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" ' � ; . .. . � .. � . . , . , . . . 2. � 1 . Appro�ai of �Minutes � , . ' � . . " ' � . ., - '� , , of 91/30/92 . , � . , , � ' . � ' i ' � . � 3. � Request'for accsptance � ' ' .� � '" , � ' ' . . , � � a into membership: . . , � , � , , � , ,�� . . , , . . � : , . a1 Ann � Scheffer �' . : , , � ' .: . � b} David �letcher , ' ' ' " . ' � . � � ; c} 5tep�anie 5tefanefli � . � � ` ' . ". .� � . , , , , , . � " � � : dy �auis Corona I! � ' . � , . � , . . �• , e3 Marga K. Gusta�son . � . , . � � � � ,� � � . � � � . f}, Daniel W. 5laughte� ' � , � . � ' : � . . . •. . g} Dprek D. A�yers ., . . , , . � � . , � � , �. h1 �Don�ld L. Welch, Sr. � , � � � � , . . ' . . . . ` ' � , . '_ ' j . 4. Pensian{s) ta be granteti: . , � ' � . � � . � . � �;. , � � .lob-Connacted Disat�ility ' � , `. , . . I .. , � a} Si�irlsy� Mabley � . , � ' � : ' . . , � . . . bj Arthur Carpent�eri � . . � ' � � � c) Calgb Winstan � . - . , �, 5. Authoriza a�ontinuation of 8% � � . employee contribucia� to the � � � , . . ` � Pension Plan for ca�endar year : � � � � � ' � ' , . ' ' 1993 ar�d designate a city . � . . � contri�utian far fiscal 1994 which . � � � � � • � ' � � is equa! to the actual emp�oyee . , �. . . :, � contributians for 'i �93 . , � , . � . , . � 6. � Other Business: � � � � � ,. . . , . , , ' � 7. Adjaurnment: ' � . ' � , . �, �,,�. . • . ., .. , , , , , .�. �� . ' . . , , �1 , � I, . , . ."�'. ..',� .. . . . .. � I �. , . « CLEARWATER CITY COMMlSSI(3fV� Agenda Go��r Niert�orandu�t 12i1a�g2 �'�y.��`n , � Meeiing DRtn: ,�,�� T�ustces of � thc Employccs Pcnsion Fund Su�ject: : � � , , ': Mcm�ic:�hip in Emplayces' Pcnsion Plun � RecommendationlMotior�: - � � Employce(s) listed belaw be accepted into thc Employces' Pcnsion Plun as recommended by the Pcusian Advisory Committce. � � ❑ and that Ihe apprapriate ofilcials be authorizad ia exacule same. BACKCaROUNU: . ' � ' . . U�tc Seniorit.y Pcnsion Nt�me aR�� ASS D D'v � E iv Ann Scheffer, . Librarian i Library � 11/26/90 � t 217/92 David Fietcher, Maint. Worker I Pub,� Wks/Pub. Ser. l�}/i9/92 � 1OJ19J92 � Stcphanie Stefanefii, Staff Asst. I. Pub. W.ks./Trans. i 1/ I 6/92 1 i/ 15/92 La�is Corona II, Pa[. Soc. Ser. Spcc. . Policc � 1/3(1f92 1 2/30/42 IViargo K Gustavson, P�lice Recruit T Policc 11/2192 I�/2/92 Dani�l� W, S�aug�ter, Policc Recruit I Palic,e 10/i9/92 lU/19/92 Dcrek D, Aycrs, Equip. Operator I Parks & Rc�. 1 1/ t 6/92 l 1/ 16/92 � Donald L. Wcich, Sr., Pal. Com. Oper. Policc 5,'10/$8 9/7/92 � Item � Re�tewed by: Origin�ting De�t.�� Costs: �� Commisslan Action: Legal�_— Nf`� Hurnan Resaurces �Dta ❑ qpprovad � Sudget _.��,..,.�.,..,^ ❑ A�proved wlconditions Purchasing �N� US�r Dept.: • U DBnfed Risk Mgml. Currenf FY � Continuod to; DIS � Fundin� Source: ACM Advert[sed: �� CapL Emp. lllhnr �i ' j�""� Attaahment$: u Submlttad by: D�3e. ' Paper: Not required AI1 cted pr�rl�es ❑ Notified Nat requirad Operaling ❑ Other Approprlallon Cade; � Npne Lclt�r(s} � , ,' , � , �, , , '. ' � ; � , . � � � '� , � � . . , � , � , �l . � � � . � � , . . � � ' � ' . � ' , . • � ' `[ . w::�..=:r�;f,• ;,F.;fs , ,..; ?I. s.. ��1� ;�,4:l9' . . ,,:i� , e .. .... � . t • . � � � ' . . ' . � '. � ' . � ' � << . � '� . • � • ' ' / � .� . . � � � . � . ' - • . ' � � . ' � - . . � ,�, . , , . . . . . . � � . . i � � ' . C1TY QF CLEARWATER . ,: ' . . EMPLOYEES' PENSIQN PLAN � ' , . PFNSI{lN ADVISQRY COMMIT�'EE • � ' 'I� �. Pensior► Trustccs .. , � . ' FROM: ' Pension Advis'ory Con�mittcc . . . . � StJB7EGT; Rr.commendt�tion For Ac�cptttnc into Pension Pian ', ' � DATE Decembcr 2, �44,2 . , � � As Trustees of thc City nf Clefuwatcr Emplayccs' Pensian Fund, ynu arc hercby natificd that thc � ' crnployecs liste� be�c�w t�avc becn d��y cxdmined hy 3 Ioca� phys�cian unci euclr nus bcen . , de'signated As a"�rst class risk". '� � These Cmplayces are eligiblc fur pensinn membership A5 noted in the Pertsion Eligibiiity F]ate ea2urnn be1Qw. �nd ii is t�te reroittmencfAtian af ih� P�nsian Acivisary Cnmmitiie ihat thcy b� ' , acccpted into mcmbership. � , � � . Pension �lig. , B1rt� D�tc �1irc I3arc � Ann Sch�f�er, Libraris�n � I, LibrAry , 612&/49 11/25�9Q . 12/7/92* • '�Employce hired fram permancnt part-time � ta ful!-timc permanent status.. Hire date ref�ccts d�te hired us permancr�t �rart-time. David Fletcher, MaintenAnee Worker 5/26/69 10/19/92 � 10/19J92 l, Pubiir WorkslInfrastructurelPublic . Service Stephanle Ste�nnelli� Staff Assistunt i, 3/30J55 11/1G/92 11/16/92 � � Public WorkslTransportatitin Louis Coronn II, Paticc Soclttt Service 9127/SS 11/3Q/92 11130/97. 5pecis�list, PalicP llepArtmeaE � . M�r�o K. GustAVSOn, Pojice Recruit x, 3/14J64 ll/O2/92 11/02/92 i'olice Department � Aan�el W. 5luughter, Pofice Recru�t I, 12/27/69 ID/19J92 . 10/I9/92 Police Departmet�t ' Derek D. Aycrs, Et�uipiment Orierntnr �, 7/2/62 Z 1/1C�/92 l I/16/92 , Pnrks . & R�ecre�ti.on Depurtment Donald L. Welch, Se�eior Police � 10/6/46 SII4/88 9�7/92* ' Cammunicattnns Operator, i'olice Department ' . � *Employee's pension date reflccts re- . employrrient dqiC (was not prcviously PCi151U11 Plan participant). Hire ciatc �djusted accordingly. � �.�» � . ' . ... . , � , . � � ��#�y~�'; � CL�ARWAT�R CITY �QMM�SSION � w � a � -�.,,1 � A�I�nde CovQr Memorandum i��, �w ' �9�'�Irfp`��. Trustccs nf �h�e Employccs' Pension �unci Meflting Dat�: �� Subject: . Pcnsinn Ta Bc �rantcd RocommendatioNMotion: S��rlcy Mablcy, Rccrc�tion L��dcr, Parks & Rccrc.ht�on T�epnrimcnl, bc grnnied a job-connecied disabiiity pcnsion un�er Scctian(s) 26.35 af thc Employc�cs' Pcnsion Plan us rccommcndcd by the Pct�sian Advisory Committcc. ❑ a�d ihat lhe appvapriate oHiclala be autfi�ortzed tn execute same. BACKGROUND: N.�.� S�irlcy Moblcy, R�cr�ation Lender, Parks & R�creatinn Department, was cmployed by t�e Ci4y on January 9, 197Q. Si�c bcgan participatin� in t�c Pcnsion Plan an May 29, 1978, when her �vsition tivas canvcrt�d ia fu11-iim� status. She has a back prablem which resultcd in her �pplicutian far a job-conr�cctcd disability pcnsion. Ms. Mablcy suh�nit[cd �cttcrs fram Ur. Cynthia Huffman (dated Au�ust 3, 1�92), Dr. 7amcs Rivcnbark (dated 3uly 1S, 1992) and Dr, David Seales (datcd Junc 17, I992} in support of her request for a job-connectcd disability pension. Ms. Mobley's disAbility pcnsior� was apprvvcd by the Pension Advisary Conjmiucr. (NAC) �t its meeting of Occabcr 21, 1g92. Based an an average salary af approximaEely �i9,175 over ihc past ��e ycars and t��c seventy-fivc perccnt {75%) n�inimurn disability bca�e�t, Ms. Moblcy's pcnsion will approximate $14,38Z ant�uAlly, Charts i'rom Financc which takc into considcration mortality rAtes and uge rcflect the "present valuc cosl of iin�neing° this pensior� wiil be apprnximatefy $170,401. On Nave�nber 2, 1992, the Trustees remandcd ti�is to thc PAC pending rcceipt �f a IcbAl opininn as to whether nr nat under thc RDA and the City's Pcnsion Plan ttie City could mahc rcasonable Accommodatians t'or ur� cmplc�ycc and pluco that cmplayc� in �not��cr position, An apinion was rcccived frorrx ihc �rm of Thonipson, Sizcmorc and Gnnzalcz, P.A., it2dic�liing th�t. thc City could m�kc an accommod�ti�n iar an cmploycc but thc cmpioycc would not havc to acccpt it. I� addiEian, t�n employcc is cntilleci to a disability pcnsion if in thc opinian af thc PAC tUat cmploycc cannoi perform thc dutics af his/i�cr job, On Dcccmber 2, i992, the PAC reviewcd this matter and thc lcgal upini�n recei�ed. Ai ihc conclusion af its reviCw, the Committee, by �nation duly madc and scconcled, again movcd to a�provc the jab-connectcd disability pension far Shirley Mnt�ley and scnd it back �o the Trustecs. Reviewed by: Lepal A1 A- Budgot �%� Purchasing ��±- ._ Risk Mgmt._�._.