fund, you are hereby notified that the employees listed below have been duly examined by a local physician and each has been designated as a "first class risk". These employees are eligible for pension membership as noted in the ,Pension Eligibility Date column below, and it is the recommendation of the Pension Advisory Committee' that they be accepted into membership. Naine. Job Class, Dept./lDI 111r1b Date- Hire 12atc EC130011 Elie, Dal Charles Howard, Police Officer- Police 11/02/51 08/18182* 09/12/92* *Employee withdrew pension monies upon resignation, but did not repay the Fund upon reemployment. Hire date has been adjusted to reflect the period of time the employee had resigned. David Fletcher, Maint. Wrkr I - P tic R 05/26/69 I0/19/92 10/19/92 Charles Charity, Comm Dev Hosuing Spec. - 10/15/16 09/21/92 09/21/92 Planning & Development Norma Mathews, Library Asst. I - Library 06/01/48 09/21/92 09/2I/92 Veronica Hunt, Staff Asst. I - PW/Water 07/09/54 12/06/85* 09/28/92* *Employee withdrew pension monies upon resignation, but did not rr the Fund upon reemployment. Hire date has been adjusted to reflect the period of time the employee had resigned. Wayman Pearson, Solid Waste Wrkr I - 11/19/70 05/04/92* 09/25/92 PW/Solid Waste *Employee hired from temporary to permanent status, Hire date reflects date hired as temporary. Ronnie White, Solid Waste Wrkr I - 12/04/63 05/04/92* 09/28/92 PW/Solid Waste *Employee hired from temporary . to permanent status. Hire date reflects date hired as temporary. CITY OF CLEARWATER EMPLOYEES'. PENSION PLAN PENSION ADVISORY COMMITTEE Pension Trustees PRONE' Pension Advisory Committee l?. SUBJECT Recommendation for Accepta ?into Pension Plan DATE: October 21, 1992 i , As Trustees of the City of Clearwater Employees' Pension Fund, you are hereby notified that 'the employees listed 'below have been duly examined by a local physician and each has been designated as a "first class risk". These employees are eligible for .pension membership as noted in the Pension Eligibility Date column below, and it is the recommendation of the Pension Advisory Committee that they be accepted into membership. Pension Elig. Name, job. Class, & Dept iv. Birth Date Hirt: Date 1?? Dina L. Ayres, Data Enty Operator 1, 5/23161 10109/92 10/09/92 Planning & Development Dept. Phillip D. Hughes, Mechanic 11, General 11/05/63 10/19/92 10/19/92 Services, Dept. Vincent R. Booker, Firefighter, Fire 11 //12/62 11 /2/92 11/02/92 Department Richard A. Carroll, Firefighter, 3/11/60 11/02/92 11/02/92 Paramedic, Fire Department • Steven M. Sears, Police Recruit I, Police 11/14/66 10/19/92 10/19/92 Department Donald E. Main, Sanitation Worker, 1/30/7I 5/04/92 9/28/92 Public Works/Utilities/Solid Waste *Employee hired from temporary to permanent status. Hire date reflects date hired as temporary. CLEARWATER CITY COMMISSION -=y Agenda Cover Memorandum Item N 121?z p?IrEA?'`°? Trustees of the Employees' Pension Fund Meeting Date: ` Subject: Pcnslon(s) To Be Granted Recommendation/Motion: Employee(s) listed below be granted a regular pension under Section(s) 26.34 and/or 26.37 of the Employees' Pension Plan as `'recommended by the Pension Advisory Committee. and that the appropriate officials be authorized to execute same. BACKGROUND: Richard D. McManus, Police Officer, Police Department, was 'employed by the City on March 13, 1968, and begun participating in. the Pension Plan on that date. His retirement will be effective on November 10, 1992, at the end of the day. Reviewed by: Originating Dep, Legal - Human Re' Budget N? Purchasing Md-- ?- T User Dept.: Risk Mgmt. iuA- D1S _ PA- ACM Advertised: Other Date: Submitted by: City Manager Paper: 9 Not required Affected parties ? Notified 10 Not required ? 1. ? x,..111.,,.... Y...4 Costs: Total Current FY Funding Source: ? Capt. Imp, ? Operating ? Other Appropriation Code: Commission Action: ? Approved ? Approved wlconditions ? Denied Continued to: Attachments: Letter(s) Request Form ? None _?aS 1.?•.'6tf[ .. ? , t.?q??'' .??w/;, ',a>' 'k L•.f ? r .. ' r r . .41lrfat?r? Porsonnel Deputmen! 462.8870 C I T Y O F C L .L . A. R W A `I' E R POST OFF ICE Box 4740 CLEARWATER, FLORIDA 34 618.4748 'Honorable Mayor- and . Members of the City Commission' as Trustees of the Employees' Pension Plan FROM: Pension Advisory Committee COPIES: Richard McManus; Dan Dcignan, Assistant Director of Administrative Service/ Finance Director; Employee's File SUBJECT: Regular Pcnsion-Richard McManus DATE: October 7, 1992. The Pension Advisory Committee received an application for regular pension from Richard D. McManus on . September 18, 1992. Mr. McManus was employed by the City on March 13, 1968, and has been a participant in the Pension Plan since March 13, 1968. The amount of Mr. McManus' pension will be computed by the Finance 'Department at such time as his last five years of service and salary can be calculated. By motion made and duly carried at its meeting of October 7, 1992, the Pension Advisory Committee approved/recommended a regular pension based on years of service for Richard D. McManus in accordance with Section 26.34 of the City Code. This pension will be effective on November 10, 1992, at the end of the day. i hereby certify that the Pension Advisory Committee has approved the granting of a regular retirement pension for Richard D. McManus and the above dates are correct., C airman, Pension Advisory Committee _? "Equal Employment and Altirmalive Action Employer'' PENSION REQUEST FORM Richard D. McManus I. do , hereby apply for retirement j from the ' City ' of Clearwater General Employees' pension plan. My benefits date is March 13, 1968 (Entry date into pension ',:plan) ' My date of hire is _ March 13, 1968 November 12, 1946 My birthday is E My job classification is Police Officer and I work.' in the Police Department Division.. t• .. 10 M y resignation date is„ November X, 1992 The type of petision for which I am applying is (check only one): x Regular Pension based on years of service - Job-connected Disability Pension Pion-job-connected Disability Pension My spouse's name is: Dependent children under the age of 18 and residing in my household are: (Print Child's Full Name) (Child's Date of Birth) 1 hereby certify all of the above to be true and correct: { i nature) September 18, 1992 (Date) (Notary P lie), ' I401•ARY PU8LIC. STATE OF FLORIDA, MY CUMro""ON EXPIRES; JULY 11. iggq• MONDEO TMRU NOTAni PUBLIC 17N4[RWRITKRI,. CITY OF CLEARWATER GENERAL EMPLOYEES' PENSION PLAN OPTIONS - POLICE OFFICERS < OPTION #1: Employees can receive a lump sum payment for ' vacation and holiday pay and 1/2 of accrtied sick leave at the time- of separation from the City. There will be no 8% deduction for pension from this lump sutra payment nor will this amount count as earnings in the calculation of the pension. The last day of work will be the termination date and pension benefits will begin the' following day. OPTION #2: Employee can extend termination date by the time due for (Only available to vacation, holiday pay, and 1/2 of accrued sick leave. employees hired Termination date will be the final day of extended time. prior to 10/1/90) Pension benefits will begin the following day. OPTION '#3:' Employees can split their accumulated sick time ' at (Only available 'to 'one-quarter pay and one-quarter early retirement time. That employees hired portion received as one-quarter pay will not have 8% prior to 10/1/90) deducted for pension nor will it count as earnings in the calculation of the pension. The • portion applied toward early retirement' time will be subject to the Sao pension deduction and will count as earnings for, pension calculations. Termination date will be the final day of extended time; pension benefits will begin the following day, Richard D. McManus an employee of the City of Clearwater, hereby apply for pension benefits under the General Employees' Pension Plan. I hereby certify that I fully,, understand the three options offered to me. I choose to retire using Option # 2 and wish my benefits to be calculated under this option. irrevocable. I understand that once this form is signed, my decision , ' l ' S SIGNATURE:_ EMPLOYEE SOCIAL SECURITY 262,-84-8711 WITNESSES; ADDRESS: 3600 Magnolia Ridge Circle, Unit: 8 Palm Harbor, FL 34684 September 18, 1992 DATE: _ :I _, CLEARWATER CITY COMMISSION 6A ?.? Agenda Cover Memorandum Item N ?nti?1TEA.Trustees of the Employees' Pension Fund Meeting hate: 1112192 Subject: Pension(s) To Be Granted Recommendation/Motion: Arthur Carpentieri, Firefighter, Fire Department, be granted a job-connected disability pension under Section(s) 26.35 of the Employees' , Pension Plan as recommended by the Pension Advisory Committee. ? and that the appropriate officials be authorized to execute same. BACKGROUND: Arthur Carpentieri, Firefighter, Fire Department, was employed by the City as a Firefighter on October 16, 1963, and began participating in the Employees' Pension Plan on that date. In October, 1991. Mr. Carpentieri applied for a regular pension based on twenty-eight (28) years of service. With his application for pension, Mr. Carpentieri exercised his option to extend his retirement state by the use of vacation and one-half of his accumulated sick leave. That request was approved by the Pension Advisory Committee (PAC) and the Trustees, resulting in a pension benefit of 70% (28 yrs. x 2 115 percent) of his last five years' average salary of $32,917 annually or 'approximately $23,042 per year. While using his vacation benefits and prior to this extended retirement date. Mr. Carpentieri suffered a heart attack. In January, 1992, Mr. Ed Hooper, President of the IAFF, appeared before the PAC as a representative of Mr. Carpentieri to ask that the regular pension be changed to a job-connected disability pension based on provisions of Chapter 112, Florida Statutes, which provides that disabilities due to heart disease, hypertension, or tuberculosis are presumed to be job-related for Firefighters. The PAC was receptive to that request; however, they advised Mr. Hooper that the employee would need to submit two letters in support of the disability (pursuant to the PAC Policies & Procedures Manual). In February, 1992, an informational agenda item was submitted to the Trustees to advise them that Mr. Carpentieri would be requesting a change from regular pension to job-connected disability. Mr. Carpentieri has submitted letters from Dr. Marshal DeSantis, dated February 13, 1992, and Dr. Akshay Desai, dated February 10, 1992, in support of his request for a job-connected disability pension, The PAC approved Mr. Carpentieri's request at its meeting of September 16, 1992. Based on an average salary of approximately $32,917 over the past five years and the seventy-five percent (75%) minimum disability benefit, Mr. Carpentieri's pension will approximate $24,688 annually. Charts frorn Finance which take into consideration mortality rates and age reflect that the Reviewed by: Legal 113- . Purchasing AIA- Risk Mgmt. jVA DIS VA-- ACM _.?y'-R/?'? 0 -- Other 41& Submitted by: City Manager Originating Dept.• Costs:,, a- Commission Action: Human Resources Total ? Approved ? Approved wlconditions User Dept.: ? Denied Current FY ? Continued to: _ Advertised: Date: Paper: 9 Not required Affected parties ? Notified ® Not required Funding Source: ? Capt. Imp. ? Operating ? Other Appropriation Code: Attachments: Letter(s) ? None Page. 2. Arthur Carpentierl Agenda, Item November 2, 1992 "present value cost of financing" this pension will be approximately $221,777. Mr. Carpentieri has no dependent children under the age of 18. This situation, while seemingly incidental in terms of cost (the difference, between the regular pension and a job-connected 'disability pension for Mr. Carpentieri is but $1646 annually), raises a major issue that may have considerable cost impact to the Pension Plan in the future. The, issue is whdther a Firefighter has to be incapacitated while on active duty to have the "presumption law" apply. The employee in this case had retired from active duty status but remained on the payroll through the use of accrued vacation and sick leave benefits and, during the time of use of the extended benefits. suffered a heart, attack. The same question' could conceivably -be raised for a Firefighter who retires, has his last "active" day of work, uses all extended leave benefits, has a formal retirement date, and thereafter suffers a heart attack. At the 9/28/92, Trustees' meeting, City staff recommended deferral of this item so a legal opinion could be obtained as to the applicability of the Firefighter line-of-duty 'injury presumption as it relates to the situation of Arthur Carpentieri. Deborah Crumbley of the law firm of Thompson, Sizemore & Gonzalez has rendered an opinion (copy attached) which relates that the presumption should not be applied in this case. The basis of that opinion is Mr. Carpentieri was not . in "active service" 'and appropriately is classified as a "retired" Firefighter. Mr. Carpentieri had signed a resignation and had exercised an option made available to employees at retirement to utilize vacation leave and one-half of accrued, unused sick leave to extend the date between their last day of actual service and removal from payroll. Alternatively, the employee could have exercised the option to be paid in a lump sum for his accrued vacation leave and one-half of his unused sick leave. Staff recommends that this item be remanded to the Pension Advisory Committee with a copy of the legal opinion of Deborah Crumbley, Esq., relating to the Applicability of Chapter 175 Presumption to Retired Firefighters. 77 LAW OfrICES ' THOMPsON, SIZEXORE 8c GONZALEZ JAM CS M, CRAIG • "OrCSWCHALA1ISOGIATION Ui 12 i aCBORAH S. C RU MOLCY u I THOMAS H. GONZALEZ Iou NORTH ERUSM STRSLT.SUITF 200 ROMP$,Y, oR611Nc POST orifice Box 830 MARK A.HANL[Y TAMPA,FLORIOA 33601 GREGORY A. HEARING 44131 273.0050 WILLIAM IC.312EMOFfr rAx NO. 18131 273.007;, ?????*? HARRISON C.THOMPSON.JR. October 8, 1992 OCT l z 1992 City Manager Kathy Ride, Deputy City Manager City of Clearwater Post Office Box 4748 Clearwater, Florida 34618-4748 Re: Applicability of Chapter 175 Presumption to Retired Firefighters Dear Mrs. Race: Referencing our conversation of September 28, 1992, set forth below is our opinion with regard to the potential applicability. of the firefighter line of duty injury presumption contained in Section 175.231, la. Stat. (3992), as it relates to a retired firefighter. Factually, as I understand it, Arthur Carpentieri was . employed by the City of Clearwater as a firefighter for 28 years. In October, 1991, Mr. Carpentieri retired from the City. While exercising his option to use up accrued vacation time in accordance with the Employees' Pension Plan Options form for Firefighters in the Pension Advisory Committee Policies and Procedures Manual, Mr. Carpentieri suffered a heart attack. Mr. Carpentieri now seeks a conversion from a regular pension to a line of duty disability pension, citing in support the firefighter presumption contained in Section 175.231, Florida Statutes. The PAC approved that request on September 16, 1992. The issue is now pending before the Trustees. The issue raised is whether this presumption applies to a firefighter who has already retired from city service. The presumption in question, Section 175.231, provides in relevant part: Any condition or impairment of health of a firefighter caused by . . . heart disease resulting in total or partial disability or death shall be presumed to have been accidental and suffered in the line of duty unless the contrary is shown by competent evidence, provided, such firefighter shall have successfully passed a physical Kathy Rice,, Deputy City' Manager City of Clearwater ?, . October 8, 1992 Page 2 examination before entering into such service, which examination failed to. reveal , any evidence of such condition. . 5175.231, Fla. Stat. The definition of firefighter within Chapter 175 for purposes of applying this presumption is "any person employed solely in a constituted firs department of any municipality, . . .,who is certified as a firefighter as a condition of employment in accordance with the provisions of x.633.35 and whose duty it is'to extinguish fires, to protect the life, and to protect the' property." 5175.032, Fla. Stat. Unfortunately, there are no cases which address this particular issue 'under'Chapter 175, Fla. Stat. of particular. interest, however, is a comparable ."presumption" contained in 5112.18, Fla. Stat., which provides in relevant part that a: ...condition or impairment of health of anv Florida municipal fireman caused by . . . heart disease, resulting in total or 'partial disability or death shall be presumed to have been accidental and to have been suffered in the line of duty unless the contrary is shown by competent evidence. Like Chapter 175, Chapter 112 also contains a definition of "firefighter:" The Chapter 112 definition, contained in 5122.191(1)(b) is very similar to that contained in Chapter 175. It defines the term "firefighter" as: any full-time duly employed uniformed firefighter employed by an employer, whose ..primary duty is the prevention and the extinguishing of fires, the protection of life and property therefrom, the enforcement of municipal, county, and state fire prevention codes, as well as the enforcement of any law ?'. pertaining to the prevention and the control of fires, who is certified ? , pursuant to s.633.35, and who is a member of a duly ' constituted fire department of such employer, and not a volunteer fireman. 