__.. DI5 �. ACM YL Other ��r _.� � Submitked by; City Martager Originatin� Dept.:�CJ'/ Cosls: Hu��an Resources User Dept.: Advertisoti; Dato: Paper. � Not roqulred A((octed p�rties �.� Notified 1?a Not re�qufred Tota! Current FY Funding Saurce: ❑ Capt. Imp. L� Uperatiny ❑ (}Iher Appropriallon Cade: Commissiors Action: �� Approved C4 Apprnvod wlconditions L�l Denied L.] Contknued to: Attachment�: U None Lcttcr(s) Rcqucst Form .�■w ,' � .. .. , . '�.. , . ,, .. � . . ... . � �r�:.�,��_ . i. , � � � � � - �: t11 .. • .. � F�raunr�l O�p�rtm�nt 4d2�070 C i T X ,t , . ' ' O�' C L E.P�, R W A T� I�, Ii � POST OFFICE BOX �748 CI.�ARWAT�Fl, F40RIDA ��d618•d7�/8 T� ��OR0�1b�C Mayor and 1Vi�mbcrs af thc City Commission as Trustecs of thc Employecs' Pansic�r� Pla� � FRQM: Pension Advisory Committee . � C�PiES: Shirlcy Mabley; Risk Maz�agemcut; Da�z Deignan� Assistant Dircctor af Administrativc SGrviccs/Financc Dircctor; Employec's File StIB]EGT: Pensinn for Shirfey �viobl�y�---7ob-Canacctcti Disability Pensia�t � DA'I� 4ctober 2I. i 992 � Thc Paasion Advisary Committec (PAC) receivcd an a�pli�ation for disabiiity pcasion from Shirtey Mob[cy on August i8, I992. �s. Mobley has bcen detcrmincd by thc Pcnsion Adv'ssary Committec ta mcct thc rcquircmcnts of the Pension Plan �'nr a jab-co�necied disab�li�y pcnsion. She was employed by thc Cicy on October 9, 1970. and bega� Qarticipacing in thc Pcnsion Plan nrz May 29. 1978. Further. shc has submittcd mcdicai documcntatio�. copics af w�ich arc attae6ed, reiati�e to hcr disability which �as becn rcvicwcd and approvcd by the PAC. Hy motion made and duly carricd at it� meeting of Octabcr 21, 1992, thc Pcnsioa Advisory Commituc appraved/rccvmmended tt�c granting of a�ab-connectcd disability pcnsion to Ms. Mobley in accordance with prflvisions of Section 25.35 of the City Cade. This peasiqn is to ba cffccti�c on a datC to bc . dctcr�iacd. T�c amo��t af Ms. Mobley's paasion will bc calcnlai�d by ti�e Finat�cc Departmen� according to lhe fvrra��a .in the Pcnsian P1an for job^CDRIIIICCiCd disability pcnsion at such tima as her last fivc ycars of service and saiazy can be computed. I hcrcby �crtify that the Pcnsion Advisory Committcc has appraved the granting of a jab-co�nccted disabi�ity pe�sian far 5Y�irley Mobiey and the sbave datcs �re corrcct. .. �� .I ` . . � Gt. G%�: f � L�-�- Ciia.irman. Pe�tsioa Advisary Commit[ee � r � J � � �� ;:�; .,, .,�: � +,�J ';��a1 Erriptoyment and Atlirmative Actio� Employer" f , � • . i ' I . . � . � . . �� . ,. � � . � ' � . . , i . . ' . .�. . .� . , . . ' . � ' . ,}:..: i.:p�y��t�'��:�>,`�,r�•.• . ,'�is .l e ;.t�..,�.. � �s„ .. • a • � � . �. .. . „ o .. ' . ..'. � . • . � ' . ' � .� r ' ° .•t�. ' , � � FENSIQN R�QUES'�' FORM . � Sttirley Mabley �� da hcrcby apply for rccircment I. frorn ti�e City af Cl�arwatcr Gcncral Employees' Pcnsiori Plan. My bettefits date ia M�y Z�, 1�� ' (Entry dat� i�to �ension plAr�) My d�cte of h�re is _,�„^�°�r 9, 1970 , , . My birthday i� Oc�obex 12, 194G � . My job el�ssific�ttion is ��creatian L�ader and i woric , , � �� 'arks & Recrear�.on Dep�rtment, ��reation Divisiqn. M y resign�ttipn d�te is_ Co be determined The typa af pcnsion far which I am applyiag is (chcck only one): . Reg�lar Ptt�sian bascd on years af service ' - x � � • 3ob-coranccted Disa6ility Fension � Noa-job-eonnected ' DiSability Pension My� spousc's aame�[s: Roman Mohley � � Dependent c3�ildre� under the age a[ ],8 �nd residin� in ' my huuSeLo[d are: (Pcirtt Chil�'s F�tli Name? (Child's Datc of Birrh) I t�ereby certify nll � af thc above to he we and �orrect; . {Auguskrl�, 1992 �[�,v� C _ (Date) �Q {Nqtary Publir) � F��I� ��uT,��{ PU�LiC S P S�PZ.Z�.199; ,��£D Tk#RU GEli�RN. IF�S. Ulifi]. ' ' � t �. . � 1 � . • �; . . , • . �.. � . .s. ,. � , ' � : , . .• � , ' � '. � � . . . �i . ' ' � . . " . '' , , � t ' � . � ' • . . k •' ' � , " � �. • � � � ' , . . ' . , . . ` . . ' . . • .. � � . . � ' � . � I , .' . . � � ' .i . � . , .. � � . , i, • ' ' t � , 1 , , ' < <� � � , +I'�.S't '.�S:i�:e 11•. �.i .�.�•, ..J.l�1r... . ....,.. .�. . .. �. . - ' . . 0 .'t�'� , . . . . . . � . . ,� , ., .1 . I .1' . � t ' CITY OF CL�ARWATER � � � , � , GEN�RAL EMPLQY�ES' PE�fSIQN PLAN � � . � � , ' � � , , . QPTIONS - G�NERAL EMP�.OYEES , ' . �• • . OFTT�ON �#1: EmQlr�yecs can rtccivc a lump sum paym.e�t for '' �� vacation and holiday pay as�d 1/2 of accrued sick leave at the tirne of scparation �'rom the City. Thcrc wijl �e na � ' 8% deduction for pensic�n from this �ump sum payrrieat � nor will this amount caunt as earnings in the . ' �a�cula�ioa of thc pension. Th� �ast day of wark wiIl be ' thc tcrminacion date and pcnsio� bcnefits wiil bcgin � , � :he followiz�g day. OPTYQN #2: � Emp�oyee can extend tesminalion date by the timo due ' {Qr�ly available to for vacation, holiday pay, and 1/2 of accrueci sic4c leave. , emp.lvye�s hired Tcrminatioa date w�ll be; t�c fnal day of extcndcd time. prior • in 1411194} Pensior� b�nefits. will btgin the follovving day. .` *�*��**�***�#**��*****«�« I, 5h4.r�.ey Mqbley , an empioyee of the Ci�y oF Clearwater, hercby ap�ly far pension bcncfits uader thc Gcneral Emp�nyces' Pcusi�n Pian. I hercby certify tha� i fully uaderstand rhe two options offercd to mc. I Ghoosc � co rctire using Option # � and wish my benefts to be calculatcd under LhiS OptiOn. I understand that once this form is signed, my decis' n is irrcvocab�e. EMPI,OYEE'S SIGNATURE:,, . tN . �SQCIAL SECURITY #: 2�7--$2�3958 W[TNFSS�=S: ADD S• __�1Q04 Palmet�o Street r.�.._. ��. , , � � C�.earwater, FZ, 34&15-423I � DATE;_ Augus� 18, 1992 9 � 6ri3a PARK STREET NORTFI surre aw ' ST. P�T�'ASHUF�Ci. FL(]RlDA 337QS1 i!! 13f :S4a-22G3 1 S' � � 0 WILLIAM R, GREENB�.RG. M.O.. P.A. QC� �y �� M�kCAL i�lttl110�00Y � . , � b3Q7 J14Alf�1 ST1iE�'i surr� �os , � NEW POR7' ii}CHEY, FI.ORl1?A 348132 �813� dds-%li78 Advisory. Committeo c/o �i. Michael Larse� Human Resources Director City o� Clearwater P.�. Box 4748 Clearwater, Florida 3461 g Qciober 5, � 992 Re: � Shirley Mab�ey Social Security No.: 267-82-�958 De�r Si�': � � The above patient was seen in the nffice #aclay far aR independent medical exa�mir�atior�. A tzisiory was obtained irom ths pat�en#, p�rtial mQdical r�cords were a�aiiable iar re�iew. ?UIs. Mobley is a 47 year old Black fema�e, right-ha �;��d, with a c3�ie# carnplaini of back an� leg pa�n. She aiso r,arries th� diagnos9s of systemic lupus, beiRg follarved by Dr. Wassan at the Diagnostic �finic. For the latter disease sha is currently taking Prednisone 2.� mg a day, also Carafate, Tagamet, Librium, ar�d Tyienol #3. She reiates a iob-related injury in September 1990, where she injur�d t�e r�ght leg. The pain went from the heel toward the Ftip, Iawer back. She was saeR at a Idcal walk-in clin�c, thQr� by orthopedic s�rgeon Pai�ic�C Log�e. He initially saw her on September 24, underwent an epidural steroid in�ection with no improvsment. A CT scar� or� �ctober 11 ��990, was repotted as nat s�owing evidence for a hemiated disk; r�oted as calcifica#ion ir� the abdominai aorta, these were also sa9r� on the� r!2�n sp�r.A #ilms vrF�ich were re�iewed today. Dr. Lague feit the patient couid r�turn to her regt�lar;�b in D�cember 199�. I do nat have full medical records, b�t she was seen by nec�rologist Michael Ar�driola in Septembe� � 991; he #elt sk�e couid be workin� a 20-30 hour wor�c week. He brought up the subject of a sleep disturbance and p�aced her on Amitriptyline, b�t I'm not sure if s�e ever actually took this medicatior�. .. . , . City of Clearwater Re: Shiriey Mobley �.