51.12.191(1)(b), Fla. Stat. ¦ r Kathy Rice,. Deputy City Manager • City of Clearwater j; October 81 1992 Page-3 ' I ' The reason we bring up the. Chapter 112 presumption -and definition is that there is a cae directly on point under the Chapter 112 presumption which, in the absence of conflicting authority under Chapter 175, is instructive regarding- the likely court holding•in this situation. More specifically, in Smith v. City of Miami, 552, So.2d -245 (Fla. 1st DCA 19,89) (copy enclosed), the 5112.18(1) presumption was held in a workers, compensation appeal to not apply to a retired firefighter, In Smith, a retired firefighter suffered'a heart attack 15 months following retirement, claimed disability due to heart disease and sought workers' 'compensation benefits. The court held that the plain meaning of the words "any duly employed uniformed fireman" contained under Chapter 112 was that the fireman "must be in active service." Smith at 246. That same rationale, we believe, would.apply to the Chapter 175 presumption since the definitions and issues are very similar. That being the case, it would be our opinion that the presumption should not be applied to retired firefighters. While you have the obvious issue of whether Mr. Carpentieri had retired because he was using vacation time, it appears from the facts given that his active service had ended. We therefore believe he is appropriately classified as a "retired" firefighter. obviously, this case could have significant cost implications for the City in that firefighters who separated from City service and who later. suffer some type of disease to which the presumption applies could attempt to come back against the City months or even years later for workers' compensation, disability pension and the like. The City would then bear the burden of overcoming the presumption, which is not always an easy task. I hope you find this letter responsive to your concerns. If we can be of any further assistance, please do not hesitate to give me a call. With kind regards, I remain, Very truly yours, Deborah S. Crumbley ?. DSC/jmh cc: H.M. Laursen r r 1, 1 P*tWAnN OSP&Mmont i , 482x8870 C I T Y OF CL E A R W A-T E R POST OFFICE BOX 4749 CLEARWATER. FLORIDA 34618.4749 TO, Honorable Mayor and Members of the City Commission as Trustees of the Employees' Pension Plan FROM: Pension Advisory Committee COPIES: Arthur Carpentieri; Risk Management; Dan Deignan, Assistant Director of Administrative Services/Finance Director; Employee's File SUBJECT: Pension for Arthur Carpentieri---Job-Conn ected Disability Pension DATE: September 16, 1992 The Pension Advisory Committee (PAC) received a request from Arthur Carpentieri on September '2. 1992, to change his regular pension to a job-connected disability pension. Mr. Carpentieri has been determined by the Pension, Advisory Committee to meet the requirements of the Pension Plan for a job-connected disability pension. He was employed by the City on Octobcr 16, 1963, and began participating in the Pension Plan on October 16, 1963. Further, he has submitted medical documentation, copies . of which are attached, relative -to his disability which has been reviewed and approved by the PAC. By motion made and duly carried at its meeting of September 16, 1992, the Pension Advisory Committee approved/recommended the granting of a job-connected disability pension to Mr. Carpentieri in accordance with provisions of Section 26.35 of the City Code. This pension is to be effective August 31, 1992, at the end of the day. The amount of Mr. Carpentieri's pension will be calculated by the Finance Department according to the formula in the Pension Plan for job-connnected disability pension at such time as his last live years of service and salary can be computed. I hereby certify -that the Pension Advisory Committee has approved the granting of a job-connected disability pension for Arthur Carpentieri and the above dates are correct. /airman, Pension Advisory Committee V a "Equal Employment. and Affirmative Action Employer" F Ir 4. ' 1 t S?/S',1 ?4..?1^;ri,?f?'`;.''l?".1:•l't1JY~,..,?.cM1'.y ".i'r'??ir?d:`d.S .jrt • .. ..! ?'??%?t?.S?'-..s,a"1:o?.tt??S`;:.?•?:ri:.?iL9 (?.•°a}?:. St At. i:', .. s?M1S=;: ;?.... r•:1'.- .....r ti'', .. i.'?? 'f?.. ... ',5?. ,. .. .. ' 1,: .»c ,. ,... n,o s>•c.i•.:'- M.D. ESFANDIAR SHAFII, t .. _ MARSHALL, DESANTIS, M.D. ' RA,YNiOND S. WATERS, M.D. FOUR COLUMBIA DRIVE 14100 FIVAY ROAD SUITE 830. SUITE 300 TAMPA, FLORIDA 33606 HUDSON. FLORIDA 34667 ' 18131 251.0526 16131 889-7497 FAX t8131 254-4697 FAX 18131 869.7156 February 13, 1992 C E • . RE: ARTHUR CARPENTERI 016-26-5816 io Whom It May Concern: Please be advised that I performed' triple vessel coronary artery bypass on Mr. Carpenteri at the Bayonet Point Hospital-on 11/19/91 for a severe left main stenosis. His conva- lescence has been satisfactory, but both his cardiologist (Dr. D esai) and myself feel 'he is unsuitable for ful.l'time employment. Returning to work as a firefighter may Jeopardize his recovery and could result in irreparable harm. If you have-any questions or if'I may be of further assistance, please. do not hesitate ..to contact me personally. Sincerely, ill ?.? ???-Q.- '?.? •:,...? S ..S-? , , .Marshall. DeSantis, M.D. MDS/klo cc: A. Desai, M.D. , GULF CARDIOLOGY. ASSOCIATES v litttsz r?afilm, ?(•?., • r?fcate?o 9. ' ul df.i, .-M-5b, -CP.,4. • ?rt?a? 56. 2,,,,,, dA.2?. 5326 GULF DRIVE, SUITE 1 14100 FIVAY RD., SUITE 110 NEW PORT RICHEY, FL 34652. HUDSON, FL 34667-1481 (813) 848-3381 • (813) 847-3002 (813) 862-8383 Febuary- 10, 1992 To Whom it May Concern, Mr, Arthur'Carpentieri is a patient under my care for' coronary artery disease and unstable angina. On November 18, 1991, Mr. Carpentieri had a cardiac catheterization done at HCA Bayonet Point Hospital which showed severe left main and severe.right coronary artery disease.- Mr. 'Carpentieri then had triple coronary artery bypass, grafts performed on November 19,.'1991, involving the left internal mammary artery to the anterior descending and rev_ . ersed saphenous vein grafts to the high obtuse marginal (ramus) and to the distal right coronary artery. I do not believe that Mr. Carpentieri would be able to perform his duties as a firefighter at this time, *The en- vironment he would have to be in would be harmful to'his health. If you have any questions regarding Mr. Carpentieri please don't hesitate to contact me'. Sincerely, Akshay Des-9?1, M. D . S4At?? CLEARWATER CITYCOQIrMISSION Agenda Cover Memorandum item 0 ? . ;? 11/2192 Trustees of the Employees' Pension Fund Meeting Date: Subject: Pension To Be Granted Recommendation/Motion: Shirley Mobley, Recreation Leader, Parks & Recreation Department, be granted a job-connected disability pension under Scction(s) 26.35 of the Employees' Pension flan as recommended by the Pension Advisory Committee, ? and that the appropriate officials be authorized to execute same. BACKGROUND: NA-M Shirley A4obley, Recreation Leader, Parks & Recreation Department, was employed by the City on January 9, 1970. She began participating in the Pension Plan on May 29, 1978, when her position was converted to full-time status. She has a back problem which resulted in her application for a job-connected disability pension. Ms. Mobley submitted letters from Dr. Cynthia Huffman (dated August 3, 1992), Dr. James Rivcnbark (dated July 15, 1992) and Dr. David Scales (dated June 17, 1992) in support of her request for a job-connected dis ability pension. The letter from Dr. Scales states that Ms. Mobley has a "lesion in your lumbosacral spinal region giving you the symptoms in an L5 distribution in both legs... Limitations on your activity would be to refrain from lifting 10 to 15 pounds. You will probably continue to have a great deal of exacerbation of your pain by your present job in which you push, pull, and lift heavy cleaning equipment.", The letter from Dr. Rivenbark states "she indeed did have injury to her back occurring on the job on 09/06/90." The letter from Dr. Huffman states that she "sustained a back injury 9-6-90...I concur with Dr. Scales that the patient sustained a job injury 9-6-90 that has led to her continued right leg pain and weakness. She should not lift more than 10 or 15 pounds." Ms. Mobley also was sent for an independent medical examination (IME) by the Pension Advisory Committee, The IME report from Dr. William Greenberg states "....I feel this patient does not represent an individual who is totally disabled, and could be handling a sedentary type of position...I do not feel she should be outside, should not be moving heavy furniture, heavy lifting, limited bending...This limitation is solely based upon subjective pain complaints and partly related to...symptoms she dates back to the job related injury two years ago." Ms. Mobley's disability pension was approved by the Pension Advisory Committee at its meeting of October 21, 1992. Based on an average salary of approximately $19,175 over the past five years and the seventy-five percent (75%) minimum disability benefit, M s. Mobley's pension will approximate $14,382 annually. Charts from Finance which take into consideration mortality rates and age reflect the "present value cost of Fin ancing" this pension will be approximat ely $170,401. Reviewed by: Legal A- f? sudg l _ Budget , N Purchasing 1 Risk Mgmt. 1JA- DIS ___--d1_ ACM L? , Other?? Submitted by: City Manager Originating Dept.: t' Costs: Human Res?iri ccs User Dept.: Advertised: Date: Paper: K Not required Affected parties 1-1 Notified Vi-Not required Total Current FY Funding Source: Capt. Imp. ? Operating ? Other- Appropriation Code: Commission Action: C) Approved Approved w/conditions [.J Denied L_l Continued to: Attachments: ? None Letter(s) Request Form h. xl 1 r r Ill.`s.. r. 5 - C' I T Y O F C L E A R W A T- F R POSY OFFICE Box 4740 CCEARWATER, FLORIDA 3461B-4740 Personnel Depsnmenl 462.8870 Honorable Mayor and Members of the City Commission as Trustees of the, Employees' Pension Plan FROM: Pension Advisory" Committee COPIES; Shirley Mobley; Risk Management; Dan Dcignan, Assistant Director of Administrative Services/Finance Director; Employee's File SUBJEC'T': Pension for Shirley Mobley---Job-Connected Disability Pension DATE: October 21,' 1992 The Pension Advisory Committee (PAC) received an application for disability pension from Shirley Mobley on August 18, 1992. Ms. Mobley has been determined by the Pension Advisory Committee to meet the requirements of the Pension Plan for a job-connected disability pension. She was employed by the City on October 9, 1970, and began participating in the Pension Plan on May 29, 1978. Further, she has submitted medical documentation, copies of which arc attached, relative to her disability which has been reviewed and approved by the PAC. By. motion made and duly carried at its meeting of October 21, 1992, the Pension Advisory Committee approved/recommended the granting of a job-connected disability pension to Ms. Mobley in accordance with provisions of Section 26.35 of the City Code. This pension is to be effective on a date to be determined. The amount of Ms. Mobley's pension will be calculated by the Finance Department according to the formula in the Pension. Plan for job-connnected disability pension at such time as her last five years of service and salary can be computed. 1 hereby certify that the Pension Advisory Committee has approved the granting of a job-connected disability pension for Shirley Mobley and the above dates are correct. r I Al GV , (. Chairman, Pension Advisory Committee rtiTZ i "Equal Employment and Affirmative Action Employer'' ¦ f PENSION REQUEST. FORM ' I Shirley Mobley ' 'do hereby' apply for retirement from the City of Clearwater General Employers' Pension Flan. r' May 29, 1978 r' My benefits date is (Entry date into pension plan) October 9, 1970 ' My date of hire is My birthday is October 12, 1944 Recreation Leader My job' classification is and 'I work the Parks & Recreation , Depatrtrtient, Recreation D i v i s i o n . M y resignation date is„ to be determined The type of pension for which I am applying is (check only one):.. Regular Pension based on years. of service • x Job-connected Disability Pension Non-lob-connected . Disability Pension My spouse's name is: Roman Mobley Dependent children under the age of 18 and residing in my household are: (Print Child's Full Name) (Child's Date of Binh) I hereby certify all of the above to be true and correct: MA ?,V, A (Signature August 11, 1.992 G!LV? t ?n ? -August (Notary Public) FE.ORID? ,JGJr''rtY Ft))1L1C SiExV ATE j.24,1944 m U1nn IS :VRO iG i1LS. 1110. I 1 0 " CITY OF CLEARWATER GENERAL EMPLOYEES' PENSION PLAN ,OPTIONS - GENERAL EMPLOYEES OPTION #1: Employees can receive a lump sum payment for vacation and holiday pay and 112 of accrued sick leave at the time of separation from the City. There, will be no 8% deduction for pension, from this lump sum' payment nor will this • amount count as earnings in the calculation of the pension. The last day of work will be the termination date and pension benefits will begin the' following day. OPTION #2: Employee can extend termination date by the time due (Only , available to for vacation, holiday pay, and 1{2 of accrued sick leave. employees hired Termination date will be the final day of extended time, prior to '1011190) Pension benefits will begin the following, day. ************A.************ IShirley Mobley an employee of the City of Clearwater, hereby apply for pension benefits under the General Employees' Pension Plan. I hereby certify that I fully understand the two options offered to me. I choose to retire using Option # and wish my benefits to be calculated under this option. I understand that once this form is signed, my decis' n is irrevocable., EMPLOYEE'S SIGNATURE:- 'SOCIAL SECURITY #s 267--82-3958 VV MsES; ADD g;- 1004 Palmetto Street: Clearwater, FL 34615-4231 DATE:'- August 18, 1992 • I I WILLIAM R. GREENBERG, M.D., PA, OCI A 2 tM IMICAL NEUROLOGY 1, ' f 1 5425 PARK OTSM NORTH, 8Ut= 4w ET. PETER SOUR4. FLORIDA 33709 {5131 a4S-2203 5347 MAIN STREW SUITE 102 NEW PORT RLCHE% FLORIDA 34682 (513) 645-75" October 5, 1992 Advisory Committee c/o H. Michael Larsen. Human Resources Director City of Clearwater P.O. Box 4748 Clearwater, Florida 34618 Dear Sir: Re: Shirley Mobley Social Security.No.: 267-82-3958 The above patient was seen in the office today for an independent medical examination. - A history was obtained from the patient, partial medical records were available for review. Ms. Mobley is a 47 year old Black female, right-handed, with a chief complaint of back and leg pain. She also carries the diagnosis of systemic lupus, being followed by Dr. Wasson at the Diagnostic Clinic. For the latter disease she is currently taking Prednisone 2.5 mg a day, also Carafate, Tagamet, Ubrium, and Tylenol #3. Shefrelates a job-related injury in September 1990, where she injured the right leg. The pain went from the heel toward the hip, lower back. She was seen at a local walk-in clinic, then by orthopedic surgeon Patrick Logue. He initially saw her on September 24, underwent an epidural steroid injection with no improvement. A CT scan on October 11, 1990, was reported as not showing evidence for a herniated disk; noted as calcification in the abdominal aorta, these were also seen on the pain spine films which were reviewed today. Dr. Logue felt the patient could return to her regular job in December 1990. I do not have full medical records. but she was seen by neurologist Michael Andriola in September 1991; he felt she could be working a 20-30 hour work week. He brought up the subject of a sleep disturbance and placed her on Amitriptyline, but I'm not sure if she ever actually took this medication. I City of Clearwater Re: Shirley Mobley October 5, 1992 Page 2 She has been followed in the clinic by a rheumatologist Wasson, also by neurologist David Seals, and.a second opinion from a Dr Huffman. Dr. Seals saw the patient in May 1991, he performed electrodiagnostic studies; I do not have the reports. There was mention of a prior MRI which was not available for review, eventually he proceeded with a myelogram and CT. scan which were reviewed today. There is evidence for spinal stenosis due to a combination of a bulging disk at L3-4, ligament hypertrophy. At L5-S1 there is difficulty seeing the S1 nerve root, there is no evidence for a herniation of a disk. In one of,the follow-up notes there is mention of an abnormality involving L5. She was seen by the orthopedic surgeon Douglas Weiland who' recommended surgery, the patient has been concerned over this as it may cause a flaraup of her lupus. At the present time, the patient is employed by the City of Clearwater and the Recreation and Park Department. Her job entails some heavy activities of being with the children, she has tried not to be outside due to the exposure to the sun aggravating the lupus. She has problems in sitting for more than ten minutes, walking, laying down gives her some relief. In general, upon awakening in the morning she has pains, difficulties getting out of bed. The pain is mostly centered in the back, radiating down the right leg, although there is also pain in the left. Some days are better than others, and she can move around. Upon walking she describes cramps involving the right leg, pain from the heel up toward the buttocks and into the back. This also occurs after sitting, and she is limited to ten minutes. She has problems in finding a comfortable position in bed. In listening to this patient, there have been problems with sleeping, both staying asleep as well as awakening and difficulties failing back asleep. This has been going on for approximately