^#aber 5, 1992 Page 2 . � She has been follow�d En the clinic by a rheumatolag�s# WassoR, also by neurologist David Seals, and a second opinion from a Dr, Huffman. Dr. Sea�s saw the pa4ien# �n May i99�, he pQrtormed etectrod�agnostic st�dies; i do not ha�e the reports. There was mention o� � priar MRI which was not ava�lable for review, eventually he proceeded with a myelogram and CT scan which were reviewed today. There is evidonc� tor spina� ster�os�s due to a combina#ion of a buRgting disk at L3-A, ligament �ypertraphy. At L5-Si t�ere is difficulty seeing the S� nerve root� there is no evidence for a herniatian oi a disk. in one af t�e follow-up notes there is mention of an abr�ofmality invQlvi�g L5. She was seen by the orthopedic surgeon Douglas Weiland w�o r'ecommended surgery, the patient has b�en cor�cerned over this as i# mav cause � i�ara�p uT ne, lup�s. At tl�e prese�t tima, the patient is amp�oyed by the City of Clearwater and i�e Recreation and Park Department. Her job entai�s some heavy activi#ies of beir�y with tt�e children� st�e has triod r�ot to be outside d�e to the expas�r� ta the sun aggravat�ng the�lu�us. S�t� has pmbieRts in sitting for more #har� ter� m�nutes, waiking, I�ying dawn gives� her 5ome relisf. In general, upon awaker�ing in tne m�rnirtg she has pains, difficulties getting out �# bed. The pain is mostly ca�tered in the back, radiating down the right leg, although there is also pair� in the left. Soma days are better t�ar� others, and st�e can move a�ound. Upon walking she describes cramps in�olvin� the right �eg, pain from the i�ee! up toward t#�e buttocks and into the back. , This aiso pcc�ars aft�r sitting, and she is limited to ten minutes. She has prablems iri #inding a camfortabie positian in b�d. in li�tening !o this patient, there have be�n problems with s�eeping, both staying asleep as well as awakeniRg and difficulties #a�fir�g back asleep. This has been going on fior apprQximate�y two years. Tl�ere has also beeR a sense of numbness of late involving the feet, a�d some tingling in the hands. She describes m�scls aching invoivir�� #he legs, on�e more mare on the right i�an tt�e Istt, some neck pa�n, upper arm discomfort as we44. There have been nn trouble ir� swalbwing, cl�ewing. �!za d�s�ribe� i�tia�ac�ies whicr stre5s has a reiationship to� #t��se havo been noted in the past a�td s�e had a CT scan done a couple of years ago for frantal headaches. She deRies any TIA li�Ce symptomatology, nn �istory of strokes. Her iupus. h�s been under pretty gnod control, s�e has cardiomegaly on her chest x-ray, t�e aforementioned calcification in t�e aorta. ln the past sho's ha� G sections, renal stones. She has been a cigar�tte smoke�. �c� exam today #he patient is in mild distrgss, dur�r�g some of tne exam portions sha became qui#e tearful. She is alert, �as grossly normal mental status test9ng and sp�ech function. Crania! nenres 2-# 2 are intact. 5 .. Y�' �. ' . ' ' ' • . ' . _ . �ity of Clearwater Re: Shitiey wlobley Ociober 5, 1992 Page 3 The neck is supple with normal range of motior�, sho�lder range af motion is normal. � � There is na pronatar drif#, #her� is narmal tone and no tremor. On muscle te�ting of t�e upper extremit+es, there is no focai weakness. The muscie stretch reflexes are symmetrical, there is a mi�d diminishment to piriprick and touch di�tally in a glove dist��bution; posftion and vibraiary are intact. The patie�t sits uncomfortably� she is able #o ambuiate r�awn tf�e hallway rrvith rtjarked favorir�g af the rig3�i l�g. She complains of se�ere pains around the hip, gluteal region, and explains t�at's why she has to limp. There is a limi#ation far ;orwa��a �'fexion to 70°, reirof�exion to 5,; upon la#era� rotation she contplains of severa pains in t�e back into th� buttocks. She has prablems in walking on her toos and heels dua to pai�, a Romberg is r�ot present. Layin� flat in bed, she get� comfortable; there is marked pair� reprod�ctior� upon palpating along the posteria� compartment over the sole�as, gastrocr�emius muscles, ar�d over the hamstrings, left a�d rigi�t. �r�nging the knee up toward #he abdomen she complains of pain involvin� the hamstrings, and on straight leg raising onca mare tha discomfort is mare invol�ing the hamstrzng� rat�er than the Eower back. T�ere is tendsmess ove� the paraspina� muscfes, but it appears #oday the h�p regIon which is quite tender, and hamstrings dominate. Muscle testing shows give-away strenc�th distai�y invoi�ing the ankl�� tae dorsiflexo!^s and pEantar flexo�s on the right. The knae jerks are 2+ symmetricaf, L am abie to abt�n an�le jerks though they are oniy 1+� the toes are plantar fisxor. Or� ser�sory exam, there is � s#ocwng diminis�ment #o pirtp�ick and light touch, cold. Position sanse is miidiy diminished bilateraliy, vibratory sensation is felt on the left ankle but not on the right until the hip. There is no spinal tanderness present. The peripheral pulses are intact. The remainder of the exam is without ab�ormali#y. � �n summary, this paiient has a combination of factors invoEving t�er iower back pain. Based upon the anatomicaf s#udies Yhere is an element of spinal stenosis, and �,nssi"!a ne^ao roc� ir�ta.�c� �� ti�e Fi,A�. i ne airiicLftie� ar��,oun#ered are bo�ng at the patient's clinical symptomatology and overal! presentation. Based upon the history obtained, she sustained a mild stretching type injury invo�ving the leg, by the exam today there are continusd musculaslceleta� problems, and I believe they dominate the clinica! si#uation �of pain. I ques#ioned her regarding ti�at at�d there is sam� relief whic� would subs#anti�te a muscle etiology. Some of the pain sho d�scribes would fit into a diagnosis of a lumbar spinai stenosis, o�e problem is the significant pains she canstantiy experiences invoiying the back while sitting, moving abau# which would be out of proportion to be expected with spinal ster�osis. � I '.. � . .. -. ��,,; , � . � ! r � • . ' ' • � ' ' � � ' � � ' ., � , . ' � . ' ; ' . .i . .� . . , . ,'r, ' ' , . ' . . . . . � , ' , . . . ,' : . � ' � 3 , .. - - , � . � , � . r � , . ♦.. x.�. . s e... , i e�.. .r+.. . �. . •.. . . . ' ,. � ..t � . .. ' '.4 �. ' , _ ! � �r�5' .. � . � . .r . �[ili . .l� . . , , � C�ty ot Clearwater � , � , � � Re: Sh��1ey Mobley . � ' , � . . � � 4ctober 5, 1992 ; . . , Page 4 � , � . � � Otk�er conside�atio�s tn her cor�ditzon a�e the poss�bi{ity of r�ascular disease, as t�ere is significant calcification on her abdominal �orta, artd #�e ather ma�or prablem . which I feel #�as been passed over is, �er depression. Tf�is pa#is�t has s�eep disturbanees� symptomato€Qgy consistan# with depressioR, aRd this wauld have a major teedback into the muscle pain, continued discamfort and Iimitations she dascribes. . � . � I specifieaffy questioned regarding fiutur� plans if s�te becomes totally disabled. She would li�Ce to care for her elder�y mother and mo#her-in-law. When q�estioned regarding how much acti�ity she wousc �e do�ng, fQr exampl�, ar�und the ��use, shs s�ata� �r�ti wou�d sit ar�ai ia��C mQStfy, t�ioug� t� Er� �s the mention o�t th� pa�ie�t's part . she can only s'st f4r ten mi�u#es. � . Anothe� consideration regarding symptomatology is a peripheral neuropathy, se�ondary to the fupus and any, ,ype oi patien# with this type of disease and overall presentation has to be carefuily selected f�om a surgical standpoint. t'm not sure surgery Krould relieve this patient's symptomato�ogy and imprave her life style. At t�is point� ! feel this patiant daes r�ot represer�t an individual wha is total�y disabled, and could be handling a sedentary #ype of position. The latter would invalve being able to make frequent changes o# �osition from sitting, walkiRg abo�t as r�ecessary,. but shoufd be able to handte a�0-hour work week. 1 do nat feel she should be outside� should noi be mov#ng t�oavy (urr�ituro, heavy �ifting� limited bending. This timitation is solely based .upon subjective pain complaiRts and pat�ly related to th� lupus manifestations and to symptoms s�re dates back #o the job related injury twa years ago. WRG/mfm Sinc:erely, ��. %s � '�`�i�li�r�� . G��:!