two years. There has also been a sense of numbness of late Involving the feet, and some tingling in the hands. She describes muscle aching involving the legs, once more more on the right than the left, some neck pain, upper arm discomfort as well. There have been no troub!e in swallowing, chewing. She dascribes headaches which stress has a relationship to, these have been noted in the past and she had a CT scan done a couple of years ago for frontal headaches. She denies any TIA like symptomatology, no history of strokes. Her lupus has been under pretty good control, she has cardlomegaly on her chest x-ray, the aforementioned calcification in the aorta. In the past she's had C- sections, renal stones. She has been a cigarette smoker. On exam today the patient is in mild distress, during some of the exam portions she became quite tearful. She is alert, has grossly normal mental status testing and speech function. Cranial nerves 2-12 are intact. City of Clearwater Re: Shirley Mobley October 5, 1992 Page 3 The neck is supple with normal range of motion, shoulder range of motion is normal. There is no pronator drift, there is normal tone and no tremor. On muscle testing of the upper extremities, there is no focal weakness. The muscle stretch reflexes are symmetrical,' there is a mild diminishment to pinprick and touch distally in a glove distribution; position and vibratory are intact. The patient sits uncomfortably, she is able to ambulate down the hallway with marked favoring of the right leg. She complains of severe pains around the hip,. gluteal region, and explains that's why she has to limp. There is a limitation for forward flexion to 700, retroflexion to 5°; upon lateral rotation she complains of severe pains in the back into the buttocks. She has problems in walking on her toes and heels dire to pain, a Romberg is not present. Laying flat in bed, she gets comfortable; there is marked pain reproduction upon palpating along the posterior compartment over the soleus, gastrocnemius muscles, and over the hamstrings, left and right. Bringing the knee up toward.the abdomen she complains of pain involving the hamstrings, and on straight leg raising once more the discomfort is more involving the hamstrings rather than the lower back. There is tenderness over the paraspinal muscles, but it appears today the hip region which is quite tender, and hamstrings dominate. Muscle testing shows give-away strength distally involving the ankle, toe dorsiflexors and plantar flexors on the right. The knee jerks are 2+ symmetrical, I am able to obtain ankle jerks though they are only 1 +, the toes are plantar flexor. On sensory exam, there is a stocking diminishment to pinprick and light touch, cold. Position sense is mildly diminished bilaterally, vibratory sensation is felt on the left ankle but not on the right until the hip. There is no spinal tenderness present. The peripheral pulses are intact. The remainder of the exam is without abnormality. In summary, this patient has a combination of factors involving her lower back pain. Based upon the anatomical studies there is an element of spinal stenosis, and posslb!e nenee root irldtation on the EMG. The oiriieulties encountered are looking at the patient's clinical symptomatology and overall presentation. Based upon the history obtained, she sustained a mild stretching type injury involving the leg, by the exam today there are continued musculoskeletal problems, and I believe they dominate the clinical situation of pain. I questioned her regarding heat and there is some relief which would substantiate a muscle etiology. Some of the pain she describes would fit into a diagnosis of a lumbar spinal stenosis, one problem is the significant pains she constantly experiences involving the back while sitting, moving about which would be out of proportion to be expected with spinal stenosis. City of Clearwater Re: Shirley Mobley October 5, 1992. Page 4. Other considerations in her condition are the possibility of vascular disease, as f . there Is significant calcification on' her abdominal aorta, and the other major problem which. I feel has been passed over is her depression. This patient has sleep disturbances, symptomatology consistent with depression, and this would have a major feedback into the muscle pain,' continued discomfort and limitations she describes. I specifically questioned regarding future plans if she becomes totally disabled. She would like to care for her elderly mother and mother-in-law. When questioned regarding how much activity she would be doing, for example, around the.house, she stated she would sit and taik mostly, though there Is the mention on the patient's part she can only sit for ten minutes. Another consideration regarding symptomatology is a peripheral neuropathy, secondary to the lupus and any type of patient with this type of disease and overall presentation has to be carefully selected from a surgical standpoint. I'm not sure surgery would relieve this patient's.symptomatology and improve her life style. At this point, l feel this patient does not represent an individual who is totally disabled, and could be handling a sedentary type of position. The latter would involve being able to make frequent changes of position from sitting, walking about as necessary, but should be able to handle a 40-hour work week. I do not feel she should be outside, should not be moving heavy furniture, heavy lifting, limited bending. This limitation is solely based upon subjective pain complaints and partly related to the lupus manifestations and to symptoms she dates back to the job related injury two years ago. Sincerely, W ??" . William, S. Greenberg, LD. WRGJmfm r i 1 S i : AiNUT14' VOLOGY Maria M, dt"T. M 0. J %m Am J. Led. M D. " ftom A. Lewlnm, M Ck Andew PlAws. M.D. Jonathan IL R6dk1. M D, CARMVASCULAR AND I THUnACIC 300CAY I H. ONO" CamP4M. M 0. DIAGNOSTIC CLINIC DVWAUXOGY Fred :04iinmen..O, August 3, 1992 Ltnda J. Ldkye. M 0. • . i W"am 0, wwd. M Q i FAMILY PRACTICE Jan" E 40 11. M.D. ' GCKML ANo VASCULAR SURGERY Randal 0. Cook. MD. Janwe T. 066 M.0. AeNwd E. Nana,, HID. IMTM AL MEDICINE 'K Grrvr ftwm , AL D. Vast Y. Een, M.O. Re DWW I>, marve nthalr. M Q Shwm At Ode11, ALD. &vwn S. nftralda, M O, James F. Wwebak, W. M.D. P~ H. Shoal. M.O. 1 Mich" J. Thwmwn. M.D. S FbChWd F. Tlmnttna, M O. b L"Eriew mMo. a Jaws & vxkm a. M o. WTZMAL MEEe0F [ J ' cc CAROMOOT ' Fadwm E Lwu, M 0, or W. Mam n M O. We Jerhey & Sager. M 0. Sura»n 0. Tw%w. M 0. $ WTEFLKAL MEDIC1N[ A DMWA iNOLOGY Milian P. CrmrL M O, WTERIIAL MEDICINE 1 GASTROENTEROLOGY ' Dnse A saiwr. M D. J0900 X. Whtawn, M 0 WTEANAL It CEMATFSC z M[oeft Cynenia A. PNwwd. MD 1 Janst AA SM9. M D. WT CANAL MEDICINE I P NEPRROLOGY Camas Farwa. M 0 toILIMAL MEO C1NE t DAKOLOOY David E Langeae. M D. x INTERNAL. MEOWMf A PULMONARY GIS[JLSES P1 Fewrca J ArwuL M 0. Rwnad E 647-WL M O. t WA1aw J, RldnrdA Jr, M.Q INTERNAL MEDICINE A s RHEUMATOLOCY WMiian M, Wamm M D NEUROLOGY T M.ahw a Evan, AA D. Cynthia Huffman. M.O. oar.d W 5saxs. M O, Off31ETRiC&GYNECOLOOY d Janws E Damn. M D. A~ J. Haar, M 0. JOWM 0. Kwbol. W. M 0. OPHTHALMOLOGY15URGERY i DISORGERS OF THE EYE to..ad M o"AWnt, MD. Jan" A. ftctmta. M 0. ORTHOPEDIC SURGERY O WHOM IT MAY CONCERN:, : Shirley S. Mobley 06-85-50 irley Mobley is a 47 year old woman who sustained a ck injury 9-6-90, Since that time' the patient has ntinued to have radiating right hip and leg, calf and oot pain. Work-up per Drs. Seales, Rivenbark and iland, has revealed, that the patient has central canal tenosis at LS-S1 with amputated nerve root at LS-S1 with acet arthropathy. The patient has been instructed to emit heavy lifting per Dr. Seales' letter of 6-17-92: concur with Dr. Seales that the patient sustained a job njury 9-6-90 that has led to her continued right leg in and weakness. She should not lift more than 10 or 5 pounds. t is possible that surgery could correct the patient's oblem; however, because of the patient's concern egarding her underlying systemic lupus, she has declined urgi.eal treatment at this time. he patient's current condition prevents her from doing er current job. I recommend that she be placed on isability. Uaar o Tofk:'IAO CYNTHIA Gabon zLwndw$w, M D. 01OLARYHOOLDGYI taA1t HOSP X TWAT CH: DU t1a or a. Dawa M D Bnm K. Hoban, M 0. PATHOLOGY Gaaye D. LaWeL M 0. A&rnu nd Not. M D, PEDIATRICS A Fr** Ganes. M 0. A RnWn Marta. M D. Pxkay 1,ulor, MO. Jar'. C. vlvereo M 0. "TIC SURGERY Rabat P. Wcwne. M 0. RADIOLOGY [ DIAGNOSTIC MIAGING AA. Unton Ha ban, M 0. Wkwnw 1Gwnr, M o. Ykq T. Lee. M.o. Hared U. Ajb-n, MD. ;llkoiOGY x UROLOGICAL SURGERY Jam" C. Cad. M 0. &wA A Sony. MD. AOMINISTRAVON Rabwn R O-Pw q ACV ,01111 , M. D. 1551 Went Bay Drive. Largo, Florida 34640 Phone: (8131581.6767 3131 McMullen Booth Road, Clearwater. Floddi 34621 Phone- 1813) 726-8871 501 S. Lincoln Avenue, Suite 12, Clearwater. Florida 34616 Phone: (613) 443-4502 CENTER FOR OUTPATIENT SURGERY 1401 West Day Drive, Largo, Florida 34640 Phone: (8t3)585.9500 i I MUTNEE.OLGQY 141100 M, 131MY, PAD Jor"W A LW M A. Hebert A. Lwrwmm , M D. Andrew pawn, M 0. Jonatrwe 3. Rahn, M 0. CA1101OVABOAAA AND THORACIC 611t1OERy N Charles Campbok M 0. DE1114IATOLOGY fired & 0urhnam M 0, Undo J. Lakyn, M.D. W44M 0. WMd, M O. VAA11LY PRACTICE James F, Lae, R M Q GENERAL AND VASCULAR SURGERY Randall G. Coon. M 0. James T. ENwr M o. lAwllai 1r ?M1', M 9. RITERNAL MC01CM A. Qrenpr DarnorL M D. Taal Y, Erie, M.O. Ohre S. Mmanowr, M 0. Sharon M. Ode". M D. Evgww S. Reynolds. M 0. AMnea P. Rhanbaek. It M.D. Ruben N. ShOba, MA Uhdtl o 1 J. Tbpmpacn, M 0 Rldlard P. Tlmmona. M 0. MI" E Lowno, K &D. Jaen S. Voice" M.D. MtEANAL MEOONO A CAPOM0DY F odor E. Lent M 0. Dormer W. Maw% 111, M D. Jerlrey rs. Soper. M 0 $1*~ D. Two or. MD. INTERNAL MEE„CINE A ENOOCAOJOLDGY • WaaMA P, Gnom, M O. NTEA1rAL MEDI IPhE A OASTROEI.TEROLOGY Drupe A. 0~. M.D. Jgeaprl K W11coan. M D M(TVV"L a GERIATRIC MEDKtNE 4CrAha R A. Pnww* M 0. Jarnna H. Stag. M D. YITEANAL MCDCME E NEPIMOLOGY Gaut" rrule. M 0. INTERNAL MEDICINE a ONCOLOGY Dart/ E. L lmose. M 0. 1WEAHAL MEOKJNE A PIN.A+QNMY DISEASES Frances J. A.rsk M 0. Runald E. EowrL M 0 WAarn J. R1rArda, Jr. M 0. INTERNAL MEOICINE a ra*UMATOLOGY Ytiam M. Wow. M 0. NEUROLOGY MKh" e. EVWW M 0. cymve Hudrnerl. M 0. Dowd M. Karat. M D. de:.TETRICSI GYHECOLCGY Join" E. Dawn. M 0. Aobw1 J.110W. M 0. Joann 0. Kusbr. IN. M 0. OPHWALMOLOGYfSURGERY a OSOMERs OF THE EYE Edward M. Doutwlw. M 0. James A, Roberta. M M ORTHOPEDIC SURGERY wiiaam J. Naar, M.D. Marv D. Taka, M o. Gordon xwmdorIW- MO. OTOLARYNGOLOGYI EAR NOSE A THROAT Goiaw M Dawn. M D. erlan K,11pbw% M 0. PATHOLOGY Geaga o. Lo," M M no r"o-4 Pia. M D. PEDMTRICS A. FranY Comm. M.D. A. Robert Moroll. M 0. Rickey Vw ct. M 0. Jahn G VIM,10. M D. PLASTIC SURGERY Robert P. McCann, M.O. AADIOLOOY 4 DIAGNOSTIC IMAGM M. Union 1Hr bat M 0. Warn Knurr, M.O. YVq T. Lea. M O, Howard D. Ruby M D. UROLOGY & UAOLOGICAL SURGERY Jam" G. Gad, M D. eruct A. Sealy, M 0. ADZIStRATION REV 101{1 ..,. r DIAGNOSTIC CLINIC July 15, 1992 TO WHOM IT 14AY CONCERN: RE: MOBLEY, Shirley S. DC n 0a a50 5I 1004 Palmetto Drive Clearwater, FL 34616 This 47 year old black female has been seen by Dr. Seales and myself concerning back pain. Please see previous letters detailing the nature of her injury, etcetera. Patient came to see me recently requesting documentation on her behalf that indeed her back problems had started while on the job. in reviewing our records, we have been able to ascertain that the patient called the Diagnostic Clinic in 1990 initially to verity that she had injured her back on 09/05/90, and requested to be seen by a physician. She also brings with her to me today a "notice of injury" basically stating that she injured her back on 09/06/90 at 8:30 PM. On May 2, 1991, the patient was first seen by Dr. Seales in consultation. The patient at that time stated to Dr. Seales that she "hurt her back" in September of 1990 while pushing and pulling on chairs and tables at her job as a Recreation Leader while at work. Hopefully the abovc at temeF=ta . and the information obtained from our records at the Diagnostic Clinic will further verify the tact that she indeed did have injury to her back occuring on the. job on 09/06/90. If you should have further questions,, please do not hesitate- to contact me. JAMES F.= IVENBARK, III, M.D. JFR/msv 1551 West Bay Drive, Largo. Florida 34640 Phone: (813) 581-6767 313t McMullen Booth Road. Clearwator, Florida 34621 Phone: (813) 726.8871 501 S. Lincoln Avenue, Suite 12. Claarwaler, Ftanda 34616 Phone: (813) 4434502 CENTER FOR OUTPATIENT SURGERY 1401 West Bay Drive, Largo, Florida 34640 Phone- (613) 585.9500 t -. _... ..1. .. ?•?' .. rya .. ,. ? . .. .. A14 3TMtS10LOGY Moto M. fl wr, M o. Jem.IM J. Leal, M D. Aeebert A. lewnsw. M D. Anpa+l4rKa. A1.D. JIMSMA t & Rsdw% M.0. CARDIOVASCULAR AND THORACIC SURGERY K CAW" Cunpese, M.0. DEIIMATOLOGY • Fred S Owlmorl. M.O. Lid. J. L4*?*. At 0. Wtum 0, ward. M 0. . FAMILY FnAmcit Jema E. L.M. IL M.D. MERAL AMU VXSC11LAR SURGERY RA?dfw a. Cdnw, M b. Junes T. EhNn. M.D. Whoa E. "W"r, M o. INTERNAL MEDICNE R, Otmov Denson. M 0. YAN Y. EFts. hi 0. Mile" 5. MmaeMhaw. M 0. Shoran W Od^ M 0. Eves na & ReYnddlt, M D. Joss F. R,ven&" NL M D. A~ N, Shaft, M.O. Mo:hW J. TROmpbw. M 0. FIWA&d F, Tlmrrxm Y a Mque1 E WwAo. M 0. Jolla S. Yaw:rtK M D. INTERNAL MEDICINE • C>!RL"OLOdr ftaemd E. ltrlt M D. Dams W. Maton• M. M D. Amm s S9964. 44 O. Slsohon b TwM, M 0. BTEPINAL MtVrONE a ENOOCRINOLoGY W,UmP Gvmk)AV. WTERNAL MEOICINE a GASTRCENTEROLOGY atwe A Sch", M D. Jowph P IL WWII.. M 0. INTERNAL & GERIATRIC MEO:CL•.E CT^t-a A. P*gWW , M D. JAIMt H Slog. M o. INTERNAL MEDICINE A NEYHROLOGY Cormels Ferus< M O. PITERNAL MEDICINE A OhCCLOGY Oa"d E. Ldfgaere, M 0. PtTERhAL MEDICINE A PULMONARY DISEASES Fror+c.s J. Awrr4 M 0. rlanad tr Dawns. M 0. wnun J. P,tltsrds. Jr. M D. wITEMNAL MEDICINE a RMEUMATOLOGY WAiun M wasen. M M tfEuROLOGY M4A*0 0. Erani. M D. CTnsn Huhrnan. M 0. 04,,c It, 54s-i. PA 0 O 65 T ET R C5 iGY rI E COL O G Y Jsmrs C Dolan. M 0. Robert J. Henn, M 0, Joteol (J. XI'". in. M 0. OPHTPALIJOLOGYrSURGERY a DISOnDERS OF THE EYE Ed.wd M. Deuiww. M 0. JAmes A. Roberts. M 0 ORTHOPEDIC SURGERY Ylghsm J. Hear, M D. Mora U Tone. PAD aofdon Zuemdort?. M.D. OTOLARYNSOLOGY1 EAR. HOSE a THWAT OathvG Oa.+s.M0. &%An k Hoban. M D. PATHOLOGY Gaape D. La,dsL M.O. Raymond Pool M 0. PEOIATRICS A. Frw* Gomel. M M A. Robyn Masai. MD. RtAeT Vtua, M O. Jahn C. vrverto. M. D. PLASTIC SURGERY Robyn P, N,ccuno. M D. RADIOLOGY a D"uOSTIC IMAGING M. Linton Nerbnr. M.D. YWrW Knun. M D, Yinq T. L M. M D. Howord 6. Ntllm M.D, UROLOGY a VROLOGiCAL suFWAY Junes 0. Cad. M D. Bruce A. Seeley, M D. ADM W ISTRATION Robes R. PPpwv Rev tarsi DIAGNOSTIC 0 CLINIC, June 17, 1992 Ms. Shirley L. Mobley 1004 Palmetto Street Clearwater, Florida 34615 Re: Shirley L. Mobley 08--85-50 Dear Ms, Mobley: It has been my pleasure to work with you over the past few months in assessing your radicular pains in the lower extremities. The offshoot 'of this evaluation is that there is what is, probably a surgically correctable lesion in your lumbasacral spinal region giving you the symptoms in an L5 distribution in both legs, right more than left. In the several consultations with you I have come to agree with and respect your decision, to refrain from surgery because of your complicating factor of lupus. Surgery could indeed be complicated by a flare which might be very disturbing for you. I have discussed with you the fact that if left unrepaired, the problem in your lumbosacral spinal region could lead to ultimately uncorrectable problems with the strength and sensation in your legs. Pain could be a permanent part of your situation. But once again I must respect your decision to decline surgery for the reasons stated abovde. I received a letter from you requesting support for permanent disability. Unfor- unatel r , the precise paperwork is absent at the time that I have finally had a chance to review your chart. I have addressed this letter directly to you to preclude any problems with confidentiality between doctor and patient. You can give this letter to whomever you please. Your permission to share this information with others will thus be implicit in your forwarding of this letter which has been sent directly to you. 1551 West Bay Drive, Lbrgo, Florida 34640 Phone: (813) 561.8767 3131 McMullen Booth Road, Clearwater, Florida 34621 Phone: (813) 726.8871 501 S. Lincoln Avenue. Suite 12. Clearwater. Florida 34616 Phone: (813) 443.4502 CENTER FOR OUTPATIENT SURGERY T40 ( West (lay Drive, Largo, Florrds 34640 Phone: (813) 585.9500 64 i e. r.xs.; i+,r"n?'.jrj ..•i ',s ,t, v , .: K..r ' i { .. .• r.' .. . -2- I i Ms. Shirley L. Mobley Re: Shirley L. Mobley 08-85-50 Limitations on your activity would be to refrain from lifting 10.or 15 pounds. you will probably continue to have a great deal of exacerbation of your pain by your present job in which you push, pull and lift heavy cleaning equipment, as I recall. You may find from time to time that you need bed rest in order to reduce,your symptomatology. Thus; I support your request for full disability at this time. But I remind you also that should the pain or other symptoms, such as weakness and loss. of aensation in your legs, become severe, that you • consider a consultation with Rheumatology to ask the question of whether or not you could be successfully prophylaxed against a lupus flare preparatory to surgery. My overall inclination has been and remains that you have this lesion repaired surgically. If you would wish to add a consultation with Rheumatology here at the Diagnostic Clinic before you complete the paperwork for full disability and proceed with the ever increasing risk of greater pain and weakness in your legs, then please notify my office and I will facilitate this consultation for you. I first saw you on 5-2-91. The level of the. radiculopathy is approximately at L5. It affects the right leg more than the left. If I can be of further help, please contact my office. 