�9rg, ".a. . � � a i f � ' . r. . � . � . . . " , . 1 1 , ' ' , � e • ' ' • } ' • . • i ' , • � ' ' ' . . . � ' , 1 ' . !'r• � ' . . '!� I. ' • • . .r ��! nt.... .. t� r ..I . . • .. , � � � � � .ww� — - r� - . � � .ww�rr�A . �nES�rH[a�o�onr . , Wn��ora��ulc. . ��. Jww�w J. ►.�M. IA o. � 11ab�r� A.1,�r4rp�, MA. �.. rw.r. t+.a ,iwe�run R 14dn. l.l d. CF�1010YASGl!lAli rUtq TNaa�t�C sunar.m kl SY+rMs G�mveMt, IA.D. 0[ludA�qt00Y r�.a a. axm,.,� � a. UMa 1. �o�� IA G. W�FtT Q 1MMA 410. FAIJi�Y Pl�ACiiC� Jan+M E L•M1 M, A1.0. IIfNfARt AND YASGULAR 6lli1GEAY � �r,nri a cao., u n. 1.m.a r. em.�. �o. � MYl�Mi E Hwn^r. Al0 MrtElwµ AlED1pNE n a� a.�+� ti o. v,,.i r. wa +�.o. a+r+. a. �+a��wn,�. tr.�. � �lurpn A�l D0d Y.�y. � Evq�rM � Nrynaqi,lr 0. Ja�r.r F. l4r�n0ark. If,110. 14oW�1 N. S1xip�, M a. ' McAiM a Thpnp��n. M 9. � W[rv9 /. nrrwnaM. u O . +rq,�M E T�.r+�a l�.a �a+n �. vr:.�w. u.o. WT[►WA� uED�Cr+F t W11fl10LO0Y � rwu+rn E t«tii M a owM w. uro� a+. u A, �ew�r s. a.q.. u.0 S� 4. Twr, ►A A. WlWiAL ufC�Gl?!� { cr�ooCwrrxoGr wn«+� r. auati u o tiTEnvx� uEpr�nE � a�staoenrEno�4nr m�. w, s�+�►,, M o. so.+ph X. Ys+co..n. 3�10 wrtwuc r tFrr,►rwc Mto�c.� . Crrw A- p.a.�.K u 0 J�mr1 N. SMq, Al O. IH1El1►U4. fJ[DYLp1E t NEPNROlG41' r.,.�r. r.�w� u n W f EPNAL M5D'G�NE L or�cp�t�ar o.+�a �. ��y.Q.. u a tfTEJw►L �tOiCarf t wwor+,u�r a�swcs Frrw. J. A.r+� u a. Ron«a E So�.�rR 1�.0 wia.m �. waurc� ,le. M o. NTERH�L �Et1iGtM+E f IWEl7w1TGtOaY MI+��rn►l. Wafai F40. ►�vaaoar laaur a e�.�s, N o cmw. w�� u o. o.w u. s«,,,, u o. ces� ern�:s�artifcotocY �,m., � pdrn, u n. no0�s J, Hdr. L! 0. Jos�d+ 0. xwD� �w �A 0 OPHSHI�L1dOCOdt�SURGEtt�f t OlSOROiRS pF THE ETE fd.rG M D�uucMr, M 0 ra+�r, A noeue� u o. oarrro�c supa�r w+�.R+ �. wr. u a. ur■ o rak., �eo. aaa� z��. µ n. O�OlAi1TtK10LpQY/ EAR N05i � TNROAT Ca�uw n. Dawa �i P. &yn K iloban. IA 0, PATtlOIOGY G�aqr 0. LrdH M 0 Rs�ma}�i Yia, M.9 pfDiA�R�CS ' �l fr� Qa+�. � 0. A FbpH Ma�NN, M 0. n�aw ns�a. u o. ,Idw� C. YMeraa Al0 � YL/I,�TIC :t1R0ERY tiob�n P. lacCun�.1i P. RAqYJIOdY !� pU1GNDSi1C IMAGINO � u. �.roo� r�«a.�+. u n. Mhrn�r IGwr�� M.G 1'Inq T. Le�. !u 0. ►lo.�d 8. Rudn. M 0 UAOiOGY• URQLD6iCal StJR6EAr J�f C. Cad 1a 0 ilryp A S�rwr, A1 0 enuwisrn�r�off FoOal (l O�Pf�q , rxv �an� 1 � � � � August 3 � 1,992 T� WHDM IT MAY CONCERN: ' . Re: Shirley 5. Mobley � ❑$--85-�50 . Shirley Mobley ig a 47 y�ar old woman wha sus�ained a back injury 9--6-94. Since that,time th� patient has continued to ha�e �adiating ra.ght hip and l�g, calf and toot. pain. Work-up per Drs. S�ales, Ra.venbazk and We,i.iand, , has revealed that the pati.en� has centra�. canal sl:enosis �t L5-51, with amputated nerv� roo� at L5--51 witt� facet arth�copathy. Th� patient has�b�en instructed to limit heavy lit�ing per Dr. 5�a1es' Zetter. of 6�1.7-92. I concur with Dr. Sea�.es that 'the pati�nt sustained a jab injury 9-6�90 that has �ed ta her continued r�.ght 1eg pain and w�aknes�. ShQ should not lift more �han 1•4 os �5 pounds. It i� possib�.e that surgery could correct the patient's prohlem; however, because o� the patient's concern z�garding her und�r�ying systemic �.npus, she has d�clined surgical tzeatment at �his time. ' The patien�'s current c�nditior� pr�vents her trom dQing her current �ob. I recommend that she be pZac�d on disability. CYNTH�A FFMAN, M. D. CA:DU 1551 West Bay �rive, Larqo, Florida 31&IQ Pl,one: �813� 5B1•B767 a131 McMullen Boo►h Hood, Cleerwalur, Floride 31621 Phone: (Bi9� 726-8911 3Qi 5. Lin�o�n A�enue, SuNo i2, CCe+rwater. Fluilda �IS16 Phone: (B1J) �49�502 C�NiEii FOR O1ITPATIENT uURGERY , 1<01 West Bay brlve, L+rqo, Florida �fi40 Phpne: (613M 585•9500 _ _ __ s�llllr�l�� pen};'.,i{.', . � �� i�' . ir. , .. 'i� °t' ,, . �%'• e . . , � . - , . .� , . . .,. , ' . . � . � ' , . . ' • ' � . . . . �.n� _ _ a� . _. .�. i�w�wM��' _"__'_ I�.w�..�r� e ��. : . • /VIESTFI[bIQi.OpY ' AI�eM AL 6�. M 0. , . JurNw A tsaR N.0. � � . Mo0r�/ A Lw�enson. M G. � 'i NW�w.P�trs.1�1.6. Jom1hM S, i1�d�n. lA.lj. f C1Ab16V7�SC11U�A NiG T110ilACY3 SUfl6�.R1' H. cTrw e.�+o6.+. u a. � .OEIMIA1pl06Y ' rr.d �. aaenw,,1.10. IMC� J. �a4Yf, A10. . . , ' YI#Mn tl. Mhrd, M p, ' Fl�411�YPMCTIGF . .►.ror. E t.a. it u n. � Gcrrtau. �r+n vua+W� suaeenr RrMM {I. Cd�. M D. ° �.m.s r. a� �u a � u�wl E Hwnsy, AA R MrEqNAL MEdGF1E � . R Grryr B�yal. I+IA. i '' YM17.EI��M.Q , . . a.�. s. uay«xn.i.,. M.o ; snra+ K aa�, �e n, i Euor�. a w�r�na.. �+ n. �.m.+ r, a�w�a.�k, n, M.o. aoo.n �. �+oo.. �to. � �n,M t n�naa � o. . nea�ra r. rt�nonx � o.. • AMqu�l C Trwk+q A16. JdnlL YreaiMl M.D. w�uaw� utad►rE a c.noq�oar r.owwa �. t.�r. u o. O�n�r W. lara�. �L �u D J�Nr�ry ! :ap�r. M D SMO+Mn C. Turli N. M d ,�as��4 ��o�c�e � �►,00rAr►�a�xr Wwrn P Gnan, M [I • wtEiwA� u40�C+r+E a � 64S?R4fJ1iEA0LpCjY Erue� A Sawr, M d JoarOK K. wico.�n, M o. �ftEANAL a G[ltAtI6C uED�CwE CN+�+'� A tiV++rni. 1.1 t1. Jur�� It SbO. I�l D a1fiEAHAL uEDICw# � atp+mou7ar Carmra Pwl; M p MTEANJk 1NfD�dM� � a+caocfr Da��a E Laqaa �, IA p urEarii� NEOraME a /VLIrONApr p;,�/�,,ES a,.nc�. �. �.rr� M a nanNA E Ba.�1, IA a . waam J, ia�roa, Jr, N 0. �1 E%WA� V EO�CtivE • �weuu�ro�oer MCrun u�. wuon. f4 4. rrEVAaaar IMcnw+G E.uv, A10. c�r,,, ►w.m.,. u o. pn+e u, sraip, i,t o. 06 5T ET il �CS! C TN ECQ►Ct1Y 1rr�! E Dar�.1�14. Rob�A �. f Wr.1k 0. Ja�d� A. MwM+. Ip. k C OPM�HAl1+�OL0AYlSURGERT 1 DtSOADER3OS TNE EYE co.we u. o.�ua�.�. u o. Jtme! rl Aotrt� FA p. ' ORTHOPEp�C SUNGfRY Wilsfti J. N�v, A1.D. . M.,u o. rch•, +� o. aaraw� Iwmoorin, u 0. 4TOlARYHGO�OGY/ uva ras� � zHpo�r aw+r o. a..,R r� a. &wn K No0r1 M D. AASHp�DOY ' �xp� 0. LMd�I 1+1 G. R�rrtwx+d PM, M D. PEdAriilcS �l fr�nt Garrs./.1.D. Il NoP�+t MaMft. M (} Wne�r Nnar. l,l O. .ww, a n...�o. �a o. r�usr�c �r�Ear fiobwl ?, A1aCw+n�. M 0. Mdpl08Y � OuGN031�C IAIAOIHG Al lnlan HwCM #� O. NMnw Kwn, FA 0. . 1'1nq r. LM. M D. ik>waitl p. Rubit M Q. UROIQGT t UROIOa�C�LSURGEAY Jamq C. Cad A1 D. 6eue� A. Srr�l. M.D. w�.��wsrruna�r Rw�l R. q�vca^Y . REY.IP�11 r July 15, I992 n TO WHOM IT MAY CQNCERN; , � � RE: MOBLEY, Shirley S. , uC x QE3 3.C, 5� 10a�� Palmetto Drive � ' . Cleazwater, FL �3�615 � This 47 year o3.d bl.ack temaZe ha.s been s�en by dr. 5eales and myself concerning back pain, P�.ease ses previous ].etters d�tailinq the nature o� her in�ury, etcetera. Pa�ient came to see me recentiy requ�s�ing documentation an her beha�.� that i.ndeed her back prob��ms had started ��hile on the job . In reviewing aur records , we have been ala�.e to ascertain that �he patient called the Diagnostic Clinic a.n 1990 initia�ly to verify that she had injur�d her back on D9/06/9�, and requested t4 be se�n by a physician. She a�so brings with her to me today a "notice of injury" basicai].y s�a�,ing that she inju�ed her back vn 09/Oh/90 a� 8:30 PM. On May 2, Z997., �he patient was first seen by Dr. Sea�es �.n cons��.tation. The patient a� �that t�.me stated to Dr. S�al.es that she "hur� her back" in Sep�Ember a� �.990 whiZe pushi.ng and pu].Zing on chairs and tables a� her �ob as a Recreation Leader while at work, Hopefu??y �he z}�o:�^ :��?L°TGP_L� ar.� �?:p .l,r:f0'_'I!l�}3.011 abtained from our racords at the Diagnost�a.c C�.inic wa.l�. furth�r verify the �act that she indePd did have injury ta her back occuxing on the,�ob on 09/06/90. I� you snou�.d have furt�er que��ions� pleas� do not hesa.tate to contact me. i . _ r , � ' �...