1551 Wnt Bey Drive. Largo. Florida 34640 P.O. Box 2901, Largo. FWlde 14640 Phone- 16191 SSI-a767 2454 McMullan Booth Road. Style 407, Ctaamikiel, Florida 94519 Phane: Ia191 7:5-am $01 So. Lincoln Avenue. Suds la Clean.ala, Florida 34818 Phone; IN13144S-4$02 H? • 1r '' fir- 'L ._ .It '.L• r .der; ,...tlrWr.tr4tS?'??',?71r.`.txY».isv'a..;??;fir L...rfry'???L•1 aL;og79 r!Llr .. •, `s.' 4'- •.• ;I.F.I.?.,•f bl• ., -3- Ms . ' Shirley .L. Mobley ' L Re: Shirley L. Mobley 08--85-50 x am absent from the Diagnostic Clinic after 6-30-92. 1 am going into solo practice in North Carolina. 'Your neurological care can be continued here by. the remaining` neurologists at the Diagnostic Clinic. Sincerely yours, 7->L' c David M. Seales, M. D. DMS : DU ' . 1551 W4%t Bay Drive, ts:go, Florida 340411 • P.O. Boa 2401. Largo. Florida 34644 2454 McMulten Booth Road, Suite 403. Voorwalor. Florida 34519 501 So, Lincoln Avenue. Style 12 Cloarwafer. Ftorrde 34616 Ind ? , Phone (6191541.6767 Phenol 16131716.6671 Phone 16131443-4502 FLVIIILIA ULPAll I MI=N I Ut• LAHUH ANU EMPLUr MLN I St%,Ul%l I I DIVISION OF WORKERS' COMPENSATION 1.eOO.342.1741 (or) contad your kraal atfice for assistance NOTICE OF INJURY Report all deaths by telephone or telegraph wilhin 24 Hours. Any person who. knowingly end Wth Intent to trrlure. defrrud of decNw any smptayvw or employer, Insurarxe ctampany of solidnsuned pncgtirn, files a stAfarrrerrf of claim containing any Isis* or n%Jeleadang Inlorrnallon In guilty of a felony of tits thlyd degree. TocomploWandriled ! PART `"'wnhln 7 days of dots of kkntvwao..1:c?e:,?t P1 NAME (First. Middle. Last} Q G?.CIiN?v11 Shirley S. Mobley Port f , ;ee e OCCUPAriON Rnc>rnnt inn Lender 102 Clearwater, FL. 3; HOME ADDRESS llnclude ZIP) 1004 Palmetto Street C1enrwater, FL 346 LS ?Ep f 3 ?g? Do you have a second )a*? 0 YES. ND It yes, er+player name b phone s TELEPHONE IN' t , (EE INFORP4ATION Sod01 5rwrny Number pees and Tim* of Amdent .47-82-3958 9/06/90 8:30 PX -- , EMPLOYEE'S DESCRIPTION OF ACCIDE T waa setting up room Tor next days clans( r 1=h involved pulling tablea and rneks of chair . The next: morai.ng I was having vary ivariorha, pains in back, stomach and lags. DESCRIBE INJURY OR DISEASE AND INDICATE PART OF BODY AFFECTED (e.g. Ampulstwn of right Index iinger at second )vino, fractured ribs, lead polsoning, tits.) w.. Gm% rwe< Lower brick. stomach and legn DATE OF BIRTH SEX EMPLOYEE SIGNATURE (if avaitebte to sgrl 10 12 1 44 ? M xj F Not available for signature pate 9 r1I 190 RMPI.OYSP INPORMATION FIRM'S NAME FEDERAL I.D. NUMBER DATE AND TIME FIRST REPORTED 7• r -,•r City of rlearaanter 5960000289 9/07/94 12:30 MAiLOIG AADOFTESS W C. COVERAGE BY POLICY NUMBER y P.O. Rex 4748 © INSURANCE CO. T-J SELF•INSUREO ? Cl.-at-zr*twnr, FL 34618 ADDRESS, TELEPHONE NAME O WILLYCU CONTINUE T1} MPANY SERVICE C .A f PAY SALARY YES 0 NO 462 6531 GALLAGHER BASSErT SERVICES, INC. IF NO, LAST DAY PAID r r 71.,. M,?.,. A..6 cW. 613 Hr•e.. - 4840 Box P O PLACE OF ACCIDENT (Street. City, County. 5latel . . Clearwater, FL 34 ,161fD-4840 RATE OF PAY 0 HR O WK E;nab tlnttvTe Recreation Center Telephone: {D13) 79$-6929 S77 PEF3 Up 0 MO 1476 G. Greenwood Av_e,? pL ^ Number of hours IW $ LAST OATE EMPLOYEE WOPXEO DATE EMPLOYED NAME, A00FIESS RAND PHONE NUMBER per day 10 90 70 9 L 9 OF PHYSICIAN OR HOSPITAL a Wn lk-In--Clirtie U r Number or bouts 40 r 1 J 1 . r week nETUr+NEO TO WORM U YES x-j NO 2600 US 19 North pe ' Clen water, K1. N t?qf a%a's 5 r IF YES. GIVE DATE I WAS INIURY FATAL? to YES "...I NO WAS ACOVE PHYSICIANWOSPITAL IF YES. GIVE DATE OF DEATH I 1 AUTHORtZEO BY EMPLOYER YES 0 NO AGREE WITH DESCRIPTION OF ACCIDENT? HAS CARRIERrSELF•INSURER NOTIFIED YOU WITHIN THE YEAR THAT SAFETY YES Q NO IF NO EXPLAIN SERVICES ARE AVAILABLE? :13YES [3 NO ?• IP SO, CIO YOU REQUEST THESE SERVICES? )t3 YES 0 NO IF REOU£STEO. 0tO YOU RECEIVE THESE SERVICES? 7b YES n -No I HAVE PROVIDED THE ABOVE EMPLOYEE THEIR COPY OF THIS DID THE EMPLOYEE WILLFULLY REFUSE 710 USE A SAFETY APPLIANCE, OR HAVE NOTICE tj IN PERSON Q 6Y MAIL, PRIOR KNOWLEDGE OF AND WILLFULLY REFUSE TO OBSERVE A SAFETY 1 / STANDARD PROMULGATED BY THE DIVISION? © YES Ej NO /_ f' hf r!, ^ t? t?? j• DID THE EMPLOYEE WILLFULLY REFUSE TO USE A SAFETY APPLIANCE; PROVIDED u _ EIAr'LU( R SIGrilcrURE DAJE BY YOU. THE EMPLOYER? OYES XGr NO Carrier s' Service Co. 0 CIS Location ? 1. Contraverfing Case--reason - - - L) 2. Lost Time C>aso-..Onto of First Paymant 1 I AWW Comp Flole First day of disability I ! -Unto of Ftrxt Contact with Claimant I I ? In Person ? Telephone ? Mail --Notice Filed Due to Multiple Periods of Disability Oates Covered by First Payment f? 3. Medical Only which become a Lost Time Case. First day of disability 1 I Adjuslnr Signrtturu Adjustor Llconse Number _ Dole I I LES rrrnm OWC• t r"F +1+901 EMPLOYER COPY ???rE >l•? CLEARWATER CITY COMMISSION Agenda Cover Memorandums Item Sc Y TEA. Trustees of the Employees' Pension Fund Meeting Date: ?? Subject: Pension To Be Granted Recommendation/Motion: Caleb Winston, Maintenance Worker II, Parks & Recreation Department, be granted a job-connected disability pension under Section(s) 26.35 of the Employees' Pension Plan as recommended by the Pension Advisory Committee. . ? and that tho appropriate officials be authorized to execute same. BACKGROUND: Caleb Winston, Maintenance Worker 11, Parks & Recreation Department, was employed by the City on November 23, 1981, as a permanent part-time Custodial Worker, He began participating in the Pension Plan on August 8, 1984, the date of his promotion to full-time status as a Maintenance Worker i. He has three herniated discs which resulted In his application for a job-connected disability pension. Mr. Winston submitted tellers from Dr. Joseph M. Sena (dated June 29, 1992) andDr. Rosario Musella (dated June 15, 1992, and May 15, 1992) In support of his request for a job-connected disability pension. The letter from Dr. Sena states Mr. Winston's "herniated disc and unresolved cervical strain Is related to his on the job Injury which occurred in January, 1991." The letter from Dr. Musella states that "because of the long standing nature of this patient's symptoms ...It is my opinion that the patient Is mildly partially disabled-with limitations as to bending, squatting, and lifting weights not greater than 20 pounds." Mr. Winston also was sent for an Independent medical examination (IME) by the Pension Advisory Committee. The IME report from Dr. Michael Slomka states "I believe that he does have a permanent physical Impairment...He may not be a candidate for doing heavy manual labor but, certainly, he is not totally disabled from doing any type of work, especially when lifting and bending restrictions can be placed upon him." Mr. Winston's disability pension was approved by the Pension Advisory Committee at Its meeting of October 21, 1992. Based on an average salary of approximately $18,402 over the past five years and the seventy-five percent (75%) minimum disability benefit, Mr. Winston's pension will approximate $13,801 annually. Charts from Finance which take into consideration mortality rates and age reflect the "present value cost of financing" this pension will be approximately $163,582. Staff recommends that this Item be remanded to the Pension Advisory Committee for a more thorough review of the Independent medical examination which Indicates that Mr. Winston has mild degenerative changes, that part of the findings are due to his age and history of heavy labor, and that his well-developed musculature is surprising for an Individual who states he has not been able to exercise normally for the last three years. Reviewed by: Legal ya Budget N /ir Purchasing - OA Risk Mgmt.-AL DIS ACM Other Submitted by: City Manager Originating Dept.: Human Resourc User Dept.- Advertised: Date. Paper: [4 Not required Affected parties ? Notified Cpl Not required Costs: AL4 a Total Current FY Funding Source: Cl Capt. imp. ? Operating I? Other Appropriation Code: Commission Action: IA Approved ? Approved wlcondilions C Denied ? Continued to: Attachments: Letter(s) Request Form None r , • k1lr,rsltle Perownet Department 482.6870 1 C I T Y OF C L E A R W A T E R POST OFFtCB 13OX 4748 CLEARWATER, FLORIDA 34615.4748 TO, Honorable Mayor and Members of the City Commission as Trustees of the Employees' Pension Plan mom. Pension Advisory Committee ' COPIES: Caleb Winston; Risk Management; Dan Deignan, ' Assistant Director of Administrative Services/Finance Director; Employee's File SUBJECT; Pension for Caleb Winston--Job-Connected Disability Pension DATE: October 21, 1992 The Pension Advisory Committee (PAC) received an application, for disability pension from Caleb Winston on June 11, 1992. Mr. Winston has been determined by the Pension Advisory Committee to meet the requirements of the Pension Plan for a job-connected disability pension. He was employed by the City on November. 23, 1981, and began participating in the Pension flan on August 6. 1984, Further, he has submitted medical documentation, copies of which are attached, relative to his disability which has been reviewed and approved by the PAC. By motion made and duly carried at its meeting of October 21, 1992, the Pension Advisory Committee approved/recommended the granting of a job-connected disability pension to Mr. Winston in accordance with provisions of Section 26.35 of the City Code. This pension is to be effective on a date to be determined. The amount of Mr. Winston's pension will be calculated by the Finance Department according to the formula in the Pension Plan for job-connnected disability pension at such time as his last five years of service and salary can be computed. I hereby certify. that the Pension Advisory Committee has approved the granting of a job-connected disability pension 1'or Caleb Winston and the above dates are correct. 1 airman, Pension Advisory Committee ''Equal Employment and Allirmalive Action Employer'' i. PENSION REQUEST FORM L ?4- eb 10. rJ do , hereby apply for retirement from the City of Clearwater General Employces' Pension Plan. My benefits date is 0f4,,,_(Entry date into pension plan) My date of hire is.-- Pi B' 1 ? 11 My birthday is G c 1Q., I 9 4 My ,job classification !$ ry?c 4.? tAt r ke,r A and I. work in the _ 1?oka Department, i2?c Ye Division. My resignation date is_ __'7. r,5C-Z : 2 The type 'of pension for which I am applying is (check only one): Regular Pension based on years of service _,,_ ? Job-connected Disability Pension Non-,fob-connected Disability Pension My spouse's name is; --&I Dependent children under the age of 18 and residing in my household are: --N?- (Print Child's Full Name) (Child's Date of Birth) I hereby certify all of the above to be true and correct: (Sign ture) n ? T (Date) '1 - (Notary Public) NOTARY PUBLIC, STATE OF FLORIDA. MY COMMISSION EXPIRE& Dm 10, 1994. BONDED TNAU NOTARY IWIL1C UNDtRWRMR! CITY OF. CLEARWATER GENERAL EMPLOYEES' PENSION 'PL'AN . OPTIONS GENERAL EMPLOYEES OPTION #1: Employees can receive a lump sure payment for vacation and holiday pay and 1/2 of accrued sick leave at the time of separation from the City. There will be no 8% deduction for 'pension from this lump, sum payment nor will this . amount count' as earnings in the calculation of the pension. The last day of work will be the . termination date and pension benefits will begin the following day. OPTION #2t Employee can extend termination date by the time due (Only available to for vacation, holiday' pay, and 1/2 of accrued sick leave. employees hired Termination date will be the final day of - extended time. prior to 10/1190) Pension benefits will begin the following day, I, F 1\ ,AZ: o-0 ] . an employee of the City of Clearwater, hereby apply for pension benefits under the General Employees' Pension Plan. I hereby certify -that I fully understand the two options offered to me. I choose to retire using Option # and wish ray benefits to be calculated under this option. I understand that once this form is signed. my decision is irrevocable. EMPLOYEE'S SIGNATURE: -•- `?? r -? _._ SOCIAL SECURITY a6 3 ADDRESS' _ 12j DATE: :3(-. <. .r. .. 1. 1a« r+l> .'i'1r.1l!+ ..rr«<...rix•ri`+: a{Y:II'esi f:•;+t'i.%.. ... .. ... _. ,?: r .f'' .'r '• ... r.. - .., .. ,.: i` ,• '.;. Wi ston. Caleb Julie 29, 1992 ; ?;,' ;,s•. ? ; ' _°`'?lE? r ?lit 'eb'`..hae rioted continued eaat neck pain without 'significant ; .• t ;i' ? ?+` ;? ?:?' r did 'omfort. I do eel ghat hirr cIt.agnosis lof hernil d dii .I.; and. unresolved cervic a l strain is related to. thi's' on ; the:: `?•? 3 iota ury vhich occurred in January' of 1991 resultilnd in a ! '? i" ?;? j' ? r twelve percent disability ' patient also Guntained an to the mdy its a whole'. 'One. apparent bac:l; strain as wn-Ij ? ,? j: Ij ' ??'f;•'r .. '.,: ` This patient z current l.imi tatiort., are ,,,a avoid liftihn ;no jT ? r, ?- [,•` ? gr later t are t onf;?r rotind?s and t:c?. avoid excessive t+ending n ti t an(? ,twisting. Joseph M. Sera, M . D .' I ''; 1+ (di ictated but not read) L JmS t kef '1 .r t ;.! i ` 1 1 i t t• r. 1 ( 1 i • i' 1 ''j1 •" 'j"i 1 I' is a ;• f' ir• , ; j ? ? ? ? l : =:' '. ,: 1r1 . -' ??'? 1: i„• - 4 Y' ? j 1 .t•r I ? rr 2 1 1 ? •, r ?'. '• + F+' r?;i ;?. i r' , i ff ?i r 1 ? :Ii iliyl? Ur t? li t f d ?; • ' ,?? ? r r '/Ci1r l e •r7.v ;`,:i4? ..v'•'.: -f .'s :'r?•i..„'t'.?41y;'?t" art, ?is;•r`:'i.,,.... o .. r ,_ , , :.. clQosa-dd c -.4. eMUJZLca, Sv d ., ?P-vq NEUROLOGICAL SURGERY DIPLOMATS AMERICAN 247 COREY AVENUE I BOARD OF ST. PETERSBURG BEACH, FLORIDA 33706.1618 I NEUROLOGICAL SURGERY TELEPHONE (613) 367.4S93 1 I I t. June 15,, 1992 Ms. Nancy Degnor Claims Adjuster City of Clearwater P.O. Box 4748 Clearwater,, FL 34618 RE: Mr. Caleb Winston Claim #: 000149 005437 WC O1' (1679) D/O/I 3/12/91 Dear Ms. Degnor: I have included a corrected copy of page _1- of our evaluation on Mr. Winston dated may 15, 1992. We have made the correction on page one, paragraph two stating that the injury was caused when Mr. Winston was picking up a "garbage can" not ."garbage big"'. We understand that this indication :rust be clarified for the Workman's Comp. Division and regret any delay or confusion that this error in wording may have caused. Thank you. Sincerely, CC: .Joseph M. Sena, M) `,14r. Caleb Winston Annette Cutrufello Office Manager to ,R.A. MUSELLA, MD, FACS, PA } I NEUROLOGICAL SURGERY 01MOMATE AMERICAN 247 COREY AVENUE BOARD or ST. PETERSBURG BEACH, FLORIDA 33706.16113 NCUROLOGICAL SUMISAY TELEPHONE (913) 367.48533 May 15, 1992 Joseph M. Sena, M.D. The Orthopedic Center of West Florida suite 101 9555 Seminole Boulevard Seminole, FL 34642 RE: Caleb Winston Date of Exam: 5/8/92 Dear Dr. Sena: Thank you very much for referring, once again, this 46 year old, right handed, black gentleman-for a further second surgical opinion. As you may recall, the patient was originally seen by me on November 4, 1991. At that time, he gave a history of an injury on the job which occurred in January 1990 when he picked up a garbage can and developed numbness involving both arms associated with constant neck pain radiating to the head. He suffered a second on-the-job injury' on the 12th of March, 1991, when he picked up a load of shells. Following the second injury, the patient was back at work only for one week. He has been incapacitated by severe neck and low back pain despite the administration of appropriate medication and physical therapy. I reviewed an MRI of the cervical spine obtained in April 1991, which I thought revealed evidence of a midline disk herniation at the C4-C5 level as well as disk herniation at the C5-C6 level mostly on the left side. This patient had severe impairment of motion range of cervical and thoracolumbar spine, which were not associated with significant muscle spasm in either the cervical or the thoracolumbar region. Otherwise, his neurological examination was within normal limits. The patient appeared to be overweight. He had a past history of insulin a=pendent diabetes and hypertension. I thought that the patient might have presented with symptoms consistent with unresolved cervical and lumbosacral V Joseph M. Sena, Mt. May 15, 1992 Page 2 RE: Caleb Winston strains and recommended that, for sake of completeness, a CT myelogram could be considered to clarify the diagnosis in a more definitive and objective fashion. The patient returned to my office on the 8th of May, 1992, with virtually the same complaints. He stated that he discussed the possibility of having' a CT myelogram with his family physician but was advised to delgte them in view of the. occurrence of a cardiac arrhythmia#.,,which has developed in the interim. His symptoms are worse, particularly headaches and low back pain associated with pain radiating down' the left leg aggravated by the Yalsalva's maneuver. Neurological examination reveals intact cranial nerves and normal gait with the patient being able to walk on heels and toes without difficulty. Muscle strength is 5/5 throughout, and there is no evidence of muscular atrophy. The stretch reflexes are symmetrical, and there are no pathological reflexes. Coordination is normal. Sensation to pin prick is decreased over the left arm and right forearm and vibration. is still decreased throughout the left arm as well as over the left side of the sternum. Range of motion of cervical spine is as impaired as it was when I originally saw the patient. Range of motion of thoracolumbar spine is also of the same degree as on November 9, 1991. Yet, the patient has no impairment of straight leg raising in either the supine or sitting position bilaterally. It is still my impression that the patient presents with findings consistent with unresolved cervical and lumbosacral strains without evidence of radiculopathy. I do not believe that this patient is a surgical candidate at the present time. Because of the symptoms associated wi it is my opinion that He should be able to basis, for the time squatting, and lifting long standing nature of this patient's th MRI abnoramlities in the cervical spine, the patient is mildly partially disabled. return to work, at least on a part time being with limitations as to bending, weights not greater than 20 pounds. .. , 'til, ` _ °',•p• s r . '4- , ,. . ." 'f '. .. 1 :f, .k,•. ° . • f . I a i; `.' f •°?• ' S r . . ,. n r ' . .. ,i.` ,rk•• . . • , i • • ` ; , . o;j ...J.y fhx rd?'ta F`•1hSt ?,"Y ???#F`j?rla?e'r w.rs+++..i,•-,:+^: •'dt•fYi 1f.., Q'f!rk.,.,- - - . .. ..r. ' i1'{? . r . ,. .. ,. _ .. . .. .?:• .. J ' oseph M.•,•Sena M.S May 15? 1992 Page 3 RE. Caleb Winston In ; my. opinion, the patient, may be . able 'to bene fit from a . ' home exercise program but, probably,'no formal,therapy is.needed. " it is my opinion that the patient's- permanent disability .' rating is 10 percent of,the body as a whole. Please let me know if `I can be offurther assistance with the management 'and/or evaluation !of ".this patient. Thank you, again, for your kind referral. Very truly yours, CAP I „ Rosario A. Musella, MD,'FACS, PA Clinical Associate Professor Department of Surgery University of South Florida (Signed in absence to avoid delay.) RAM/ac 0leor=oz, :S- a ivan, cSfom. a A.12]., _('P c7q, t DERMOT J. O'CONNOR. M.O. DIPLOMATES OF DONALD C. SULLWAN. M.D. r? ?u THE AMERICAN BOARD OF MICHAEL 0.5LOMKA. M.0. o a c f t9Lty ORTHOPEDIC SURGERY HOGAN G. YI. M.D. STEVEN B. WAFIREN. M.b, inE ?Qc -S-UT'elty C4t1It0= 0f1ia Outgcty Please reply to: cS?avrfs c??cc?icLtr ORTHOPEDIC EVALUATION Re: Caleb Winston Our File No.. 03525 D/A: 03/12/90 Caleb Winston was seen and evaluated in my office on August 31, 1992. The patient is a 46-year-old black male who is 611" tall, weighs 225 lb. and is right-handed. He states that he was working as a groundskeeper for the City of Clearwater and that he was injured on March 12 1990. At that time, he was trying to lift a garbage. can that was filled with water halfway and he states that he slipped on the concrete, lost control, and fell to the ground with the garbage can behind him. He had immediate pain at that time and was seen on March 15, 1990, by Dr. Patrick Logue. He was started on physical, therapy and was given pain medication. He had several Cortisone injections into the neck area. He was given Naprosyn and was last seen on March 19, 1991, after about a year of treatment. He was next seen by Dr. Sena who referred him for a MRI scan of the cervical spine. The MRI showed bulges at the C4-C5 and C5-C6 levels. These are bulges or.very small herniations and as a result of this finding the patient was placed on a cervical collar and a TNS unit was prescribed. He was later seen by Dr. DeSousa and had nerve conduction studies done which were somewhat equivocal. He was also seen by Dr. Musella who felt that no surgical intervention was indicated. The patient states that he now hurts in the neck, upper back, lower back, right shoulder and the left shoulder. He states that his pain is increased with standing, walking, bending, increasing activity, lying down and sitting but not with coughing, sneezing or bowel movements. He is most comfortable walking and is uncomfortable bending. He denies previous accidents or injuries, although it is clear from his records, available to me, that he was seen by Dr. Logue on August 2, 1989, for an injury which appears to have been the injury described above, except that this occurred on Jj!j 2, ]969. It would appear upon further examination that accidents occurred on July 22, 1989, March 12, 1990, and February 11, 1991. 4000 PARK STREET NORTH ST. PETERSBURG. FLORIDA 33709 _ _ • PHONE: IS 13) 347.1286 2845 FIFTH AVENUE NORTH • ST. PETERSBURG. FLORIDA 33713 rr PHONE: (8131323-2888 iv;i. Re: Caleb-Winston 2 - August 31, 1992 Evaluation reveals a large black male who is 611" tall and weighs 225 lb. He wears a TNS unit in the cervical area. He walks very, very slowly and moves about. very, very slowly. He is very demonstrative about expressing discomfort and appears to exhibit a markedly exaggerated pain response. He has difficulty with walking on the heels and toes but can do so. The Trendelenburg test is accomplished with difficulty and is negative. Forward flexion is barely begun before he complains of pain. Likewise, left and right lateral bending cause discomfort at only 200, each. There is no spasm. There is pain to palpation from the neck down to the sacrum. This pain is present even when I palpated the soft tissue of his back as lightly as I could with my own small finger and, in fact, he complained of pain when I palpated the area with a'Q-tip. Straight leg raising was to 90° in a sitting position and the patient complained of severe discomfort and grimaced at 20° of straight leg raising in the supine position, both left and right. There is total weakness of the great toe dorsiflexion bilaterally. There were no distinct sensory deficits The weakness appeared to be voluntary. Examination of the cervical area again revealed a markedly exaggerated pain response, even to light touch. He flexed and extended to 20° each and complained of gain. He did not rotate his neck at all. Lateral bending was to 20 on the right and 10° on the left. All of the tests, such as Adson's and vertex compression were invalid at these motions. The deep tendon reflexes were symmetrical. Grip strength was adequate. No atrophy was noted. Examination of sensation in both upper and lower extremities revealed a non-dermatomal decrease on the left side, both upper and lower. The MRI was reviewed and I agree with the findings of the bulging at C4-C5 and C5-C6. X-rays were taken in our office today. New x-rays of the cervical spine reveal adequate alignment on the AP projection. The neuroforamina are well-maintained. There is some straightening of the cervical spine with a forward curve at C2-C3. The vertebral body heights and intervertebrai disc spaces do not appear to be markedly involved. There is slight narrowing of C4-CS and slight anterior spurs at that level. Examination of the lumbar spine reveals some sclerosis in the facet joints. The lumbar vertebrae are well-maintained, as are the intervertebral disc spaces and the thoracic spine also appears to be within normal limits. This patient gives a history of an accident which occurred in July of 1989, three years ago. As far as I can see by the objective evidence, he has mild degenerative changes, not out of keeping with his age and occupation. However, his symptoms are far greater than one would expect given his history and general body condition. The injury would appear to be a strain and sprain injury involving the cervical and lumbar areas with a degenerative problem in the 5•. [v. ..'ice. ?.. ' ' • ? s ? i t ,. .... ir..v r.i.i.1l";'j':YH :w r. .e .., .. ,. .? `1.-. w3'... •_ .i.` ...f r.' 'i •;;: . (i Re: Caleb Winston 3 - August 31, 1992' cervical spine which,has resulted in disc bulging at:two levels. I do not believe that he is a surgical candidate and I. believe that part of the'obj'ective findings would be related to his accidents, starting in 1989, but'that part of.these are also due-to his age and history of heavy labor. I believe that he does have a permanent physical impairment, rated at-5-6% of the body as,a whole and I feel that his pain behavior and response to his current symptoms is grossly exaggerated. He' may not be a candidate for'. doing heavy manual labor but, certainly, he.is- not totally disabled from doing any type of work, especially when lifting or bending restrictions can be placed upon him: It was evident to this examiner that this patient's reactions were grossly exaggerated and I was somewhat surprised to see well- developed musculature in'a patient who states that he has not been able to exercise'nbrmally for the last three years. if we can be of further assistance, please.do not hesitate to contact us. Michael D. Slom a, M.D. O' CONNOR, SULLIVAN 1. SLOMKA & YI, M. D . , P . A. MDS : bav osytaiori ?ars+oIRIL>rt • ? - FLORIDA DEPARTMENT" OF LABOR AND EMPLOYMENT SECURITY ' DIVISION OF WORKERS' COMPENSATION 1.800.342.1741 (or) confect Mr focal office for assistanco . -,,NOTICE OF INJURY . Report all deaths within 24 hours (904) 488-3044. .IMP OYEE IN ORMATION FOR CARRIER'S DATE STAMP RECD BY CARRIER SENT TO DIVISION - NAME (Fir t. Middle, Lest) Social Security Number Date and Time of Accidont Caleb Winston ,•263-96-5341 2/11/91 M A E • prictude Dp) % EM PLY 'S ESCRIPTION OF ACCID NT - - 125 Fex'nwood Avonue, Clearwater, FL Injured neck while shaveling shell for, warning TI1MFHONF_ Am can4 Ko"M DESCRIBE INJURY OR DISEASE AND INDICATE PART O BODY AFFECTED le g Arrlputirtion of ri ht k?dnx fin er at seconq joint f••aGtured l b d i OCCUPATION 1D - 9107 . . g g , n s. po en soning, eta} Neck arpo E Or- BIRTH X Dip YOU ACaUEF,T MEDICAL CA9E7 JO YES ' ? NO Q 10 ! 47 a M OF IF YES. DID EMPLOYER PROVIDE MEDICAL? YES [3 NO trat EMPLOYER INFQRMA-nON FIRiVI u NAME AND ADDRESS FEDERAL I.D. NUMBER DATE AND TIME FIRST REPORTED City of Clcaxsirater 1600 59--60000289 2/19/91 at 11:30 AM P.O. Box 4748 W.C. COVERAGE BY POLICVMEfAGER NUMBER Clearwater, n 34618 Q INSURANCE CO SBLF•INSURED -f NAME. ADDRESS, TELEPHONE OF TtG PH NE INSURANCE CO. OR SERVICE COMPANY WILL YOU CONTINUE TO PAY' - a,nc,,,.613 4,,.w 462-6531 GALLAGHER BASSETT SERVICES, INC. SALARY? AYES C3 NO PLACE OF ACCIDENT (Street, City, County, State) P.O. Box 4840 LAST DAY PAIL] THROUGH Carpenter Field Clearwater, FL 34618-4840 r ? 651 Old CoachaSlt Rd. Telephone: (012)796-6929 RATE OF PAY fiR ? vyit Clearvat er • Pinellas. FL NAME. ADDRESS AND TELEPHONE S9 363 XPER ? DAY ? Ma ? OF PHYSICIAN OR HOSPITAL Number of tours 8 ? 010 THE EMPLOYEE KNaMNGLY REFUSE TO US APPLIANCE PROVIDED B YOU, THE EMPLOYER E R? YES?XI NO Dr. s ??kr A'?Z>iG Numee of h"", 40 DATE EMPLOYED LAST DATE EMPLOYEE WORKED x1600-US 19 North Nr? ?k aye 5 Clearwate , WJ- 34&21 PAID FOR DATE OF INJURY 111 23 ? $1 2 r 19 1 91 RMPNEO TO WORK WES r_ NO AUTHORIZO ' PL rYES ? NO YES 2: NO ^u IF YES. GIVE DATE ? 7 (3 LOCATION! D E WAS INJURY FATAL? Q YES ?tC1 l ' IF YES, GIVE DATE OF DEATH ! IL CAT t r IF APPLICABLE) AGREE WITH DESCRIPTION OF ACCIDENT? [A;,PRE OF BUSINESS YES C NO IF NO ATTACH EXPLANATION 14unici lit: '1r:y person who, knoNrngty and with intent to injure, detraud OF deserve arty employer or am4t a rnsurifnce comoarry or satf•usstued program, fries arty statement of warm contunrng any False or mrsleadmg iniormabon is guilty of a felony of the third aegr I have provided the emtrloyes their copy of this nose: In Poison Fa By fA Not available for nigaature EMPLOYEE SIGNATURE at nvur.a. w vg^1 oArE EtcnoeFR slaty t o„r CARRIER i 1AnoN Carrier Audit Af ' L.oca0on # Service Co. 08 Carrier File ? 1. Controverting Igase-DYIiC-12, NOTICE OF DENIAL ATTACHED ? 2, Lost Time Case-Date of First Payment AWW Comp Rate Fist day of disability f ? ,-Date of First Contact with Claimant ? In Person I5 Telephone ? Mail ,.-Notice Filed Due to Multiple Periods of Disability. Dates Covered by First Payment - ? T,T.D. ? T.P.D, ' bate Form Recd. ? Catastrophic. ? P.T.D, ? Death ? 3. Medical Only which became a Lost Time Case. (Complete all information In item 2 above) REMARKS: ADJUSTER NAME. CARRIER NAME, ADDRESS b TELEPHONE: DATE: ? ` GALLAGHER BASSEiT SERVICES, INC. ADJUSTER SIGNATURE. P,O, Box 4840 j,• Clearwater, FL 346184840 Telephone: (813} 798-6929 LI:S Fong awC•1 11190 EMPLOYEE COPY 1 0- !CM Notice of Injury ED. wart wee •awropaoot AWW rr? MAnWX IEHAts. us EXP. lepo" all deaths by telephone or telearam within 24 hourt_ nt FAgF TVPF STATE OF FLORIDA DEPARM- )F LABOR AND E'.?f4'LAYMEN'i' SIrCURiT1f Division of Worirrs' Comprns•[ion 7728 Crnurview Drive, Suite 100, Forrest Building Tallahassee, Florida 12999.0661 ATTENTION: 1N.C. CLAIMS OFFICE Ptionr!t 1-Ann.3d2.1741 EMPLOYER INFORMATION EMPLOYEE INFORMATION PIRM'S NAME NAME (First, Middle, Last) SOCIALSECURITY NUMBER Citim, r 4aa a Caleb Winston 263-96-5341 MAILING ADDRESS (InClud• Zhu Codel HOME ADDRESS UnClud¦ Zip Cobol OCCUPATION P.O. Box 4748 125 Fernwood Ave. 01 arks Worker/Rec. Fa Clearwater, FL 34618 Clearwater, FL 34625 SUPERVISOR'S NAME award Seliq DEPARTMENT NAME Parks & Recreation TELEPHONE TELEPHONE ? DATE OF BIRTH SET( Ate Coda: 13 Numbert ' 462-6531 Area Codo:813 Number' no hone ;A 4 ®M ? F, - LOCATION Samesa Madinq How long Number of hows0Per Week Number of days RATE OF PAY City Hall At m* e& •m I Y,3 ,f ? 1 worked 4Q ©P•r pay worked per week 5 i ? Per Hour 10 Souy.?. Missouri Ave. If iet:e work or Commnsron, enter e it board, lod n or other ''1$ 2 Y r] Per Oa v Clearwater, FL 34616' av rage weekly amount advantages futnnhed, enter weekly amount + ? Per Weak WORKER'S COMPENSATION COVERAGE BY ?Insuranc• Company SolI-Insured GIVE NAME, ADDRESS AND POLICY NUMBER OF INSURANCE COMPANY NATURE OF BUSINESS OR SELF-INSURED SERVICE COMPANY. •- _ GALLAGHER BASSETT SERVICES INC. , FEoenAL EMPLOYER I.A. NUM(SE BOX 4&W 7, _ Clearwater, FL 34618-4840 . - 1 ACCIDENT INFORMATION --•?•---- _ DATE AND TIME OF ACCIDENT - DATE AND TIME FIRST REPORTED NAME, ADDRESS AND PHONE NUMBER OF PHYSICIAN 3 11 2 1B , PLACE OF ACCIDENT IStreet, City, Countv.State) LAST DATE EMPLOYEE WORXED - F C ld , 49 a Walk-In-Clinic t arpenter ie Old Coaeb? Rd FtETuhNED TO WORK Yn _Nn ! r ? ?e$ g? J PHYS ,91,FA71T10J?I? 9 EFAPLiO L,1 free t?N. . IF YES, DATE ? - r NAME, ADDRESS AND PHONE OF HCSPITAL Clearwater, Clearwater, Pinellas, Florida mnro.r+ O?e• or 1n V/Y ,.0 Yes 0 No .., EMPLOYEC MISSED ONE SHIFT, ONE DAY OR MORE? ?Yts ONo - WAS INJURY FATAL) C]Yas qNb if Yet. Date of Coach i PTION OF ACCIDENT (Give data+is such as, fell, was struck, nC.) EMPLOYEE'S OESCnI GBSCF;11)E INJURY. OR, DISEASE AND INDICATE Amputation of riot[ nc.x an BOGY AFFECTED f _ 'while IIlQWj.IIg with clra4e17 mower, 15311. "track . oar at s•eond nd joint. Fractured ured ro ribs, Load wheel of tracts, r. Employee dodged Poisoning, •te.l _ ....,?_ .• .__- i r . .,' ? ?• ?. -- _ ball and sr-rained neck muscle. cervical strain to neck,-area Tt"RWATC-n OFFICE + J'A EMPLOYER' I agree with this d•fcriptiOn7 YasQ N4 i1 h0. •x Plein II - n C4mrh•r1h. -Any person who, knowingly and witlf intent to injure, defraud err deceive any employer or employee, insurance company, or self-insured EMPLOYEE (Read and'Sign) COMMENTS: ]Empbmyee seen by City purse and went to '.'Walk--ln--Clinic. %AX4AWM1oi program, tiles a statement of claim containing any false or misleading information is guilty of a felony of the third degree. - ? PLEASE FILL IN ALL SPACES ABOVE I.-O r ! L EMPLOYER (Read and Sign) - kSIAT R[; PATE r - ,. ??/--'? ?-?L/•?-? SIGNATURE ? ATE:/ ' LES Farm 9CL I ERav. 6•79} 1619 Or crnr PAKroraoar Arnr • t0HA9. ? ly1y, y? ? leport all deaths by telephone at telegram within 24 hours. DEPART MEN, " - LABOR AND EMPLOYMENT SECURITY L on of Workers' Compensation 1321 Executive Center Drive, East r"" "?r"tx Tallahass Fiurida 3230 ,151 ATTENTION, W.G. CLAIMS OFFICE PLEASE TYPE Phone: 1. O 42.1741 EMPLOYER INFORMATION EMPLOYEE INFORMATION FIRM'S NAME NAME (First, Middte, Last$ - SOCIALSECURITY NUMBER City of Clearwater Caleb E. Winston , Jr. 263-96-5341 . MAILING ADDRESS (Include Zip Codal i .;; ;,?:•" ME ADDRESS (Include Zip Codel OCCUPATION 9102 Parks Worker P.O. Box 4748 - ::'125 Fernwood Street #1 SUPERVISORS'NAME 1 ?v Clearwater, FL 346181 ` .,, ??+?• -? ,-Clearwater FL 34625• Howard Seli , g_ r-..,-:i `??• DEPARTMENT NAME .,,,•?t':y' Parks & Recreation TELEPHONE _ J UL 2 1LEPHONE DATE OF BIRTH I SEX Aran Codas Number, Area Coda, Number'SIT-- 101.1-0/47 ?i M O f' LOCATION Sarre all Mailing How long Number of hours Per Weak Number of days RATE OF PAY employed? worked worked per week 11/23181 4 ©Per Dw 684.59• ® Per Hour City Hall Annex l l piece work ar Commission, enter If board, lodging tar other I] Per bay 10 S. Missouri Avenue average waekiy amount advantages furnished, enter, weekly amount ? Parw..k Clearwater, FL 34616 WORKER'S COMPENSATION COVERAGE BY C]llnturance Camping Soll•insured GIVE NAME. ADDRESS AND POLICY NUMBER OF INSURANCE COMPANY SELF-INSURED SERVICE COMPANY NATURE? OF BUSINLSS , OR INC. GALLAGHER BASSETT SERVICES munWnalitv , FEDERAL EMPLOYER I.D. NUMBER 2953 U.S.'19 North, Sulto 301 59--80000289 Clearwater, Florida 34621 • AUI.;lU1:r4I iNFUIiMAf IUrJ OAI'c /1N8 TIME OF ACCIDENT Y -_ DATE AND TIME FIRST REPORTEO? r NAMi*, ADDRESS AND PHONE NUMBER OF PHYSICIAN 7/22/89 =A. Rro 11:30 PM Z177'89 Annrnv- 11-30 PM Doctors Walk-In Clinic- PLACE OF ACCIDENT (Street. Laity. County. State$ LAST DATE EMPLOYEE WORKED 2600 US 19 North Eddie C. Moore Complex 7/74/89 at 8:45 AM Clearwater, FL 34621 200 N. McMullen Booth Rd. RETURNED TO WORK Yes No pHYSICIAN AUTHORIZED BY EMPLOYER ?Yes QNo Clearwater, Pinellas, FL 34619 IF YES. DATE NAME, ADDRESS AND PHONE OF HOSPITAL turnover ew .q. 2 Y n CINC EMPLOYEE MISSED ONE SHIFT, ONE DAY OR MORE? , Yat ? r1a Same WAS INJURY FATAL? 