�---_-_� + I . � J,AMES i'.1 �VFNBARK, III, M.D. JFR/msv 1551 IHnat 8ay nrtva, Larqo, Flar4da 34WD Phane: t8{3} 58t-8767 31�1 McMulten f3aolh Road. Cieerwalar, Florkda �621 Phane: �8t3) 726�887t 501 S. l.lncoln Avenve, 5u11e 12. Clcarwaler, Florlde 3�61fi Phane: �BtS) I43�502 GFN?ER FpR OIiTPAI'IENT 5URGERY i3Ot Weet 6oy Drivn, La�pq, Flqndn 94W0 phona: i81�1585•95W Di � � . i ' , I�F"� , , . . ... ... ' . .'Li..... .. Ai�[STi�slpipGY AWif M.1r�0►. V 6. ` �KJ.I�M,NI1. Iwew, k. u.«+.a�ti ti.u. �na.. r.�wti u.d. Jon�c+an R 1t�An. Al0. • CAiiU�OYASCULM N!0 1f1Q1111C1C SiJpl1ENY ►C CxrMS C�++qON, M O. pER11.4TOLO0t r,w s a�.,TM. M a lYd� 1. Ldf'r. �A 0. Wrlrn 4 Wr4 M.p. FAAIItY �141CT10E � J��rr1 L tan. ll �► 0. O[FIEA+L /W D YI�SWLAFi SUIIGifi� R+e4aR 4. Caok � 0. dsn� T, ERiw+� AI.O A�thwl £ IM�mr1r. Li.d. � NTERtfAL MED�pME R a.�c.• �«► �ta YtN 1r. FJ�s, 4.0.. AaM S. lJapw+�+Wr,1�l U. SMron I,L pd�R Rl 0. . Ef/q�.w S A�yrwes,lJ p, � s+�+�.. r. a�e.�. u� ►�o. nca«, ��. sroa�. w a µenw �. Tr�a+w�nn. M a. . AtRrd F, 11�on� kt p, ►�q�el � i7eww.1+1 q. JoM 3. Yr[raf. u.C. WTE�NA� A+EdGHf • CML40l9CY ha�nco L tent �I O o.,»� w. u.� �n. w o. , �nrti s. s+on� ►i o. S��peyri 0. T„Aw. R1 p, 11�YL1111AL F+ED�C7NE a . EMOOGAiNOIOGY wnun ►. Gaa+� IA G u�TE�U+�L I�+ED�CU�E 1 GASTAQ�EAO�OGY wve. w su+o.r. � o. Jowon K w.eo. M+. u o. wrEnr�.� a c�a,►zroc �co:c�� Cr�w+r� ti P+�7we�4. i�l.�. ianys !l S�sQ.1s D. n+Tfn++u u[trun� a �Er++AO�oar c.+R.n. tr„�� u o. tY'fERNA� MECK�HE l� CIiCCLqGT ' a.ha t �a�aw., u o. KTFJIk�� 4E6�GNE 1 RlIJUDHAAr �Sf�5F5 F�ana> >, A.w�. A10. MnW E. po�.u�, N O w+ram i. aa+�rati �r. r,t o. wrEnru�� u�o�HE � . PNEUW1TqLOGY Wfi�n M Watp+, M p, �.�,�«cr E+�cn.M e. e..ro. � n. C1M�u Nuh�.+a fl. Oaw 4. :au[t. AI O QBRt Et R iG51GYl1 E CO LO4T J�,sw� � Oa�n. Id.O. 7�o0en J. Hr4r. !A D. louan O. Kw W4 �R M G. orHrr+��uatoarrsUnGern a O�SCaDERS OF TME EY� Ed.ud AA U�x�dMr. Al.p. .1urw /l RoMta. tii 0. ORTHOPEpC 5[fROERY Yl�un 1. fMr. I,i 0. ura 0. ronr. �t G. [iaAOn Zurn6orf�r, M 0. o�ounrrraaocri CAft HOSf i THS�QA1' aw,e. a, ow�s. r� n. en,n K. raa.�. �.o. PATYiOLOfiY c.ao. o. t.�a�. u a. a�,m«,a v+n� u.o. FEDIATWC3 IL F�an� Gwnn. 1� q A Fbwn �a�n. Iu.O. R�ck�r 1n�la. M.D. .hx�n G VMm�a. M.R. . PL�SYIG SUR6ERY Ro0et1 P. MaCun�. A1 p. Mp+OLORY r Dt�GNOSTiC ihlApllK3 �. un�a, rMro«+. �1,n. Nhm�r Knun� AI 0. Yinp f. L�e.1+10. N9wrd a. RubM1 1+1,0. UROL06Yl UiIOIOGIC�I Sl1A0ERY JMnr� C, Cad. M.q B+uea l� S�n4� M tk /��NISTRAT�Q1t noo.n n Dnaa�o �tv. wm June 17, 1992� ,� . � Ms. Shirl�y� L. �Mabley ' � Z�44 Pa�,metto Stzeet . C�.earwat�r, �'].ora.da 34 615' Re: Shirley L. Mobl�y�� ' OB-BS-SQ • Dear Ms. Mobley: � It has been my pleasure to wvrk with you over th� pas� �ew mon�hs in as�essing your radicular pains in th� �.aw�r pxtremities. The offshoot vf this evaluatian is that there a.s what zs probab3.y a surgica�.ly correctab�e ].es�.o:� i.n your Zumba ,acral spina2 region giving yau the symptoms .�in an L5 distributifln in both l.egs, ra.ght more than 1e�t. zn the sPVeral consu3.tations wi�h you Y have came to agree with and =esp�ct �►our decision to refrain from surgery because of your camplicating factor of lupus. Surgery coul.d inde�d be compli.cai.ed by a�laz� which might be very disturbing for yau. � I have discussed with you �he tact �hat i� �.eft unrepaired, the problem in your lumbasacral spinal region could J.ead to �Ztimat��.y uncorrectable prob].ems with the strength and sensa�ion in your 1egs. Pain could be a perman�n� pa=t o� your situation. Hut once agaxn I must � respect your decision to decline surgery �or the reasons stated above. I received a I.ett�er �rom you r�questing sup�ort for perman�nt disability. ❑n�o��una��lr, �h� precise paperwork is absent at the time t�yat � have final�y had a chance to revi.ew your Chart. � have addressed this letter direct].y �o you to preclude any prob�.ems with confidentia3.i.ty between doctor and pati�nt. You can gxve this letter to whomever you please. Your perniission ta share this information witl� others w,�11 thus be imp�icit in your �arwarding of this letter which has b�en sent di.rect�.y to yau . �MJ • 155t Weat B�y tirlve, L�rqo, F1orldR 31W0 Phane: (619) 581-a7dT 31J1 I�cMullnn Booln floed, Glesrwalsr, Floridn 51a2i Phone: {g13� T28•BB71 50t S. Lincoln Avanue. Sulle 12, Gloerwnla, FlOrld�! 5i$16 Phonb; (E1�� 4A�.ISQ2 ' CENTER FQR OUTPATIENT 5URGERY 1J01 Wast t3ay Orlve, Lerpo, �lorida �46�0 Phono; {@ 19} ,y15•95W � � ' ' .. . . 4 . . ' . . . . . ' , ' , , ' • . . . . ' � ' � . � . . . ' ' ' . . � • . . ' � ' ' ' � . . ' . . � , ' . 3 . .' . � ' � � . '1 . ♦ � ' ' ... ' � ' ` . ' • . ' ' � ' t. I ' , ' .. . . � � . , i '�If ' � f �. ' ' '.t . . , ' , '. . � . • I' , ,'+ � . . � 5 � � . ' � � �( . � . , . E � ' ' I , . � " � . .. � . . i' ' . • . . . . . 1 ' . � 1 t � . ' , ' , � ' . �1 . � � .. . , . � ' . I. ` . . . . ' ... �� . . . . ., . . � ' , , . . � . . � Iviv,sMkTl.:'. � ..��ras.,.^rr.,, ��Y''�`i:yi�•r��c.a�.'. !- � ir �1 • ..o. .. . • ., � :fs 'F}.�. .r .'.�� ,.. ' o � , r r .. „ ' is , , . � , . �. I.. ' ' . , � . ' ' ' ' . ' . I � i . �' .. � ` �� • • . , . . � ' � ' �� ^�r • . !• ' • . i �i ' � . Ms'. Shirley L. Mobley � . � ' ' . Re: Shirley L. Mob].ey , ' 48-85-50 � '�imitations on your activity would be to refrain from. ` liftinq 10 os '].5 paunds, you` wi�.l probably continue to have a great. deal ot exaceriaatian Qf. your pa�.n by yaur pr�sent �ob in which � you push, pu�.� � and �.ift heavy cleaning equipment, as � recall. Xou may'�ind �ram tame to t'ime �hat you ne�d bed res� in order to reduce your �'symptomatolagy, . ° Thus, I suppnrt youz request for �ull disabi�.ity at this time. �.But � remind you also that shauid�the pain or . other symptoms, such as weakness and loB� of gensation in your legs, beco�n� severe, that you� cahsider 'a consu�.�ation with Rheumato�ogy to ask the qu�stion o� whether or not you couZd.be succeasfully prophylaxed agains� a lupus flaze preparatory to surgary. My overall a�nc�ination has b�en and remains that you have this l�sion rePaired surgieally. �� yc�u c�oul,d wi8h �o add a .� consultation with Rheumatology here at the Diagnostic Cli.nic be�ore yau comp�.ete the pape�rork for �u11 , disabil.ity and proceed with th� ever i.ncreasing risk of greater pain and.weaknes� in your �.egs, then p�ease noti�y my o��ice and T will facilitat� this consultation for you . � � I�irst saw you �n 5-2-9�.. The leve�. a� the raciiculopathy a.s approximateJ.y a� L�. it a�fects th� right leg more than the left. If I can be a� �urther hel.p, please contact my oftice.. 1551 W�sl Day p�N�. Larqa, Fia+d� ��6a0 • P O. Ra� ?901. Laiya. Flo�ld� SA61P phpn�:lel�l ys1.61E1 2�5� MtMUll�n gppEh Aar6, Suiu �a3, Ct�arwq�r, f�a�d� 3�aiP PHOm' Ib1a) 71d-dsll bOS 90. Lintaln Arqnu�, 6w1� 17 ClurwslN, vi�id. a�a�e pnonr. �e�sM ��sasa= e i �'^S°F: �f 'f�' t :{�: 'J !ki��s3�I J� �1 . .� . • .i.. •i. °i: i1 '!' t , i�5 <<i'�. �,� �' E� .k'� :tf. �I`• , , . �.: . . . eli.. : �J� 1, f�l�' :` • ` ';'. k: ..i'rtis . •'%,. 1'1' • f • e , . � . � . ; . , r.11;:1 ^ �1• .tr�. . ! 31" e�' . . . � . t , f , . . ' . . a . r: ,11j.� ,�1: .. , . . ,• 1 ��. nJ 3�'i3?t�lt'.'> �•° e5f,' '' . e •fl�. ' �k . r! . ' . I• . ., . (.• r1' .rl.. �t � g,'/l�� . �• ' . • I " � ' . ' . � � s , ` ' �l � .f . . . .. � �. �`i . S�' �.`��1 t 'is ' :.I. � ' . . � . . • : , • - - . .. . . .5:� , . +''�.+ . 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' ., . , . , , . e . , . :., � . �. - ' , . . �,,,.. � . � ,� . , , . ,,. . . . ., . . , . . . . �� . . . .. ,. . , �`:� ;; . � : � :,, , 1 . "• .. � , . , � ' �. • . . • ' . ' � : � � . � � � , ' . , ' • .. . .. . , , • , . • , . iJ'� : �.' ' � +' ' ` , . � . � r • . . ' : � , ,.. . � �: .� " , ' � � . ,.. � : � ,, � , . � , : . . . . .. � ' . � � r � . � . . . � � � � . � 4 � . . . ��.'�.I• r . . ' � ; �. .. � . '�� y� . ' . ' ;' ' ' .. . . . . , 'r, . ' ' . , � ', . , ' � �� 'i, � ' � ' .