0Yes &)No it Yes, onto of Dust" EMPLOYEE'S DESCRIPTION OF ACCIDENT (Give oeralls such as, foil, was struck, etc.) DESCRIBE INJURY OR DISEASE AND INDICATE Mr PART OF BODY AFFECTED le.g. Amputation of right Employee was emptying trash cans. Due to rainy conditions index linger at second joint;rractured ribs, Lead ? cans were heavier than normal. Employee went to lift ft 44 Poisoning, etc.) gallon rubbermaid trash can onto Cushman vehicle when his Cervical Strain- foot slipped on the wet: grass, causing him to take a mis- (Neck/shoulder bladel--- step. Shifting of weight caused strain in neck/shoulder t blade. - EMPLOYER: I agree with this de,cription? 55 Yes C] No It no, explain In comments. COMMENTS: r Any person who, knowingly and with intent to injure, defraud or deceFve any employer or employee, insurance company, or self-insured program, files a statement of claim containing any false or misleading information is guilty of a felony of the third degree. PLEASE FILL IN ALL SPACES ABOVE, EMPLOYER, (Head and Sign) Si NATURE TE EMPLOY EE'(Readand. Sign) _ N/A for aign:7r•„TU ?}......? SIGNATURE DATE LES Form 8CL•1 Iflov. 6.791 I CL.EARWATER CITY COMMISSION = Agenda Cover Memorandum Item n Trustees of the Employees' Pension Fund Meeting Date: 1 1 r2/92 Subject: Pension(s) To Be Granted Recommend ation/Motion' Ray Brock, Maintenanco Worker I, Public Service Division, Public Works Department, be granted a non-job-connected disability pension under Section(s) 26.34 of the Employees' Pension Plan as recommended by the Pension Advisory Committee. ? and that the appropriate officials be authorized to execute same. BACKGROUND: Ray Brock, Maintenance Worker 1, Public Service Division, Public Works Department, was employed by the City on June 3, 1975, and began participating in the Pension Plan on December 4, 1975. He has a herniated disc which resulted in his application for a non-job-connected disability pension. Mr. Brock submitted a letter from Dr. Douglas J. Welland (dated September 25, 1992) in support of his request for a non-job-connected disability pension. Although Mr. Brock has applied for a non-job-connected disability, there is the possibility that his current spine problem Is related to an on-the-job Injury he Incurred several years ago. In view of this fact, Mr. Brock also submitted copies of the medical documentation contained In his City of Clearwater Worker's Compensation file. There is a Worker's Compensation claim pending for his current injury, but a final decision will not be rendered until after a hearing to be held in January. If the ruling Is in Mr. Brock's favor, this pension would be changed to a fob-connected disability pension. At its meeting on October 7, '1992, the Pension Advisory Committee passed a motion that Mr. Brock be sent for an independent medical examination (IME). This examination has been scheduled for December 23, 1992. Mr. Brock has exhausted all his City benefits and has no income other than food stamps. There Is no question that Mr. Brock is disabled from performing his duties as a Maintenance Worker I. This is substantiated by the letter from Dr. Weiland. In light of these extenuating circumstances, the Pension Advisory Committee at Its meeting of October 7, 1992, passed a motion granting Ray Brock a non-job-connected disability pension based on Dr. Weiland's letter and the other documentation from his Worker's Compensation fife. The Pension Advisory Committee requested that the Trustees approve this pension request as a non-job-connected disability in an effort to alleviate this employee's financial hardship. Based on an average salary of approximately $18,046 over the past five years and using the formula for computing a non-job-connected disability pension, Mr. Brock's pension will approximate $7,218 annually. Charts from Finance which take into consideration mortality rates and age reflect the "present value cost of financing" this pension will be approximately $57,020.69. Reviewed by: Legal O -n= _ Budget d4_ -- Purchasing Lln Risk Mgmt. _ ah- DIS ACM _ ±lf It 1 •? Other__ u` Submitted by: City Manager Orilglnating Dept.d4 Human Resources User Dept.: Advertised: Date: Paper- W Not required Affected parties ? Notified 0- Not required Costs- 441 Total Current FY Funding Source: ? Capt. Imp. ? Operating 0 Other Appropriation Coda: Commission Action: lJ Approved Approved wlconditions U Denied EJ Continued to, Attachments: Letter(s) Request Form ? None i?:,'i ? ? 1. ? ? u • t? '..' qtr' .`,' .e?? - ?1.? .. ? ,?1. •' 1 •. , ,' .• ,' r ' rl? ..I .. ,• • r. i.}??.i ?• 4i• •?eJ••Y ''1. 1. '.'.iF.??? Is ?'a'f. S. ryy.'Qe ;i,.. si iii.' f-. .E ? .. c., l.'tr J D?'f L4•e, y, C `a%r :• ri-.'s.qf' ;s. '.1, 1?i' ,. `'r• f?... :r. ???` „?''M• jF ?. ?,. ,?. k: }5. 4i8kvd!! ? a.."??``•?•1' YF J.'. Y ;tr yf .fr ?S' f `I" ./? ''i?;•??' :.„?:±•,??.,:}x:11.• Y.. '.r..?.,r,?.., .,s?•C•a,' 's;? 3!a,.•7!! !{?.?, •.ie a, ', 'r ? "::.• , . •'e s 4' ?1; ,. , , i Ray Brock Agenda Item. ; ~r: Page 2 ,.. November 2, 7 992 Staff recommends adherence to. the provisions' of the Pension Advisory Committee Policies and Procedures ' ,. • :. Manual....This Manual was adopted by, the' Pension Advisory Committee and the Trustees. Provisions of the Manual relating, to the subject :area "Processing Disability Pension Requests" (p. 6) require that an applicant 'V for, disability pension submit '"letters from. at least two (2), medical doctors (MD or DO)' in support of the employee's request." Mr. 'Brock has not submitted two letters and approval with only the single letter will .. Ilkely,be seen as a precedent leading to other similar requests. Staff recommends that the Item.,be denied until ' -,the 'IME is received and. reviewed by the Pension Advisory Committee and a subsequent recommendation; is submitted lo' the Trustees: . ¦ 1 C.1 T Y 4 F C L E A R W A T E' R I POST OFFICE -BOX 4740 CLEARWATER.,FLORIDA 34Gt8-4748 Perswinal Department 402.6870 70: Honorable Mayor and Members of the City Commission as Trustees of the Employees' Pension Plan FROM: Pension Advisory Committee COPIES: Ray H. Brock; Risk Management; Dan 'Deignan, Assistant Director of Administrative Services/Finance Director; Employee's File SUBJECT: Pension for Ray H. Brock-Nan job-connected Disability Pension DATE: October 7, 1992 The Pension Advisory Committee (PAC) received an application for, disability pension from Ray H. Brock on September 21, 1992. Mr. Brock has been determined by the Pension Advisory Committee to meet the requirements of the pension Plan for a non-job-connected disability pension. He was employed by the City on June 3, 1975, and began participating in the pension plan on December 4, 1975 Further, he has submitted medical documentation, copies of which are attached, relative to his disability which has been reviewed and approved by the PAC, By motion made and duly carried at its meeting of October 7, 1992, the Pension Advisory Committee . approved/recommended the granting of a non-jab-connected disability pension to Mr. Brock in accordance with provisions of Section 26.34 of the City Code. This pension is to be effective on a date to be determined. The amount of Mr. Brock's pension will be calculated by the Finance Department according to the formula in the Pension Plan for non-job-connnected disability pension at such time as his last five years of service and salary can be computed. I hereby certify that the Pension Advisory Committee has approved the granting of a non-job-connected disability pension for Ray H. Brock and that the above dates are correct. i xi, _AY,0j_4, ,Lff111F11Z A hairman, Pension Advisory Committee s- ''Equal Employment and Affirmative Action Employer'' PENSION REQUEST FORM IRay H, Brock do hereby apply for retirement from the City of Clearwater General Employees' Pension Plan. My beneFits date is December G, 19755 (Entry date Into pension Plan) My bate of ,hire is June 3, 1975 My birthday is September 1, 1933 My job classification is Maintenance Worker I and I work in the Public Works Department, Public Service. ?D i v i s i o n. M y resignation date is_ to be determined The type of pension for which I am applying is (check only one): Rejular Pension based on years of service • job-connected Disability Pension x Non-job-connected Disability Pension My spouse's game is:' Donna Jean Brock ?` . _?- Dependent children under the age of 18 and residing in my household are: (Print Child's Full Name) (Child's Date of Birth) I hereby certify all of the above to be true and correct: W a,4 ??.rrr_., • _.,•.., ((Si nature) September 21, 1992 p (Date) (Notary Ptolic) 1i07At1Y PUBLIC. BTA`rt 6F f' DR1D& My C(1MINS1oN EXPIRES: JULY 11. 1994, . *ONOI[O TkRV NOTARY P1INLIG UNULAWR17YR1. CITY, OF CLEARWATER GENERAL EMPLOYEES' PENSION PLAN OPTIONS - GENERAL EMPLOYEES 1 r , OPTION 41: Employees. can receive a lump sum payment for vacation and holiday pay and 1/2 of accrued sick leave at the time of separation from the City. There will be no 8% deduction • for pension from this lump sum payment nor will this • amount count ' as earnings in the calculation of the pension. The last day of work will be the termination ' date and pension benefits will begin the following day. OPTION #2: Employee can extend termination date by the time due (Only . available to for vacation; holiday pay, and 1/2 of accrued sick leave. employees hired Termination date will be the final day of extended time. prior to 10/1/90) Pension benefits will begin the following day. I, Ray H. Brock an employee of the City of Clearwater, hereby apply for' pension benefits under the General 'Employees' Pension Plan. I hereby certify that I fully understand the two options offered to me. I choose to retire using Option # 1 and wish my benefits to be calculated under this option. I understand that once this form is signed, my decision is irrevocable. EMPLOYEE'S SIGNATURE: _ & ' ? 'SOCIAL SECURITY ##: 263-44-3889 WITNESSES: ADDRESS: _ 1404 1/2 North Garden Avenue Clearwater, FL 34615-2430 DATE: _ September, 21, 1992 - L? Florida . S ine, Institute neSpineCarnEtrperd Florida's Largest Center'Devoted Entirely to Medical and Surgical Care of the Neck and Back Orthopaedic Spine Surgery Douglas J. Weiland, M.D., RA. Elizabeth C. Sims, M.D.. P.A. Paul J. Zak, M,D. Pbyated McWeIne & Rehabilitation Robert D. Gruber, D.O. September 15, . 1992 Constantine D Bouchlas, M, D. Neurology Sandra H. Roth. M.D. TO WHOM IT MAY CONCERN Neuroradlology C.F. Shah, M.D. Paychology Re: Ray Brock Richard N. Frank, Ph. D. #4402 Spine Care Services Imaging MRI ' CT Scan Myetogram Spine Surgery Spinal Reconstructions Laser Discectomy Perculnneous Fusions Scoliosis Spinal 5tenosis Herniated Discs Electrodlagnoslie ,Medicine, E INIG Nerve Conduction Study SSEP Neuteloglcal Assessment I Spinal Disorders ? Headaches & Seizures Rehabilitation Services Physical Therapy Physical Reconditioning Aquatic Therapy Back School Arthritis Relief Psychological Services Evaluation & Treatment Pain Management Biotecdback Soft Tissue Injury 6tanipuiation Physical Therapy Epidural Steroid Injections Trigger Point Injections i , Mr. Ray Brock,is a patient of mine who had a two-level herniated disc with increasing radiculopathy. This was markedly debilitating and, because of this, he was taken to surgery where he had a cervical fusion. The operation was very successful, and overall his pain has been markedly decreased. The cervical fusion looks very solid. However, I do not think he will ever return to full manual labor with heavy lifting. He will essentially be on a permanent light-duty disability, which I would define as lifting less than twenty-five (25) pounds on a moderate level, and he will not be able to do continued overhead work with his hands. I do believe that this disability is permanent. If one looks at the disability in regard to the Minnesota Medical Guideline Tables we would rate this disability as approximately 'fifteen percent (15%) whole body. I do believe the patient would benefit from another round of physical therapy over the next three to six weeks. But, other than this, I believe he has reached maximum medical improvement. Please contact me if x.••may be of any further assistance. Sincerely, Douglas J. Weiland, M,JY. ' DJW/rab / cc: Attorney / Workmen's Compensation 2250 Drew Street, Clearwater, Florida 34625 (813) 7D-SPINE q (813) 797.7,163 • Fax (813) 726-1580 W-' ' ? q !! naroRt,.ns scc, tT+s AcG sauK; otic6 ?of Rni # DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY .norm Mi. 141 Division of Workers' Compensation 1321 Executive Center Drive, East aARr :? P407 QI 0001 AWM TPM %ATW Tallahassee, Florida 32301 ?B. ATTENTION: W.C, CLAIMS OFFICE ?rt all death: by telephone or telewarn within 24 hours. PLEASE TYPE Phone: 1.800.342.1741 EMPLOYER INFORMATION EMPLOYEE INFORMATION M'S NAME NAME. (First, Middle, Lartl SOCIAL SECURITY NUMBER sty of cLea"atar stay B. BtOCk 263-44-3889 ILING ADDRESS [Include Zip Code) HOME A0014ESS Ilnclude zip Code) OCCUPATION 5509 0 i?taaiAt. ?Orkelr I * . ftz 4748 1400-1/2 R. Carden Ave. SUPEFIVISOR N NAME 1sarvater rL 34618 Cle atvatar, PI. 34615 M. Abdur-Itahiia 4,}t DEPARTMENT NAME Pub. 1lL1us/Pnb. Service LEPHONE IpS IN r ?? 2 TELEPHONE DATE OF BIRTH SEX , ON Cade: 813 Nu irl QSb 56 .17 4 Area Code: Numbar, _ . _. ?... _ -' 09/01/33 M ? F ICATION S?q 'WMail ng '?r6t ? P OL 04ow long Number of hours Parr Week 1a •o7 orkrq Number of drys w k r k d RATE OF PAY 4 ? , w r• 40 ? Per Oav or e pe wee $68?Lr 59 Q Per Hour IF piece work or commission, entarr If board, fodq,ng or other i-wealLlp per Dry I It 2Jr Onc'tr,QY,a average weekly amount advantage+ furnished, enter weekly O Per w..k ? ' amoun t r :l11ia.r?rt?tnlr 3dC7 1fi L s P WORKER'S COMPENSATION COVERAGE BY ?lnsuranca Company t._1 Self-Insured GIVE NAME, ADDRESS AND POLICY NUMBER OF iNsu 3ANCE COMPANY &.TUAE of BUSINESS OR SELF-INSURED SERVICE COMPANY, ? 1=icipal.zity, GALLAGHER BASSETT SERVICES, INC. EDCRAL EMPLaYr;A I.D. NUMBER 2953 U.S.19 Norih, SUlte 301 59-6000389 Clearwater, Florida 34621 ACCIDENT INFORMATION ,ATE AND TIME OF ACCIDENT DATE A140 TIME FIRST REPORTED NAME, ADDRESS ANC) PHONE NUMBER OF PHYSICIAN 10/28/88 -- 10:00 10/78/84 - 10:00 a. m. Doctor es Walk-xa C3.iniec LACE OF ACCIDENT tStreet, Cily• County, State) LAST DATE EMPLOYEE WORKED 2700 U.S. Highway 19 N. 1OIA-1189 Ciesarvaerr, rL 34619 (813-799-2727) Cluarwate City Sall RETURNED TO WORK Yes Na PHYSICIAN AUTHORIZED BY EMPLOYER ?Yes ONO 1 12 S. Osceola IF YES, DATE NAME, ADDRESS AND PHONE OF HOSPITAL. C.l.earl rata.re P'L 34616 fl4ay 0.10 ! ;" !! ?°' Yet ONa D; L EMPLOYEE MISSED ONE SHIFT, ONE DAY OR MORE? E) Yes QNo WAS INJURY FATAL? QYes 93Na If Yell. Dart Of Dttth . EMPLOYEE'S DESCRIPTION OF ACCIDENT Wiw gstufs such 4s, fell, war struck, alt.) DESCRIBE INJURY OR DISEASE AND INDICATE PART OF BODY AFFECTED (e.g. Amputation at right Back dOO)C CA truck wmag open hit:t Jmg R AV i.n the b"k. index finger at second faint. Fractured ribs. Lead Paitonrng, etc.) Contusion of right shouler EMPLOYER: 1 agree with this detcriprion7 erYrrs O No if no, explain in comments. NTS: Any person who, knowingly and with intent to injure, defraud or deceive any employer or employee, insurance company, or self-insured program, tiles a statement of claim containing any false or misleading information is guilty of a felony of the third degree. PLEASE FILL IN ALL SPACES ABOVE EMPLOYER (Read and Sign) ; SIGNATURE DATE EMPLOYEE (Read and Sign) - - --- SIGNATURE DATE LES Form 8CL4 (Rev. 6.79) 7 . ' 1 fil?Mi: ', `? P" - : ?: • ?c' ? - ? ,lor?.?t:etrjA?s?fu??onl?:?ea.hea ids ?Ire,t?d.,«x, N..la, ?• ? ? '"'? .:`. ;•,..?r? ? u ?;?•?"'•;??:s?;?,101?0?NTM??fT, TAX f.D.,*59-2281883-. w . 26600U.61il h a?i` 9 K tidtdar 9164.91 J* Aez • SC/SS •i p [ H 1 W11; G' Y G.J I, L c ,ra J 1"L?LEAG?g ; C? Irsaffs ? ?. ST?1 21 I?? t cl e L, r • 1 TRTTAmn Vor I e.a s a-?oras r-lv+ym wwR 31 31 F7 ?YT UE3S L14P q 1' •} t r i i ? y 01AC140STIC IMPRESSION: PATIENT R PONSIMUTIES: PRt35CRI?7}ONS: 2} 2I 3) 3) A - 10?fe Al _ 41 RES ONSIB1UT•IES UNDERSTOOD Xp 7Tf ?nrr1F` I ? . A?d _ S}GNATURE OF PATIENT OR RESPONWELE PARTY NURSE'S SIGNATURE 015POSMCIN/FOLLOW UP r [.i Tmaled - Released Q Relerma to Or. PAnun surEAIEm OF 0.1 wss OR vAxRY G[unG pKy5i--m OlD BAL AIIC£ RECHECK FIGHT RIB CASE 209 10 T"e IN BATE REWOr+Va>.E wwrr 9 39 12!27/87 CTY. CLEAR.-SAFETY ` AooHas? ? 1400 1/2 N, GARDEN AVE. CLEARWATER,,FL.34615 PAnENT NM.1E LAST FlH5T umrmTE AGE SEX ACCOUNT 1 i ' BROCK , RAY H . 9/01 J33 54 M WC236 . • 1 r m 3 i• .+oaw CALAIS y pfwtty A66 r,?wr of .ooy R+rM ytsa. N^rtIRS; i. Sax *11 deaths by telephone or telearam within 24 hours. PLEASE TYPE urrmn I mLiv l vl `.1V+"++ ,,I L. __ ...._._. ..__r i... . Division of Workers' Compensation 1321 Executive Center Drive, East Tallahassee, Florida 323101 ATTENTION: W.C. CLAIMS OFFICE Phone: 1'$00.342.1741 EMPLOYER INFORMATION EMPLOYEE INFORMATION M'S NAME NAME (First, Middle. Lattl SOCIALSECURITY NUMnER 11.,INQ ADDRESS (include ZIP Coda) HOME ADDRESS (Include ZIP Code) OCCUPATION V O. ifl 474.8 .140% No CAR= CzzA6R'CLVM0 R , 0 ?i SUPERVISORS NAME 4 r1 -+ 74E r - 13 St ILMM n?y1G? 1: 4 V'M pOg V 1 3351 D EPARTMENT NAME -` r TELEPHONE DATE OF BIRTH SEX dot Number: Area Code: Number: M F CAT ION Same as Mailing How long Number of hours Per Week Number o1 days RATE OF PAY emplayod7 worked worked per weak 0 Per Day [; Per Hour [ s i ?i? If piece veer or commnslon, anter board, lodging or orher 7 C, © per Day overage weakly amount furnished enter weakly i e , ek r w 1 D Po ?r?