� ,� , { , ' . ' . �. ' , :f . .. . ' �', �',. , ,�iYj:, �� . .' . � , ` `, � . ,, , t , • . 'r. ' � � � ' :' � . � M� .� �Shizl'�y L'. � Mobley � , , � � � . , . . . , , . . -. . , . . -�; . . . . , . � .. � . - ' ��.: �. � :� .., . ; Re:' Slzirl�y I,. Mobley, • ; � � , , , , .' . . •, • r . .. . , . . . .' ' , , �E � ° � � . , a . 08-85-SO ' ' ' . . � , � . ' � � . . � . . . . � . � , ,�,..�, � , , . � � � . � � � . . �. -- � ' . � I 'am• absent from the Diagnosti�� Clinic a�ter 6-�30-92. � � ' � � . � . . • � . •� � � .atti going into salo practice. in Narth Cara].ina'. �Your � ; ,:�: .� � . � � . � neurol.ogical care can be continued he�e by the .=emaining'� -. . , ' ' . , � , � : �. � neurologists at� the� Diagnostic C1.in�c. ` � � , ; �. ' � � � � • � . . � . . � . . 5inc�sely yours, ' . � . . . .. . , , .� �: . , . � � . . . ° . ' . : � �, . � r,�.� 7� �'.��•-_._- � , . , , . � , . . , . . : ... David M. Sea�es, M. D. �- : . , , , ; . , . � DMS : DU , . , . _ : � . , , . . , . . . ' . . � : , � . , � ', : , . . � . � . .. . .;. ,I . ; ' , . . . . . . . � � . • � � . . , , . , . > ` � � • � ' • � � . � ' . . � , . I , _ � . .. � � . . , . ., , . . � � , . . � . . .' � : .. ` •. . , . ',, . � ' _ ', �p: . ' . . , � , ' . , . � ' � . ' . ' . � . . .' . � � � li t'. � 1 ' � . , , . .' � ' , , , ' � ' ', � . ' � � � � ' . . � ' ` i , ' . � � , � , � � � ' . � , � . . � ' � I , . . . � � . , . . , . . ' . ' � .�. . . ' ' , • ' � • � , ' , r , ' ' . . I . ' . � ' � 1651 Wu1 BaY OrM�. L�rqo, Flontla �1610 � P.O, nox 7flUl, Laipo. Fbrld� �I6�9 Phonf• (I117� 5E1•!T6! � ' 7151 �.ICA1uu�n Baplh Roac, 5ulk� 10.7, Cl��rw+rv, fiorMla 3461y � ° Phan�� E1�� 1�6•EE11 . � , SOl So. Uncaln Avrnur. Suu��t2 Clurwrl�r. FlWida �616 Phan�:tip1�1+,7-�b07 • ....�..-�. .,.:.,....' , ., ' .,. . „ti . �' . . . .i , �'x ' � .. � . _ . ' . , . , } , , , . , . , � ' . FlW11L}A U�I�AFiiMrNl U1- 1.A13Vhi �ar�u cmrtuen�r�� ,,..�..++��. � ' []IV1510N OF WOFiKEAS' COMR�FtS�t3iQFi 1•8D�1-34Z•17<1 (or) conioCt,yssur iqcAi Offictl tor essfstence NDTlCE �F INJURY � F��or! a11 doalhs by� iele�hone vr te[Qgraph wilhin 2A hours. Anr p�non rrho, k»owin�fy �nd wiih tni�ni ta tnjurr�. dafr*srd or d�celw �n� �mplo� pr emPl+rys�. iresuranrs campNny or s�H-Insund PtoOrarn, nirs � stst�snerA cl cl�1m , conlRfnlnp sny 1i1�� ar rnlal�sdlnq Inlarmetfon le yultey d a hia�y ot t!� thlyd d�qrs�. ro b. ton,Q►.r.a.++d n►.e 1K`a�rer. n� n,,,. PART t""—'�nr,in � a.y. or e■e. ot t �d�. of'�cc�a.�. ��A£C)Yi�� INFQF3MAT14N . NAME ��Kf�t. M�s�n. �a��a Y� �� CL,r�` H�rVA.I '�� a�ry r�� flm,� � o�,�aa� ��ti .�.� 7-8x-3958 �/06j90 Bt,�F? P�i - • " = •" 5htr�� S. ?iub�,e ,� . � � OCCUPATiC7N • ' ^ '� EtriPLOYE�'S QESCfi�YTK7N QF I►�CGlDE� 7 . ftr�r.�nntian Lend�r 102Cr��f, ��. �; �~�� '°�ttit�g np zaQr� �or next duyQ clne�a, '�' ; Hoµ� nao�ESS �i�+uaa z�v1 ich involv�d �ra.113rig tr�blea �snd tacks of cha3r . 1�44 E'aLsuetLa 5CreuC Tha nfx� �orair�g I ira� k�avin� Yerp �+�x�.onn, ' Cl�nx�rator, FL 345iS . S�p� 3,t�qp� paf.nr� S.a b�ck, r�to�cech 4Il�S �.f�Dr ly� � U� yov ha,ro r secand }obi p Y�5 '�1 N/O % if ypY. IIR�pI�Yff RtIRd �i CIiC171 �I. � • (v "�' ` �� V 7EiEAHON$ � w.� c�. ►,..�.. o�r� QF g+r�r�t 1Q � 12 ! Cib � ❑M �jF FIpM'S NAM� Cit� c�E �1.�:��rnter ►,'• ! IrtAIUfIG ADQilESS r.�. R:1x �7�8 Cl.r.,tirtrnt�Y, F7, 34fi18 � �.... w-.a...�,., c«,. �i; 3 �..�. 4 b:�-l55:31 ALA�E QF ACCIDENF (BtreD1, C�ly, County, S1�Ee1 �ina� f�nrton Ftc�cr�ntiaa Centa� L!� 76 �_. Gxeenwood Ave�, C3,�r. , Pi. OaT� E+�iPLQrEQ LAST p�AT� EMpLOYEE WORKEO j r 9 r7a 9 � 10 ,90 �E7U�►NED T� WQI�Jf [j VES x', Nq tF Y�S. G�VE i7ATE I ! YIAS I�1)U�iY FATA�,y (� Y�S '�] t+IC} � IF YF,S, GIV� pATE {?F O�ATH I 1 l�GREE WITN [7E5CpIPTION QF ACCIOENT7 F� Y�S �J NQ IF NO �XPL+ktl� } I HAVE Pi�t7vlpED THE A80Y� E1.IPLOYEE THE1Fi GOPY OF YHIS NOTICE t� �H PERSOH Li BY i�lAll �� - �' � ,� , �- -.-. J ,/� ��/' E+.��'IUYEA S�G►ix7URE • q�i� pESGA16E IN.IURY �fl 1715EA$� AND IN�ICATE PART OF 8t]OY AFFECT�p (e.q. Amputntfon ot riqhS k�das Ilnqhr st seCaid yol�t� feaeturod r�Ds� bed Pslsonk+9� �1C,) Lowex bacic. sco�ach nna �.egv EMP�OYFE SIGNATEfR� jlt ��;leb�s ta �lpn) No� nv�i.fnb�,� for a�,gna��xre Qete � rX� r�Q F�OERAI i.4. MU�BER DAtE AME7 71� �9�6[100�2B9 91C37/90 W C. GOVER�IC'iE BY � O �rrsv��rrc� cn. � seLF•�NSt1fiE0 1JAM�, ADORE55. TEL�PHONE OF lNSURAt�lCE CO �F! SEf;VlC� COIrlFANY GALLACFlEFi Q�,SSEiT S�RVEC�S, IHC. P.�. OoX 4844 Clnarrrsle►� fl. �d818-C844 �'efephor�e; �819) 79B-F929 IaAME, AOOi7ESS Ate� AHOh� NtlME3�R QF i'MY51C1AN Of� HqSPiTAL �X.�r i�'r:tic-Itt-C1�.n�C x6vo us i� t�orth Clear�rntar, FI. lRST FtEPpATED ) 1 �-i't • , ZZ:30 P2[ J,`� �• ;I, PO�ICT ftUMBER . • y . , n. �`, PAY SAUAY7�] YES p M4 1F Np, U�ST QAY PAID RATE OF P,�Y p HFi Cj WK iZ.I.�3� F'�F� p�]AY ❑ 1.10 1„ A1umi>u d harn $ Pe� dry -�------�-- Humter o1 houra �� pa, we�k � Number pf tlo�rs � par +veek ._,�.� WAS I�BQV� PHYSICIAN►HOSPI7A� A{JT1�iOn1ZE0 6Y �MpLbYER Y�5 ❑ Np tfk5 CAAFi1�p15E�F•1N5UAEF3 Np71F1ED YDl1 WITNIN TNE YEAR THAi SAF�TY SERVEC�S AAE AvAll.l�9LE7 � YE5 � NO IF SO. Dt0 YOU H$QUESi 7NESE 5EFIVICES7 �] Y�5 p ��O IF �iEQUESTE�. D�p YDEI AECElVE THESE SERViCES7 �.7 Y�5 ❑ NQ OIO iH£ f�fPGQYEE W�L�FVLLY AEFEISE T�] USE JI S�F$T'Y APPLIAIdC�, OR HAYE FF�lQR rit�lOWLEDGE DF APJp IHtLIF[3Ll.Y REFUSE Ta dFlSEFiVTe A SAFEiY STAN�ARU PitOMULGlITE{] 9Y TN� UIVi51QN1 [3 Y�5 �t T14 bIA fiiiE Ei.IPLqY�E 1Ht��F111.1.Y HE�US� iU U5E A�FET`f APPLlA1�fG� P�WIb@4 [iY YUU, TFE� EMPLOYEFi9 �) YES �C] NO Car►ier M 5ervice Ca. � 0� Lnca1►on M � 1. Canlroverting Casa--Fieasqn ' � � � � ' � C] 2. 4ost Ttrne Case-»Dale o! Fiesl Pbymant ! 1 AWYY Cornp Role First dny ar disabi�lty / 1 —Unla �1 First Canl�c! wilh Claimant 1 1 p In F'erson p Tobphonn ❑ Mnil , --Natice Fil�d Duo lo Muttipfe Poriqds d Ois�bih�y ila�va Cavarad by Flrst Paysrre�i ❑ 3, i�lcd�cnl On�y wl�ich �eame a Lost Time Cosa, Fi�st drry o� disesb�l,ty I ! Adjustnr Signalurn Rdj�star Lknnsa Numt�er Dc+le _ 1_ _ 1 LE� fa,m pVYC•1 F'■rl i(3r0Qy • kh1PL.QYER Cf]:iY � � a��r - — 0 � �:.�.�...._._.�... �. .,_ . .�....._w .�....�..__.,.. ...�...,...,......_ � __..�__..._�_..._.._..... �.�. �: �_.. �_�_..._._. � _ - --�. .: ._.:_ � ��..____.___.. ....__ . _ � ��`� ~�' � CLEARWI�TER GITY Ct?MM�SS�ON � �, ��. � �lgenda Co�er ll�lera�arandum i3�m � > �s � a A'�'�PEA�� '�rustccs of thc Employccs' Pcnsion Fund Meotinfl Dale: Subject: Pcnsian(s) Tn a� Granlea . �ecammend�tion/Motio�: Atthur CAmenticri; Fircfighter, Fire Dcpartmcnt, be granted a job-co�nccted disability pcnsian undor Scction(s) 26.35 of the Emplayees' Pension Plan ns rccammendcd by tl�e Pension Advisory Committcc, ❑ and thnt thd approprlate o�ficials be authorized ta execute sam�. BACKCRC?U�D: Arthur Cnrpentieri, Fit-efighter, Fire Departmeni, was cmpioycd by t��e Ciry as a FircC�htcr �n Octobcr 16, 19G3, an[! bcgan participating in t�c Employecs' Pcnsion Plari on that d�tc. In� �October, 1991, Mr. Carpentieri appSsed far a rcgular pension based on twenty-cight (2S} ycars af service. With his application For �cnsion, Mr. Carpcnticri excrciscd his option ro extend his reteremcnt date by ci�c usc of vacation and one-half of his accumulated sick lcave. TE�at req�est tivas apprnved by thc Pcnsian Advisory Committce (PAC) and the Trustees, resulting in a pensian bcneCt of 70�'0 (28 yrs. x 2 1/5 percent) of his last f�ve ycars' avcrzge sasary of 532,9I'1 anr��ally Ur �pproximatcly $23,042 per ycar, tiVhile usis�$ i�is vacation bczic�ts and prior to this extcndcd retircment dute, Mr, CArpcntieri suffered a heart �ttack. In lanuary� 15�92, Mr. �d Hoo�er, Presid�nt of the IAFF, appclred beforc thc PAG as a reprCSen�ative of Mr. CarFaenticri to ask that thc regular per�sion bc changed ta a job-eonnectcd disabi�ity �cnsion bascd an provisians ai C�apter t 12, Florid� 5tattites, which provid�s that disabilities due to heart aisease, hypertcr�caor�, or tuberculosis are Presumed so bc job-relatcd for rirefig#�ters. Mr. Carpentseri has subm'stted lcttcrs frnm Dr. Marsh�l DeSantis, dated Fehruary i3. 