==k rL, 31616 amount o . WORKER'S COMPENSATION COVERAGE BY Insurance Comttany Self•Inaured GIVE NAME. ADDRESS AND POLICY NUMBER OF INSURANCE COMPANY ATURE OF BUSINESS OR SELF•INSURE0SERVICE COMPANY. GALLAGHER BASSETT SERVICES, INC. EDEFIAL EMPLOYER I.D. NUMBER 2553 U.S. 19 North, Suite 301 Clearwater, Florida 33575 ACCIDENT INV TE AND TIME OF ACCIDENT DATE AND TIME FIRST REPORTED NAME. ADORESS AND PHONE NUMBER OF PHYSICIAN D • S y01= XN CLMC LACE OF ACCIDENT {Street, City. County, State) LR T RATE EMPLOYEE W0RKE0 R. - RETURNED TO WORK 0Y. [F. PHYSICIAN AUTHORIZED BY EMPLOYER ?Yeg 0No IF YES, DATE NAME, ADDRESS AND PHONE OF HOSPITAL .w,gl.rn ¦.d ro. ]Yes ]N4 Oat% OF In ..v EMPLOYEE MISSED ONE SHIFT, ONE DAY OR .YORE( ayes CINO WAS 1rijunY FATAL( 0Yes Net If Yes, Date of Death CPAPLOY6E'S DESCRIPTION OF ACC ENT (Give dauil 6 such as. Iali, wag struck, ate.) DESCRIBE INJURY OR DISEASE AND INDICATE PART OF BOGY AFFECTED (e.g. Amputation of ripti index finger at second joint. Fractured ribs. Lwd C8OP1?? PZH= AND TRIXTED QV= {UThR W21?F Potsaning, etc.) AHD 1-74 ED One RIG= SE CONT. DP RIG= RIH CAGE EMPLOYER: I ¦g+se with thin description? Imoes [] No It no, explain In comments. NTS: Any person who, knowingly and with intent to injure, defraud or deceive any employer or employee, insurance company, or self-insured program, files a statement of claim containing any false or misleading information is guilty of a felony of the third degree. PLEASE FILL IN ALL SPACES ABOVE - `,o' EMPLOYER (Read and Sign) SIGNATURE DATE EMPLOYEE (Read and Sign) SIGNATURE DATE LES Farm BLCG1 (Rev. 8•79) .. r. M . / a ??;:..,+1 ?"a?:T.?-.S`". Rz.??'t?;L?;;'i'?Jr;?'?'+,?.?;,}e...1.,_..» . ,, a ,,., °•s,, , o?., .... . .. ' r, `i ,? ` . ? 1 ?. Y?+?i11?? YIW?? ? ¦?•? Irk , .1??.• 1 Irk f ,f 1 • .r ??y?1lr/?l/1 I ? 1 aryyr •?{ t ', .. •"rr'?R C 7? CM?a.? ? ? ' ? ti.,?ir? T?? ? z?r.w~.?i? . "*E;ual Emptoyment and Affirmative Ac-ion Empiovcr" AM ZED RZrJRN M VKWZ. IF Nm, wm%r. I NM APPOI TJM-r= I5: IREMSLI'IONS • SI= M. D M5 .D. "Eaucl E,-npioyment and Affirmative Action Empiover" I _ fir } P ?• ' ? ? ? ' ? ' ., i ! ? ! i? .ivP. r.?tr :.'?.. '.f: r riff ;I. ., n. ...lewf .?M •?r '•1: , . . ? .f; .. ? _ .. .._ , .. ? . f 1 i t M I f :r?r _ere4?n+f • ??? s ? ?? 1 r ? r F 0%0= Q -r•- • TO ritiRr: iiVw 1M- =-? S I i ON'S "Equal Empiovasant and Affirmative Ac-ions Erpiover" 3 BROCK, -Ray. .6-11-87 (TS) The patient is status post a partial anterior acromioplasty, excision' of coracoid acromial ligament and excision of distal clavicle. Surgery was on 6-1-87. The staales'. were removed, steri 7-stri ps applied. The patient is to.wean out of the sling, start active ROM exercises, which he was instructed in and we will see him.back in'three weeks for re-check. (cg) 7=2-87 (TS) Problem #1. The patient is r'tow approximately four weeks since his surgery. He is doing well. The wound is healing up nicely. He has approximately 45 per cent ROM. He was told to continue with '. regaining his motion. ' We will see him back in three weeks for evaluation for return to work. 7-23-87- (TS) The wound is healing up very nicely. He has about 75 per cent ROM and he has noted marked improvement since the surgery in his pain. f feel that he needs physical therapy. We will schedule it three times a week for two weeks and see him back at that time to see what kind of motion has been able to be attained. '(cg) 8-6-87 (TS) The patient is doing well. He has about 80 per cent ROM. He is essentially asymptomatic. We will allow him to return to full duty 8-10-87 with no restrictions. He is to return in four weeks for recheck.'. (cg) G ' ?.%X. E C ^°' C 2~ t , (cg) M " 1i:???1 r? i?ItiftG?•1? . c? ?`?, or c?.taQV?trs?R ma, ' F AY ? . Pc?' t?e Sox ' s 3 to to G4?u DATE OF OiFRATION: 6--01-87 PPECPEPATIVE .DIAGNOSIS: Chronic c:oracoacrop&1 arch impinge- ment syndrome. 5 POSTOPERATIVE rIAGNOSIS : Chronic coracoacromial arch Impinge- ment syndrome. OPTPATT.ON TrE'RFOR14ED: Excision of coracoacromial ligament, partial anterior acromioplasty, and excision of distal clavicle, right houlder ..UR .xJCN : Thomas 0\ Schwab , M.D. ASSISTANT: ?Rarru Steinman, M.r , ?? f Gzil;•Sagro. a 5 A N E S79S S I P.: L,L.--.-?-•? G e n e*,rd 1. - PROCEDURE IN DFTAII : Unde`?general • tin `s£bees to . the patient was placed in a tarbershop position with,,•1a sandbag beneath the medial border of the right scapula. The pat1ent<s?righi'4arm was then prepared and draped in the usual sterile manner, ?""'"' A !peer approach was used and the; incision was carried from the corticoid distally to the tip of the anterior4a onion, down through skin and subcutaneous tissue.: ' The deltoid was identified and ;th'e` patient had two centimeters of the deltoid excised in line with its fibers from the acrcmioclavicular distally, for 2.5 centimeters. The deltoid was then reflected from the distal clavicle and the anterior acromial area. The •cora cacromial ligament was then excised and partial acromioplasty was carried out. There was still noted to be impingement from the inferior surface of the distal clavicle. One centimeter of the distal. clavicle excised and all bony ridges were smoothed and no impingement no ted'. The sutacromial bursa was excised inspected. There was one area of tears were identified. 1 The wound was then irrigated and the deltoid vessel. #1 Vicryl for and then the rotator cuff was blistering but no full thickeness r closed in layers with #1 Vicryl for the fascia, 2--0 Vicryl for the w? .r .. ti 1 1 ?...a J.J. •• •u. • PAGE -1 `'?_ SGfiWAB MEDICAL RECORDS MA 25 REV,, FROCK, subcutanecus'tissue and skin staples to the skin. TENS pads and compressive wrap were applied'or+ i Tbp patient was placed-in a shoulder immobilized, awakened and taken tc '-the recovery roam in,satisfactory condition. r ?iIt'll Ali .NJ G5 4,? G; G. a 41 're "ne P_ THOMAS 0. SCEWA?, M.D. -? i--e T:.6/1/r=7. , . PAGE -1 r • 632 MEDICAL RECORDS MA 23 REV. 9 r . 0 Ray .. , ? ' •... ? ? ?t `• r 2-2-87 (TS) Problem #1 Coracoid acromial 'arch impingement syndrarrie:: -' #2 Possible interstitial tear, rotator cuff, (P) shoulder. #3 Lateral epicondylitis, (R) elbow: MAY 2 9 1987 The patient is'presently having more problems with his elbow. Clinically, he has, a lateral-epicondylitis of the right elbow relieved with an air cast splint. We will continue with this. The area of point tenderness was injected with 1 cc of Decadron and 3 cc's of .5% Marcaine. ; The shoulder does not appear to be symptomatic at* the present time. The patient may continue working. He is to return here p.r.n. (dvl) A • h/?? - 3 .A// 37,5'" z D ?-- ? _ _ _a EFILI.S ?..? DA E -, ?.. n ?d d REFILLS DATETJ rT 41.0 kJc S? 5/14/87 (TS) PROBLEM #1 and 2 / The patient is still having problems. He had re-exacerbation of his pain. We re-inject- ed the subacromia.l space with 1 cc of Decadron. and 5 cc of 0.51 ldarcaine. We will see how he responds to this. If he continues to have persistent problems, he will possibly need decompression. (STS) 5-•18-87 (TS) Problem 01 and #2 The patient had re-exacerbation of pain, mainly over the posterior rotator cuff area. We injected the subacromial space with lcc of Decadron and 4cc of .5p Marcaine. He is to return to work tomorrow. If he is unable, he is to call and let us recheck him. (cg) 5-21-87 (TS) Problem #1 and #2 Posterior shoulder injection did not work. He is having acute pain. He is unable to lift his arm because of the severity. We re- injected the anterior shoulder with lcc of Decadron and 4cc of .Sro Marcaine. He was told if he continues to'have recurrent episodes, he will probably require a decompression of the coracoid acromial arch. (cg) f. NAZ S CITY OF CLEARWATE-•R POST OFFICE ]SOX 474a CLEARWATER, FLORIDA 33SIS f REQUEST AND AUTHORIZATION FOR PHYSICIAN;- NAME: DATE : F E fi w ADDRESS: COMPLAINT: PLEASE SEND MEDICAL REPORT T0: AUTHORIZED BY: OCCUPATIONAL HEALTH MMSE CITY OF CLEARWATER P.O. BOX 4748 CLEARWATER, FLORIDA 33518-%r<.?tJ„ ?• ^ 7? Nancy Degner"R.N. TO BE COMPLETED BY ATTENDING PHYSICIAN: . ? 1 0? ` DIAGNOSIS : 2 V TREATMEN'T' : REMARM : 1 ,.r? - ,, -n-c. ABLE TO RET[T N TO WORK: IF NOT WHEN? RESTRICTIONS: SIGNED M.D. .?S?gAtz RD?? gvy 046 PLEASE' RETURH COMPLETED FORM WITH PATIENT rb "Equal Employm*nt and Affirmative Action Employer" i . ORZHOEPAEaIC SURGERY CENTER oP CLEARWATER LAKWIM• RoAS, cLP.AAWATit, 19 O=A, 33516 (813) 461.6026 G::aAaQ M.D. JOHN M. MCCLURX III, M.D. THOMAS O: ScxwAs. M.D. HAUY •STmvmm, M.D. QLvi m E. •A9KAH msrN, M.D. BROCK';Ray DOB: 9/1/33 '.1400-1/2'N. Garden Avenue Clearwater, Florida 462-6585• AGE: 53 1/15/87 (TS) PROBLEM #1: Coracaid acromial arch imuingement syndrome PROBLEM #2: cuff Possible interstitial tear, rotator This is a 53 year-old white male who has had 1•'' problems since September 29, 1986. He was post hole"digging when he jerked his hand and shoulder and felt something "give"•.in the shoulder. He has been followed by Doctor's Walk-In Clinic in Countryside, and also by Dr. Nach. He has had approximately fddl 'injections of cortisone into the right shoulder area. He has been on' MOTRIN, and FELDENE with no relief with these medications. The patient states that he has not missed any work since the injury. He has problems with doing activities which require him using his arm- and lifting. He also has numbness and paresthesias in the arm when he does any type of pushing or pulling activity. XRAYS: r-r XRAY OF THE RIGHT SHOULDER IS NEGATIVE. ARTHRO- ".„ GRAM OF THE RIGHT SHOULDER WAS NORMAL. PLAN: The patient possibly has an interstitial tear ''•' •' •.' of the rotator cuff which would account for his chronic pain and also has evidence of a chronic supraspinous tendinitis secondary to coracoid acromial arch impingment. The pa- tient. will be tried on NAPROSYN 375 mg, po, tid. If ultimately he is unable to relieve his pain, he will probably need a partial acromio- plastic.. excision of the coracoid acromial ligament and search for any interstitial tears of the rotator cuff. (STS) f . ' .. .,':,? 1.4 1 DIPLOMATES OF THE AMERICAN BOARD OF ORTHOPAEDIC SURGERY FELLOWS OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGPON4 . •r } Cx 4, 3qY??, Fs?,?, S t CITY• O F C LE A R W A T E R POST Qrrict Box 4746 CLEARWATER. FLORIDA 33319 REQUEST AND AUTHORIZATION FOR PHYSICL0. r NAME: DATE: JAN 14 1987 ADDRESS: . COMPLAINT : - . PLEASE SEND'MEDICAL REPORT TO: AUTHORIZED BY: OCCUPATIONAL HEALTH NURSE 1w I CITY OF CLEARWATER P.O. BOX 4748 CLEARWATER, FLORIDA 33518 ]f,?t.??wt/ ?PJl Nancy Degner W- TO BE COMPLETED BY ATTENDING PHYSICIAN: DIAGNOSIS: l nv TREATMENT • ` `" J ??'S (? o -T ?o> C -e-? . REMARM: ABLE TO RETURN TO WORK: IM NOT WHEN? J RESTRICTIONS: SIGNED M.D. _?1su i-iCE DEPT.. u CITY of Cl EkRYJATER p, D. Box. 4748 CA -WATEr?+ E LA. 3518 PLEASE RETURN COMPLETED FORM WITH PATIENT IAN 16 198I"Equol Employment and Affirmative Action Employer" R .7i . C I T Y0 7 C L E A R W A T E R rowr orricc nox 474E CLEARWATER. FLORIDA 33518 REQUEST AND AUTHORIZATION FOR PHYSICIAI; NAME: DATE : 3AX $ 1987 ADDRESS ; his=-? ?? 71, ?u 1 . COMPLAINT: PLEASE. SEND MEDICAL REPORT TO, AUTHORIZED BY: OCCUPATIONAL HEALTH NURSE CITY OF CLEARWATER P.O. Box 4T48 CLEARWATER, FLORIDA 33518 71- Nancy Degne ?R.N. T0- BE C014PLEM BY ATTENDING PHYSICIAN: DIAGNOSIS: 1I-, E K i VA TREATMENT : `-7 v { 1?- RE?sARxS ,?,., nc.?-?' l?r? -•?. ?- jam, r f ABLE TO T WORK: IF NOT WHEN? SIGNS? M.D. RESTRICTIONS: kj;CIL DEPT o' Ci.?hBiATEA PLEASE RETURN COMPLETED FORM WITH PATIENT . L "Equal Employment and Affirmative Action Employer" +'? ;1 '['^?1`f ?:" .: s; ?'?'r.::eS477??i:'?r. .,. ,.=u•r. 4' .., ? : I : .° ° ., :i. ? ? .. .. ,. ? , e .. , TO BE • .? ? ?pgg? ?..e ?+-?-?? ?Y+?-mow,. err, TD R.. TA VMxZ: NCT WMI? TtiT T? : S MI "E;ual Employment and Affirmative Actiari Employer" / f • • • :ICJ. • • C Y T-7 0 V C ' E A' R WA T E R. F,,awr orrice ¦ox 4.:-ga • CLZARWATER, FLORIDA, 33518 EMMST AND AUTHORIZATION FOR MSICUIN. •r , •• 1/,, V 10 NAME.- DAM' 1/yADDRESS : /Y <'`' COQ: PLEASE SEND MEDICATt! REPORT TO: -AUTHORIZED BY: OCCUPATIONAL HEALTH NURSE . am OF CLEARWATER - '' P.O. BOx 4T48 1221 - CLZAE TATER, FLORIDA 33518 _ 'rte/ 2*-- Nancy Degner R.N. TO' RE COMPLE= BY AMIMMniG PHYSICIAN: DIAGIiOSrS: E9LC?? ' . ? ? -rte REHAPM: Ud' TO REI'M- TO WORK: f 2A 6 IF NOT WM? RESTRICTIONS: _SIGlam M.D. 1 SAFETY ?RSLTRAgcp, 13E2T- CITY of CLEARWA.TM . p. q . BOIL4748 CLEARWATER, FLA. 335113 FrYUSE RETC M COMPLETIM FORM WITH PATIRli'i' "ir oual Emolovm*nt and Affirmutivo Action Employer" 462 65H5 AI1OCK NAY H ' .Af?wrMAA? ?. •'t. ... Lrr+ an . , , 263 44' 3889 . M 53 ' 090133 ?? .,_ .........w....?...,,...rw:«•.?-.?...... . . NACH, MD. 1400 /2 HORTH GARDEN AVENUE, CLF.ARWATER,FL ' i.MY MUaM1E11 • ? . ? u r +? •, + •. i w .!••Rf71 e' qA •erc !lM[T GUAAANTpl NA+i[ t11D Z0?t>i +.f. r •. r•? •• I+t•• ?? ?. nw? .L..+t: ..?43 . s ra i ?AA++ATTnllt?louaaTtD..>,..:+I..••+..?e ,. .:••? ,• - ?,•.::•• - ?•,? •r?:•.r:,:y.r;.`s:..'•?..4erit• :•s•' er+ArTntt.•e a.r. RIGHT StiOULDER ARTHROGRtIM ONC of tTATaLdlNT Or IMA00M MR l1fMW"toM 4* F9MWMMT CLIP"M "10"Y ? ?•s :' Via::.: •s, ; +? . ?s?•i,J: a1 u.a:Y ?f" "I.L "? ' grA0A1l40% Z f; POSS. ROTATOR CUFF TM •aiaA>f7rtJi]vttiTilaA=A.• 0A=pP%0M2T :vL"' tLATY OF[lt^M .. r1iR/AJ?[D We ?• 1RQUltTSNO bOCfP1 •- tSMT10N PCMA A aTRRpmR w.u =wA =nvq --P a r. 103186 Dr. Hach 0 Q Q Q Q Q /Q)6Mt'• 'WVOWT rmo'"W LAST "Nue - I pKr1710NIaY "•• AlLIIA4la •1sA-•?•?'.••?.4.5?'!':+• ,a• ""VMS on me "S No NI(A ? no O ND 31 OCTOBER 86 RIGHT SHOULDER ARTHROGRAM4: The AP view of the. shoulder obtained before injection of the contrast material reveal the presence of a calcific density adjacent to the greater tuberosity and suggestive of calcified tendonitis. After introduction of the contrast material there is a prompt and'satis-• factory visualization of-the glenohumeral joint and accesory bursa. No evident of extravasation into the subacromial--subglenoid bursa was noted. I14PRE-SSION: I. NO EVIDENCE OF ROTATOR CUFF INJURY. 2. CALCIFIED TENDONITIS RIGHT SHOULDER. THANK YOU FOR THIS REFERRAL. IE SCOPPETTA, M.D.- MIS: aaa cc; Dr. Nach 31 Oct 86 BROCKr RAY H. OUT PATIENT DATE - 1t 01b goy - ?SURA?CE UE??At S)?YEq CLE?A?JR CiTx OT 4B BflX 41 A, 33518 P Q ? vpT'SR. FIB CL •EF . RADIOLOGIST DIAGNOSTIC X-RAY oa•xr•aol T>-I'A' OpAnT rr1T)y 1 r ' f C x T Y OF C L E A fit. W A T ]E R ? tosT QrFICC BOX 4748 I CL&ARWATER. FLORIDA 33518 REQUEST AND AUTHORIZATION FOR PHgSICIAN• 27 hd6 NAM ? • DATE: l U::?4 7 d f- 11. ADDRESS : / r QUO `Ia ?• /? ?? _ _ _ ... COMPLAmn PLEASE SEND MEDICAL REPORT TO: OCCUPATIONAL HEALTH NURSE CITY OF CLEARWATER P.O. Bor 4748 CLEARWATER, FLORIDA 33518 TO' BE COMPLETED BY ATTENDING PHYSICIAN : DIAGNOSIS : •` ?`'? ??^ f AUTHORIZED BY: R ncy6Degn* R.N. .? s S6.41,? ABLE TO RETURN TO WORK. ?? ?" `•.' 1 IF NOT Ww? ! RESTRICTIONS: SIGNED D. 5 & ` vl AVER 48 CLE47 Y ? $OX PLA 33518 DL??RwA?ER PLEASE RETURN COMPLETED FORM WITH PATIENT • "Equal Employment and Affirmative Action Employer" . 5 ,? • . • , ?rtliaparliir ?rurgann `I. -,Spinal ?Iifarbers W ,*coliasis - 011?=Vspin 13-461-1255 October 17, 1986- Karen Pennington, M.D. Doctor's Walk-In Clinic 2600 U.S, Hlghway 19 North, Clearwater, Florida 33575 RE: Ray Brock Dear A Dr. Pennington: CHIEF COMPLAINT: PAIN,:IN THE RIGHT SHOULDER. HISTORY OF PRESENT CONDITION: 1217 26ing Jkvsnue f ? ?sffarba? 1 f91rarfatfsr, AWba 33515 This is a 53 year old man who is presently employed by the City of Clearwater. , He was digging posts in Clearwater,.Florida.. The patient injured his right shoulder about three weeks ago. Date of injury was 9/24/86. The patient was seen in Doctor's Walk in'Cli.nic. The patient was injected withrDepo Medrol and Marcaine into the scapula and right elbow. The patient sustained an'allergic reaction to the injection "and has a rash spread over his legs and both his upper and lower extremities. The patient is being treated with cortisone cream and has been prescribed hydroxyxene. ALLERGIES : None to medications, SOCIAL HISTORY: The patient is married.and drinks alcoholic beverages occasionally. The patient also smokes one pack of cigarettes per day. PAST ORTHOPEDIC AND MEDICAL HISTORY: The patient has never been disabled. SyFETY & NstM"CE DEPT. continued on page two CITY of lATER P. 4. BQX 474 4748 CL"LARWATER. FLA. 33518 cc, 22 to r•?S.. s. . a:: yrs.. . .. _ . Page 2 Re: Ray Brock EXAMINATION: The patient's height is 5110" and weight is 160 pounds.. Age is 52 years. The patient's range of motion of the riclht shoulder, patient has full .abduction and adduction and full forward flexion and backward flexion, and full internal and external rotation. The patient is tender to .palpation over the-superior medial border of the right scapula and over the posterior capsule of the right shoulder. ,The patient may,have also sustained a photophobic reaction to the medication. X-RAY: X-ray of the right shoulder demonstrates calcific bursitis of the right shoulder. X-ray taken on 9/24/86 at Doctor's Walk In Clinic. DIAGNOSIS: CALCIFIC BURSITIS, RIGHT_SHOULDERL RULE OUT POSSIBLE ROTATOR CUFF TEAR. TREATMENT AND RECOMMENDATIONS: i r If the patient's symptoms'persist, S would recommend that he continue with. physical therapy program and he may require an arthrogram of the right shoulder to rule out rotator cuff tear and inject,:and_I:•am reluctant to inject the right shoulder with any further cortisone since he did have a severe reaction to the previous cortisone and Marcaine injection. I also recommend that if his rash does not subside that he seek a dermatology consultation. The patient may also have bicipital tendinitis. He is tender to palpation over the biceps tendon of the right shoulder. Thank you for referring Mr. Brock for orthopedic evaluation and treatment. Sincerely, Charles D..Nach, M.D., P.A.' CDN : dsh + Y? cc: Nancy Degner, R.N. Alttil. City of Clearwater q 151b516 DL`u 2210 C I T Y. .'O F C L, E A R W A T E R. POST orrICS ¦OX 4746 CLEARWATER. FLORIDA 33318 REQUEST AND AUTHORIZATION' FOR PHYSICIAN, i NAME : DATE : Li 1 $ 1986 ADDRESS: _1 sf-aJ.-ti?e? COMPLAINT : ? rr -?,?_ ? •?.?? PLEASE SEND MEDICAL REPORT TO: AUTHORIZED BY: OCCUPATIONAL HEALTH NURSE CITY OF CLEARWATER P.O. BOX 4-148 CLEARWATER, FLORIDA 3351$ ?J ??c •?c-C_.?? ? i? Nancy Degner/ R . N . TO BE C093fi7 _ }Y- ATTENDING P3I SICIAN: DZ4G' SIS: °"° TREATMENT : d'. ?• ACS : .? ?r +.+ r• ABLE TO REriTf;,N TO ORK IF NOT WHET? Adz RESTRYCTIONS: STONED M.D. r 1 .? --...,1 •CE 712T . ? ?i?ttSURAh Sh ETI k 3 CITY of C ,E)A7 THR P, 0. 30x CLE?H:',ATEP,. FLA? 3 1986 PLEASE 1UTURN COMP=ED FORM WITH PATIMIT OCR "Equal Employment and Affirmative Action Employer" C - I T Y O F ' C L E A,R W A T E R POST OPPIC9 nOX 47an CLEARWATER. FLORIDA 33516 - REQUEST AND AUTHORIZATION FOR PI37CSICIAI NAME: DATE: ADDRESS : / ?? x-a• ?•2 /?-4 .r??aC? COMPLA32IT : PLEASE SEND MEDICAL REPORT TO: AUTHORIZED BY: OCCUPATIONAL HEALTH NURSE •- C ITY OF CLEARWATER ?.,. BOX P.O. 4748 LEARWATER, FLORIDA 33518 ? CLE Nancy Degner R:'N. TO BE COMPLEX BY ATT MING PHYSICIM: ' D AG,NOSIS : ,.P %1o& -Cee f7 , TREATHRIT : REMARKS :? st- -- r ABLE TO RETURN TO WORK: IF NOT W mi? r?C?,l C RESTRICTIONS: SZGNEEI t OCT P PLEASE RETURN COMPLETED FORM WIT$ PAT= "Equal Employment and Affirmative Action Employer" i • 1'. C CONSULTATION SUMMARY /PROGRESS.REPORT DOCTOR'S WALK-IN CLINIC. Q 2810 V BUFFALO AVE 0 206 EBOANIDOII BLVD ? 1321 O M 30TH ST• • - TAMPA, FL 331GQ7 ' --- BRANb0h, FL 33511 TAmrA, FL 33612 (813) 877-9 3,0 (813) 689-5371 (913)1977-2777 609 U.S. HWY 19 R ? 801 1: HYY 574 CtEARVATER, FL 33575 SEFFNER, FL 33564 (0131799-7727 (813) 684-4424 TO DR. ATE EXAMINED: PATIENT: pGt/? _ DIAGNOSTIC IMPRESSION: c?2 X41 TREATMENT: i i r i7 fv Cel?ll? CA 1_77?t 1 REMARKS mrtliopurbir 5urgrnn F, •` & L? ? ; ^ -"a1°.? I spirtal Disnrhrrs - 5coliusis - (Q in ?Y Fi!ti5 IV? EWING AVENUE HOURS BY APPOINTMENT IOFF JEFFOFtOS) (a 13) 461.120 CLEAR WATER. FLORIDA =SIG v t PLEASE SEND A COPY OF YOUR CONSULTATION REPORT TO ME AT THE ADDRESS CHECKED ABOYE. THANK YOU o{ Q•G? c M.D. 60 CxT''Y' O"F CL"EARWATER CZ2 rDST GFFSGC BOX :t748 TElk. Oslo CLEARWATER, FLORIDA 33518 • REQUEST AND AUTEORIZATIQN FOR PSYSICIAI3• , NAME-:• / DATE: SEP 2 6 1986 COMPLUM : i r ? ern 1' -7? .? L? eL 1G PLEASE SEND MEDICAL REPORT TO: AUTHORIZED BY: GCMMATIONAL EZkLTH NOSE CITY OF CLEARWATER P.O, BOX 4748 (? - CLEARWATER, FLORIDA 33518 Nancy Degner dfl.N. TO BE COMPLETED BX ATTE TYG FSYSICIM: DIAGNOSIS: et 3'.ftEM4ENT:, ?4q-L-Q„ ,0 REMARKS: Ltkz. o _ '? '?f.! •C`SZ_ L,"`-''?? SS's tf?S?-s?. ?S . ABLE TO RETURN TO WORK: IF NOT WHEN? RESTRICTIONS : SIGNED„ ? wt? LLD' M.D. • fS rltSilF?ti ACS DZPT- 1-f Cf y • S{K8 C: EaFinF_?i+: 'L3.. 83515 OCT 2 198 PLEASE RE'I W CONFLETED FORM WITH PATIENT i l ' 4! I . p "E=qual Employment and Affirmative Action Employer" = 1 ,•, Irt all deaths by telephone or telegram within .h .4 hours. Division aI Workers' Compensation 1321 Executive: Center Driver East Tallahassee, Florida 32301 ATTENTION, W.C. CLAIMS OFFICE Phone: 1-800-342-1741 EMPLOYER INFORMATION EMPLOYEE INFORMATION RM'S NAME NAME !First, Middle, List) SOCIAL SECURITY NUMBER City Of =>tlalrrattar Say N. BSoc, . 263--44r-3889 AILING ADDRESS llnrlude Zip Code) HOME ADDRESS Ilncludo Zip Coda) OCCUPATION MSA nt. workr I (tiioq ? 1400-1/2 X. Carden Ave. P. O. B" 4748 4 + Clt?7fitiW YL 33516 SyUPER?VLI,SsAR'S NAME ?.r? ? l C1?mWS?a rL 335{ `e a iTla l?LJ?ctL ' DEPARTMENT NAME ' Feb. ea wV?XS/a.'ttb. Sox 'W LEPHONE TELEPHONE DATE OF BIRTH SEX reo Code: s 13 ^ • Number: 462--6565. Area Coda:1113 Number, 09-01-33 M ? F OCATION S.M. as Mailing How long Number of hours Q Per Waak Number of days PATE OF PAY a. 17 3 N"t worked 8 r.?' ' 13 Per Dar wo5ed per week ?JXPer Hour 12 S. Ql a AY.e Sr,paece waste or commission, enter if board, lodging or ocher [ PaQr Day C16131> Ate Fa 33516 average weekly (mount advantages furnished, enter weekly ? P r W k . am ount e ee WORKER'S COMPENSATION COVERAGE BY ?Insurance Company Sell•Insurad GIVE NAME, ADDRESS AND POLICY NUMBER OF INSURANCE; COMPANY ATUAF OF BUSINESS OR SELF•INSUREDSERVICE COMPANY. Huniciplnlity £4ERAL EMPLOYER 1.0. (NUMBER 59-6000299 ACCIDENT INFORMATION ATE AND TIME OF ACCIDENT BATE AND TIME FIRST REPORTED NAME, AOOAESS AND PHONE NUMBER OF PHYSICIAN G9,rW86 •- 7:45 A.N. 09/24/6.6 - 7:45 A.H. Doctexr $ z Wjc-lri ClLnic PLACE OF ACCIDENT IStreet, City, Count V. State) LAST DATE EMPLOYEE WORKED 2WO U.S. 81ghvay 19 t;_ 09/24/66 Cleea?ratesra PL 33575 ( 813-799-2727 n Bo*S Prop etrty Sh tv od A RETURNED'TO WORK Yes L:JNo PHYSICIAN AUTHORIZED BY EMPLOYER ?Yes ?No a o val. IF NAME ADDRESS AND PHONE OF HOSPITAL YES. DATE , ClCa"atlIX M=017.01 ) a Pl=idol mnaarrr va.a roc Yes ?No Oar• ?1 1n u,r EMPLOYEE MISSED ONE SHIFT, ONE DAY OR MORE? Yes C) No YJAS INJURY FATAL? Yes No If Yes, Date of Oeain EMPLOYEE'S OESCRIprlON OF ACCIDENT {Give derads turn as, tall, was struck, etc.) DESCRIBE INJURY OR DISEASE AND INDICATE PART OF BODY AFFECTED [e.g. Amputation of right index finger at second point. Fractured ribs, Lead An f],c>}rea vela loading a rail of ttanee on the flat bed Poisoning, etc.1 t=rk and it rolled off the other side and hit Ray oa the right leg. Abrasion of right leg SAF%TY EMPLOYER: I agree with this description? ? Yes ? No If no, explain in comments. ,.- .,, r.* r» r a{-F r*L'p COMMENTS: P. 0. BCa 4745 FLA.. 3351E Employee not available to ni.ga OCT 2 1986 Any person who, knowingly and with intent to injure, defraud or deceive any employer or employee, insurance company, or self-insured program, files a statement of claim containing any false or misleading information is guilty of a felony of the third degree. Y-.?-9a' ?G EMPLOYER (Read and Sign) SIGNATURE DATE EMPLOYEE (Read and S4jn) SIGNATURE DATE LES Form 13CL•1 IRev. 6.791 EMPLOYER COPY ??:? F tr~Au 1341 poRiall deaths by telephone or telegram within 24 hours. DEPAH I Mt N I Ur LHt$Un AluU tlvir?.u t wlcrv I or4uni i 1 Division of Workers' Compensation 1321 Executive Center Drive, East Tallahassee, Florida 32301 ,ATTENTION: W.C. CLAIMS OFFICE Phone: 1-800.347.1741 EMPLOYER INFORMATION EMPLOYEE INFORMATION RM'S NAME NAME (First, Misldlr, Last1 SOCIALSECURITY NUMBER City Of Cloa=,sater Ray S. Brack 263-"-3889 AILING ADDRESS (include Zip Coda) HOME ADDRESS (Include ZIP Codrl OCCUPATION Ha int., Yorker x (5409) P. Oe III 44Bd 1400 -+ 1/2 N. Garden ime. SUPERVISOR'S NAME C'laaZW&tese YL 3351a Cleartrsstore narift Me AWUr-bAWX DEPARTMENT NAME Pub. Nazko/Pub. Service ELEPHONE r TELEPHONE DATE OF BIRTH SE X was Code: 813. Number: 462-$595 Aram Code: 813 Number! NOR& 04-01-33 M ? F OCATION Same its Mailing How long Number at hours ? Per Week Number of days RATE OF PAY pl=, sue? 3 ft worked g ? D worked par week 57.33 per Hour Osceo n 112 S « aY . - Clsaxvatare FL 33516 It piece work or commission, enter if board, lodging or other average weekly amount rcvantages lurnishad, enter weakly ? Per Day amount ? Per Week WORKEn'S COMPENSATION COVERAGE BY Qlnsurenee Company Self-Insured GIVE: NAME, ADDRESS AND POLICY NUMBER OF INSURANCE COMPANY INSURED SERVICE COMPANY OR SELF AURE [?F BUSINESS T . - ? t ?0 9YER I.D. NUMBER 7 ZifS9? - ACCIDENT INFORMATION ATE AND TIME OF ACCIDENT DATE AND TIME FIR5T REPORTED NAME, ADDRESS AND PHONE; NUMBER OF PHYSICIAN 109/23/'86 -• 11:30 A.M. 09/23/86-- 19;30 A-1q. DoctOr+a V&lk In Clinic PLACE OF ACCIDENT 151reet. City, County. Statal LAST nATE EMPLOYEE WORKED 2600 U.S. Highway 19b A. - . x _ • S/- 4. Clearwater, FL 33575 (813-799-2727' S. E. Pe=t RETURNED TO WORK Yn o NNo PHYSICIAN AUTHORIZED BY EMPLOYER ?Yes ?No 3290 S.R. 590 IF YES, DATE NAme. ADDRESS AND PHONE OF HOSPITAL Clft,nrWat *r (Pinol3aall Floridit mn10vN414.Plor Yn ?No r 0Jlf ton EMPLOYEE MISSED ONE SHIFT, ONE DAY OR MORE? Yrs G No WAS INJURY FATAL? OYp SNo If Yes. Date of Death EMPLOYEE'S OESCRIPTION.OF ACCIDENT iGivr aeulls suet, as, fell, was struck, etc.) DESCRIBE INJURY OR DISEASE AND INDICATE PART OF BODY AFFECTED (a,g. Amputation of right Bay was digging a hors for a f+enaa posst sthan the pout Po toning, etc.)at second IQlnt. Fractured ribs, load hole digger got ztuck !.n the gram-id. When he tried to pall it up, the trigger got zt=lc and twisted his assts iato the holder of the post }tiClg .digger. Contusicm of right amts Fj DEPT f.• 5? EMPLOYER: Iaguewith this description? ?Yes ?No 11 no.raplainin comments, T,„?/„c7 ?• COMMENTS: •?rr'? rLA- 3351.8 Zinployee not available to sign n A. P' a• gt7 ?7 9 ...,, O CT 2 19861 Any person who, knowingly and with intent to injure, defraud or deceive any employer or employee, insurance company, or self-insured program, files a statement of claim containing any false or misleading information is guilty of a felony of the third degree. ? 4.4 4. EMPLOYER (Read and Sign) SIGNATURE DATE EMPLOYEE (Read and Signs --„- - SIGNATURC DATE ' 677-/J,-? 7 ?-e-•f ?. ?f 14-P7 LES Forrrf ACL•1 IRrv. 6 713) ?.a.?:? v? .?...... F:h4pl nYFR COPY -7 ?a 1. ?.ZC7 L ??Ei?t?"?? CLEARWATER CITY COMMISSION Agenda Cover Memorandum Item a 11/2/92 ?9??rrEa`?°? Trustees of the Employees' Pension Fund Meeting Date: Subject: Purchase of Pension Service Credit Recommendation/Motion: Lois Maroon be permitted to puchase pension service credit for a four-year, four-month period of time between July, 1985, and November, 1989, by the payment of the equivalent of 8% of her salary during that period of time, without interest payment, and that the payment of monies for such purchase be allowed over a reasonable period of time through payroll deductions. ? and that the appropriate officials be authorized to execute same. BACKGROUND: Lois Maroon was employed on September 27, 1978, and resigned on January 4, 1985. Upon resigning, she received a return of her pension contributions. She subsequently withdrew her resignation and was re-employed in her former position on July 15, 1985, During the 191 days between her resignation and re-emplayment, she turned forty-five (45) years of age. On August 13, 1985, she appeared before the Pension Advisory Committee (PAC) to request to rejoin the Pension Plan by returning her pension contributions so she could receive pension service credit for the time of her original employment period. The request was denied due to the age provision in the pension ordinance. Ms. Maroon was not allowed to buy back her pension service time nor re-enter the Pension Plan at that time. Four years.later, the age-45 limitation was removed from the pension ordinance and employees were given an option to join the Plan. She rejoined the Plan In November, 1989. On January 8, 1992, Ms. Maroon returned to the PAC to request to buy back her previous pension service credit (for her original employment period of 9127178 to 114185). She additionally requested that the Pension Plan grant her credit for the four years between the time of her return to work and her re-entry in the Pension Plan. The PAC passed a motion that Ms. Maroon be permitted to buy back her original pension service credit time by returning the pension contribution amount which she withdrew upon resignation In 1985, plus interest, and that the Pension Plan grant to her pension service credit without contribution by her for the four years and four months she was not covered by the Plan (July, 1985, to November, 1989). The amount of pension contribution withdrawn by Ms. Maroon when she resigned In 1985 was $10,090.12 and the interest calculated by the Finance Department was $2,320.04. The Finance Director advised that there would be a considerable difference between the cost to the Pension Plan and the amount of pension "contributions" that would have been made to the Plan for the four years and four months Ms. Maroon served before being readmitted to the Pension Plan. The pension "contribution" would have been approximately twenty percent (20%) of her salary for that period of time (an 8% contribution by the employee and approximately 12% by the City). The total "contribution" amount was approximated at $27,717.48. At that time, the Finance Director advised that the actuarial cost to the Pension Plan for granting the four years and fours months of pension service credit to Ms. Maroon would be considerable and could only be determined by an actuarial study. Reviewed by: Legal PA- Budget NA- Purchasing UA` Risk Mgmt. V/1" DIS Mi?- ACM _-k Other WA- - Originatin Dept.: A Human Resources User Dept., Advertised: Date: Paper: E Not required Affected parties ? Notified 54 Not required Costs: a-f-le Total Current FY Funding Source: ?.i Capt. Imp. Operating l-) Other Submitted by: City Manager Appropriation Code: Commission Action: ? Approved IJ Approved wlconditions ( Denied L Continued to: Attachments: Actuarial Study L] None Lois Maroon Agenda Item Page 2 November 2, 1992 a The Trustees, at their meeting of March 2, 1992, approved that Ms. Maroon could buy back her original pension service credit time that accrued between her Initial employment on 9127178 and her resignation on 1/4/88 by the return to the Plan of her, contributions ($10,090.12) plus the computed Interest ($2,320.04). After this Trustee approval of that portion of her request, Ms. Maroon made the payment to the City Pension Fund to gain the pension service credit for her original period of employment. The Trustees rejected granting pension service time without an employee contribution for the four years and four months of time. Ms. Maroon subsequently employed an attorney and actuary to further pursue her desire to be credited with the four years and four months of time between her re-employment and her re-entry Into the Pension Plan In November, 1989. A presentation was made to the PAC at their meeting of October 21, 1992, with the employee requesting to be credited the above-referenced time without employee contribution. This presentation included a report from Eugene H. Frost, Enrolled Actuary with Dun & Bradstreet Pension Servlces. Upon discussion as to whether the City should have an actuarial study performed on the cost of the employee's request, the Finance Director Indicated that the actuary's report submitted by the employee was reasonable. It was the position of the PAC that Ms. Maroon be allowed to "buy" the requested four years and four months of pension service time by paying to the Pension Fund the amount of monies, without interest, that she would have paid Into the Plan had she been covered by it at the time and that the Pension Fund absorb the employer cost. It was further the position of the PAC that Ms. Maroon be granted a reasonable period of time in which to make this payment through payroll deduction. This decision was predicated upon the efforts made by Ms. Maroon upon being . ro-employed to rejoin the Pension Plan and the circumstances which precluded that occurrence at the time. After the PAC's recommendation, staff contacted the City's legal counsel as to whether approval of this action would impact the current suit by AARP against the Pension Plan. Counsel related that to allow Ms. Maroon to buy back pension service credit for a time when she was not eligible to be in the Plan might adversely impact the position of the City in the suit. Based on this opinion, staff recommends that the PAC's action be deferred for further review as to whether an error occurred in not allowing Ms. Maroon to rejoin the Pension Plan when she was re-employed (and, if so, how to correct that error) or, If no error occurred, the deferral be made until such time as the Pension suit is concluded. e ?,; .,_?.. E .,, ..: ....... ........y ;'?f i. , is .j.., .t: •t` , ' `_' ,' "`1?l?.' }..,_.?.. , Dun & Bradstreet Pension Services = WW 01, 'try ihcn 'r,a > ? r orK,on 2838-F-1-85 Sbuth Service Road ' P.O. Box 669025, Charlotte, NC 28266 (704) 392-1610 1-800-627-1610 FAX: (704) 392-4187 ,September 25, 1992 Nancy Paikoff McMullen, Everett, Log an, Marquardt & Cline, PA . Post Office Box 1669 Clearwater, FL. 34617 Re: Lois K., Maroon Your letter dated 09/22/92 Dear Ms. Paikoff: Based on the suggested salaries, we would have the following salary history: Year a!a 1985 S 14,950.79 1986 $ 28,186.19 1987 $ 29,55950 1958 $ 31,890.88 1989 S, 34,320.95 $138,908.31 The employee contrib utions which would have been required is ,08{138,903.31} or 511,112.65. The benefit 2.5%tirnA high 5}'ear salary. The salar; for be.^.ef;t purpoves would be as follows: Year a!a 1987 $29,559.50 1988 $31,890.88 1989 $34,320.95 1990 $28,713.32 1991. $39,370.82 Average $2,564.26 The benefit lost would then be .025 X 4.333 X 2,564.26 or $27-7.77 per month. Actuaries * Benetit Consultants • Pension Administrators i w•?'i 1 .. 1" .?.1'.S? -.`Sa. • y .+.',_!. r '''r?..=s'.+ . ,=1.... t.=. .. .Y9r F ' Ws. Nancy Paikoff ` September 25, 1992 Page, 2 ; Assuming continuous employment, Loss Maroon would be eligible to retire after a total of 20 years of service. 'Section 2634 of the Clearwater Code allows retirement at age 55 with 20 years of service. This would be payabl ' e at age 58 assuming service is counted or age 62 if service for the 4 year period is not considered. he problem then is to consider the dif rename„ the present value annuity _of 20 X-M5 ?2,CL4 26 -o $12.82,1,payal?le at 5$ versus the 5 m er?efit „per le at age 62. According to your information, there are no survivor benefits payable to Ms. Maroon. 65sumptiQna Mortality:. Unisex Projected to 1984 Interest: 7% Lump Sum Present Value: @ Retirement Age 58:, 198,748 @ Retirement Age 62: 131,968 (Assuming the same average salary) Difference in lump sum = 66,780 If we look only at the $277,77 per month payable at 58, the lost value is 521,529. Therefore, if we look at the . total lump due Ms. Maroon, she would be due $66,780 - 511,113' or 555,667. If we look only at the lost benefit, we would get $21,529 - 511,113 or $10,416.. The retirement age is vitally important. Sincerely,. DUN & BRADSTREET PENSION SERVICES Eugene H. Frost Enrolled Actuary EHFJkjk .•.1