1992, and Dr. AkshAy Des�i, datcd February lQ, 1992, in sup�ort of his rcqucst Far a job-connecicd disai�iiity pcnsion. Thc PAC a�praved Mr. Carpcntieri's job-connected dis�bility at its mecfing an defcrrcd thc itcm pending recci�l o#' a linc-vf-duty inj�ry presumption. Upon Thonjpson:, Sizccnorc � Gonzalez, P,A., rcmanded ihc isst�e to thc PAC. rcyucsE to change his ye�rs of scrvice pcnsion to a Septcmbcr lb, I992. Thc Trustccs on 5egtcmbcr 2$, 1992, jegal apiriion as to lhc applicability af thc Fircfightcr's rcceipt anc3 review of � lega! vpinion from thc firm nf statin� ihat thc pres�mption docs not apply� �hc Trustces Qn December 2, I992, thc PAC movcd thal this mattcn c� rcm�ndcd ta the Trustecs indic�tlin� thc PAC approvcd t�c disabitity pcnsion as jab-connectcc� undcr thc presumptian bascd on the f�ct M�. Carpenticri wAS an active cmplayce using uvailabie bcneCts. Revi�wed by: Ler�al dV%�' Budgot Purchasfng +��' ...� Risk Mgmt, �%�- DIS ACM Qthar_.., � Submltted by: ��_ City Manager Originating Dept.: l/� Human Resc� rt�s Usex Depi.: Acivertised; Dat�: Paper, �-Not requ9recf Atlacied parties ❑ �lati}iad �-Na! requlred Total ' � Current FY Funding Saurce: ❑ Capt. imp. �7 Opsrating ❑ Other Apprapriatian Codo: �mmissEan Actlon: L7 Approved �.� Approvod wlGOndilions �� Denied U Continusd t�: Att�chmante: ❑ Nona Lcttcr(s) t�. it � { �t.' , . I �. . • ,. � - �.1 , � ; , . . . : . . . �, '' � 'f . , i .. • . . . . . . � ' ; � � ' , ', ' „ . .n. . . - . .. . . . . . . � . ' f,. � ' ' . . . . I � ' � . , � ' . . ' � . ' ' r . . .1 . • . ' . . . . r . • . : � ' .1 .. • • • • � . . . • . ' ' I . � � . . . � . . � . e . . 1 i ' ' ' ' . . . . r ' `. . . � r. . • � . , ' ' ' 1 . ' Fri� e ' � , .. . �' .. � . . � . 1 ' . . . . . ' ' •. � i , ' • . . I . ' . • . . , . . , •• ' . ..i . . . . . , , • �I .; � , . � � ' � , . � � � 1 • � • . F •! � . ' 1 . r ' • • . � •1� . �1 i .' ' . � I i ' . � . . ' . . • •i • • . � r . , . . � .. . . . . � � . 1 � . , i . I jy� ' .' '' • � �. s� • ' r�. ,' " � . . " ' � . � ' ' . , . 1 . ' .! � � . . ' . , , ' . � .� � ' ' . . . ' 1`�4P.`i'`is'�_ . '{'.. '��Cr'.Fr�y�ft.ae�0�,r.y�y^��%u_ >�-wail^p,�r�..4.C':,r4r.��..,<., .. ..i ,� ... . .�`jC� ' .r. . '�f „ . 6. . . � , -. . . � . . . , . t ,.. . . ' � . � t �r . ' . ' .�. � . ' . . . , , ° 4 , , .. .. f ,. . . - � - ' � Arthur Carpenticrt Agcnda Yicm ' , ' Page 2 � � Deccmber 14, 1992 Based on 'an avcr�ge sa�ary , of approxirnatcly �32,Stt 7 over thc � pasi ii'vc ycars and tlie sevcnty-Civc '. percent .(75p1o} minimnm disabiiity bcnefit, Mr. Carpcntieri's pension will upproximAte �24�688 annaalty. Charts from Financc which take 'intn consicicration monality �ates and , agc reflect the .' "present val�c cast. of financing" tD�is pensinn will be a�proximat��y $�21,777. .. This situation� whilc secmingly incident�l in tcrms of cost (the diF�'ercncc betwcen the regular , pension and a jo�-connected disability pcnsion �far Mr. Carpcntieri is approximatcly $1d�6 . an»ually}, raiscs a maj�r issue �l�at may have considerahlc cost smpact to tt�e Pension Plan in the futare. Thc is'suc is whethcr a Fircti�3�ter has to be incap�cit�ed whitc on ttctive d�ty to have lltc "pre��imption �aw" apply: The . employce . in this case �ad retired from active duty and selectcd :�n option to r�emain oa the payroll tt�rough thc �se of accrucd vacatian und sick [eavc bene�ts {as ' opposed to an avail�ble optinn to be �aid � in a�ump sum for those benerts), Duri�g ihc isme of use �f ' the vaaation � p,ortior� af suc� extended benefits, he saff�:red a heart atts►ck. •. Whether a . . FirCfighter wha rctices can utilize the "presumption St�w" aFtcr �is/hcr last active workday because he/she suFfers a hcart attack during use af a r�tirement benefit which s�llaws � an extendcd use af vac�tian a�d/or sicF Ieave matcria[Iy may impuct costs of the Pensian Plan. The issue may ppssibl3+ �c raiscd ev�n afcer a formal sctirment date (i.c.. a former Firefighter wha suffers a ., � hcart or l�ng disability nyonths ttfter a formal rct'srcment has occurred), Based on tt�e pctober $,, 1992, legal apinion oF Dcborah Crun��bley af the �ran of Tt�ompsan, Sizemore & Gonza[ez that "...It � v�ould be our opinion that the presumption shpuld itat be applicd to. retired fircfig�iters,.,,," it is staf£s rcca�mendation that the Pension Advisory Committee's actiun be rejcctcd anci shttt Mr. Carpe�ticri's pension rexnain as A yct�rs-of-scrvice rctirement. If t�e Trustees ac�ept stt�ff's recamm�ndatian, et is likely that a lawsuil wiEl result o�� -behalf ui Mr. Carpentieri �nd the Internationu[ Association af Firefighters: � � ; ' , , � � �.. . , . . . �,, .. � , . , , � , . ; . . . ,. . , , . , , .,: _ ;.,. . . . . . � . ,,� ..:�� .�.. . ,. . � � . �. � � . . . , , �. � ., . . . . ,. , . . . . . , . . , , , . ,' .,, , . : � _ ., , ,,.-�y . .._ . �. . .. ..._. � � �. �,. , : . . . . . . . , . . :.. � ... . . . - ., , , , :, ;� � . . . ; _ . ; _ . , .� � . � � �.I � � �,-- � � I T Y. O F C L E A R�N A�' E R � . � � � . - �� '' PDSi OFFICE BOX 47�te � t11;,,�:jt�.i } ; ' ' . CI.�ARWASER, FLqR34A 34biB•b7d8 1 � � . � FKSCrrnN i?�Wutrnrrtt � ' ' ; �Q2�65T0 ' ' � T�} Hanorable Mayor . and Members oF the City Cammissian as Trustecs af thc � � Employaes' Pcnsion Plan ' f • . � FROM: PcAsian Ad�isory Committcc . ; . � ; COPIFS: Arthur Cacpentieri; Risk Iviar�agement; b�n Dcignan� Assistant I]irector of ' � Administrative Serviccs/Fi�at�ce Dircetor; Emptoyee's Fiic 5LTH.lEGT: Pension far Arthur Carpcnticri—Jab-Connccted - Disabilily Pcnsion • , DATE September l6, 1�92 � � ' � .�:r. Thc Per�sion Advisory Cpmmiuc� {PACj rcCCiv�d a rcqucst from Arthur Carpertticri on Scpt�m�er 2, 1992. to c�an�c his rcgular pcnsion to a jab-connc�ccd disability pensian. Mr. Carpentieri has bccn dctcrmincd by chc Pcnsion Advisory Committce to ruccc thc rcr�uiremcr�is af thc Pcnsion Plan for a jub-cannccsc� disabiiity pensiQn. Hc was er�iplaycd by thc City oR OctQber lb, 1963, and began �articipatiag in �hc Pcnsiar� Plan an Qc:tobc� . i6. 29b3. Furthcr, he ttas s�bmiiteti medical aocumcnta[it�n. capics oE which arc attacheu, rcl�tivc t� his disabili�y which has bcca rcvicwcd and approvcd by thc PAC. By motion �ade and duly carricd at its mceting of Septembcr 16, 1992. the Pension Advisary Commictee a��ro�cdlrccommcnded thc granting oC a�nb-cannectcd disabiiity pensian to Mr, Carperitieri iri accardance with provisions of Scction 25.35 of Lhc City Code. This pension is to bc effcetive �►�gust 3 i, 199Z, a� the end of thc day. Th� amounc of Mr. Carpenticri's pcnsinn wil! bc calcujatcd by thc Financc Department accnrding to the formuia in t�c Pension Plat� for ,�ob-connncctcd disabilicy pc�sion at suc}i time as his l�st Five ycars aF scrvicc and salary can be comp�tcd. i�creby ccrtify tt�at the Pension Advisory Committee has approved tue grantsng o� a ,�ob-conn�cted disability pcnsion for Arthur Carpcntieri and the abovC datcs are corrcct. , � a�rm�n, Pcnsian Advisory Comrnitt�e , � . ❑� � �f �� :.�:; �� . �.... ,,.,,,. . . . . ' _ _ . � _ . _ . _ . . _ _ r a .�i ;��r.� , ��. � � . . ' � � .,.. . .. . . . ' 't' � . '� ti f,', , ' E . ' °�•� 4�.a� . �i�L'� } i� <.�4,.. �� , . . ... . .�i . , � .. . .. , . ' . . .. � . . � � . �f� � . ' ' � � . � . • `. . .' �'. 5'. .��'j� ,• , . �k 'I ` • } ^ • " •. �. . . . . . • ' � 1 , .1 ., i 3 •.. . 1 .' � 1 . ... . .!. � ,, r �'4F e • . ' ' . . � ,' � '� " ' ' , . . '.. v . ^ . . ,• ' , .. � . .. � j1 •et � t .. • I., i . � �. . , i' . . • � � 1 � . , � • ' � ' � f ' . r . � � . . � . . � , i` ' i , il . ` :•1 . . .� , ' � � � .� � ' , " � . � ' �� , , � • . t � . ..[. ., � ' . . � " • . . � . ° .� . . � . . . S,'�. ' . . , '�; � . ' '. r . i'' .1� . .. , . ' . . . , . '� � � ' � ... , . ; . � • . . � . . . � . ' _ . . • . ,; ;'' . ' �. +,'r' :� '..'F: i:5 '.i'� . ^ , . � , . � . �,. �.�'' , , • � ' ' � . . ',+ . . , • ,'i 1 �. , .,. ' J. ' � v(1 �� ' � . �•t�i� .. . ' �. .< . . • ..' ' t , , . . . ' ' , _ � . . riy � .. ' . `,�. ' �;'' _ . � . � . ; , .. . . .� . � � h[,;§''Fti. t,�' ,/ ;s'f; ,''V ,� , '�i �c` 4, ' ..: � , • . ''�� . '�. ' .. . , . � , . • . � 5` rtf+.ka*xii:"i :"it'?°#'r%rs^�-.a�� . �e. ... . . ....w, .�..._e..., ....r.F'•.r..,. � ..' ic��.+•i:a �. , ,•;, '� . ' ' ,s ' ' � �,y- i . ; � , � . � . • i.. ' � � ' . , . , � • . � . , e ... -. ,.. i r ...' . , r , . � . .�. . . i . . . . . ' . ' . . � � • . '� .• � • ' �. ' � � � � � . • ' � ' � � . ; .. � . . . . �. � V�1�Y��G�x, M. D. � . . . :��:� . ' . . . .: , , .f . � � � � : ESFANpIAR� SHAFIi; M.�. � . � . . , t. . , . - , - . �# , ' �tu15��L �r'.�S��Sy �.�. � . . , �� . . , . . � . ' ' , . �RAYM4ND S. WATERS,� M.D. . :� . . , . , FOUR CQLUM[ilA DRIV� . � ' , " � ' i4100 FIVAY ROI�1D . . �,', ! . 511ff� 830 • � � � � .SllI7E 30G . TAMPA, FLGRIL�A33$OG " , HU�SON, FLQRIDA 3a667 j - , ' .[813! 2'St-0�2B ' ' � ' c8131 86�-7at97 ' �- , rN%, t�13s 234•a897 _ .. ' FAx s8131 869-7156 ' .;��° • ' � � � Febzuary 13, 1992 ' , ' . . . , . . . �; � . � .. . . . , . 1 � � ' , � ' '� RE: 'ARTHUR CARPENTERI . . � . ' . . 016-26-58I6 � � � � ' 'To Whom z� M�y Cancexn: � . � � - ., � �e[ . . � ' 4 ,•' ' , • 1 � � � 1'Zease be advised that I performed tz�.ple vesse�,• caranaxy artery bypass on Mr.' Carp�:nteri � at �he $myoneC Point Hospi.Ca], on Z1/19/91 for a severe' left main stenosis. H�.s conva- � lescence has�bQen satisfacCary, buC both his card3.alog�.st (Ar, Desai) and,myseif Eeel �:�� he is unsu�.rabJ.e far fu�.1 ��,me emp].ayment. � Returning to work as a f3refighCer may �� ', jeopardi.ze his recovery and could r�su3t in'irreparable harm. . � � I� you hgve any ques�ions or if I may bP of further ass�.stance, p�ease do not hesftate �, to con�act m� personaily. • Sf.ncexeXy, � . , , , , �i\, p.S Yv..i�-� �..� w.,.� b . �.'r'' � 1 • - ' • . • . . . Marshall DeSantis, M.D. � , � MDS/kIo . cc: A. Desai, M.D, ' ' � . �, . � .� . . . , 1 ` ... . . . ,, . , . . ,. . . ... . , . .. .. - .; . . . . . ' ' . .------- -- -- �rrr��ri�s� .��, . , . . . , . . � .� � " ... . � ' � .`•.. . � � , � F.- :tI-} i.�. le . , r .. ..i, ' . . ' . . � .' . , . � � ' '.. , .' . . , . , ' . . . � ' . ' � � • � . ' . � ; y�. • ' . � ` f ' ; . , .. , , , , ' F; �. ° f ' , , ' . ' , . . � � ' . . � , ` " . ' ' • ., .,; : . � , . ' ;�i<. • � , , ,. � . i i . � . . . . . ' . . . . . � . � � � . It, ' .rt l'. . ' . . � . . . • . .. -� , � . , r . . . 1 f ' ' ' . ` � ' . � ' ' . . ' � ' . ' � . . . �� ' . ' . . )� ` .. . . 1. ., . .. .. , . , e .' .�'' t Y I , • . • . ' . . ' ,��• I � , � 3� ' • � . . . . . . , ' " ' , .. � . ' . , � , ' � 1';''' .o' � ' �� , '� t' ;� , .. ' • �. ' ' � • � . '' . �� ,•� . . ., ss.' ' I � � r . .1j ,. 'e .' � � �t � '. ' ' ' ' . . ..-' - . ' . • ,..�,.:j�r�^.��i��.�}.i�:7Li�i':.t��:.�.,.. �..�. � .,..,�. ,.a.e•w.. ...�.z_. . � _...., ' � '.E . .. ..� . . . . , 'r:. .. i ' . � .. . ;r , � . . >. , ' �:i � ., ' . . . � � . ' . . ' � . . . . /� .? ' ' . . , `• � ,' , . . . . � , . .�1 � ' • • ' � ' � . • ' ��_..; �� . � � . � �[JLF CARUI�L.C)�Y AS��YA'I`J�S � � ;�,.; ..: ,... :" �GdLLti ��; �.�., �.�¢. • �r��da �. R�GcCI'LLx, dLi.�., �?�. • a¢��2�, �ts.�c, r�(.�. � -' � � ��'` ��5326 GUI.F DRNE, SUITE I . � . . � ' 14�OO,FNAY E3D., SU�TE I10 y' `� �. �'.• - NEW P4RT RICHEY, FZ: 34b52 ��, � HUDSON, FL 346f 7-�481 : ; � . � , (8�3) 84&3381 � �813y 847-3002 � . , . �8Y3) 862-8383 � ��` . � � . � ,,,r� � , . . , �, . . ; � � . . . ��j� � . . . , �.. � � '. . '' � � . . , , , . � . . . , , , , � � � � .�e � ,� Fehuary 7 fl,� '1992 Ta Whom it May Concern, ,� , � Mr. Arthur Carpentieri. is a patient undez my care �or coronary artery d�sease and uns�able angina. 'On November � � 8, 1997 � M=. Car�enti.eri had a ca=a3.ac cathe�erization done at HCA Bayonet Point Hospi�al which showed severe let�. ma�.n and sever� r�ght �oronary artery disease. - � � Mr. Ca�pentieri then had �riple coronary artery bypass g.rafts' perfarmed on November .19, Z 99� ,�.nvo�.vi.ng the le�t , .� �.nterna�, mammary artery to the anter�or descending and rev- , ersed saph�nous vea.n graf�s to �.he.high obtu�e marginal {ramus) and to the dis�al,right coronary artery. I,do no� be].ieve �ha� Mr. Carpentieri wou�d b� ab3.e to perform his duties as a�i.refighter ati this �ime. The en- vironm�nt he �aou7.d h�ve �o be in would be harm�ul to his health. If you have any qu�stions regarding Mr. Carpen�ieri please don't hesita�e to contact me. '� Si.ncere�y, u�-r , ' � ' , , . Akshay D�M.D. �, . � i. . l �. �''�� CLEARWATER GITY COM�VlISSIOIV � � � � ��=.�- � � Age�da Co�er. ll�emvrandum uem � _ r*+ 'r: ;� � . - �AwAr�a`��°4 � Trustees of the Employees' Penslon Fund Meeling Date: 1 2/14/92 subject: Pension To Be Grant�d Recommendatic�nlMotion: . . Ca�eb Wir�s+un, Maintenance Work$r II, Parks & Racreatton Departme�i, be granied a job-con�ect�d disabiiity �er�slan under Section(s} 2�.35 of 1he Empioyees' Pension Plan as recommended by the F'ensi�.,n Advlsory Cammittas. C� end thai the appropri�te olilcials be authorized to execute same. BACKGROUND: � C��eb Wih�ton, Mairtenanc� Worker il, Par�CS & Recreation Department� was employac� by tha City on Nevsmbar 23� 1�t}� , as a parma�ar�t p�rt-ilme Ce�stodla! Warker. Ne began participating in ihe Pension Plan on Aug�st 6� 198�, t�e date af his promation to iuli-time status as a Mair�tenanc4 Worker I. HQ has three fterniated discs which resulted in his application ior a�ab-car�nectett disability par�slori. Mr. Winstan submitted letters from Os. .laseph M. Se�a (dated June 29, 1992) andDr. Rosario M�salla �dated Jur�e 15, 1�92, �nd May 16, �992} fn suppori of f�is req�est far a jab-cannected disa#�il€ty pensian. Mr. Wir�stor�'s disab�l�iy pans�on was �ppraved by tho Pension Advisary Committeo at its meotin� of October 21, 1992. Basod on an average sal�ry of approximately $18,A�2 ovar the pa�t five years and tk�a seventy-fiva percer�t {7'�%) mir�lmum disability benef�i, Mr. Winston's pension wiil approximate $13,SD1 annualiy. Chans iram Finance wt�ich take into c�nsideration mortafiiy ra#es and age refEect the "present value cost of tinancing" lhis pension wil[ be approximately $1 fi3,582. On Navember 2, 1992, the Trustees remandod this to the PAC pending rPCelp1 of a iegal n�in�on as io whother or nnt under the ADA and the Ciiy's Pensfon Plar� iha City couid make reasonable accammodations foT an employee and place thai empioyee �n another positio�. An opinion was recsived irom the ffrm of T�tampson, Sizemore �nd Gor�zalez, P.A., irtdicatirrg that the City cot��d make an accommodatfnn far an employee bt�t tl�e employee wouEc! not ha�e io accept tt. ln additian, an employee fs entitled to a disabiliiy pansE�n it in 1he opinton of the PAC that employse cannot peKarm ihe duties af h�s/her job. Tha Trustees afso r�quested that t�e PAC revtewed tha tndependenf inedicai Qxamination (iMEj whtch cantained a siatement indfcating t�at Mr. Winston had well-developec� musculatu�e for someone wl�o has nat been able ta exercise n�rmaily tor threo years. Gn Decembar 2, 1992, t�e f'AC review th� IME and the legal npinlan r�celved. At the conclusian ai its review, the Committee cietermined the medical c{ocumontaiion su�port�d Mr. Winston's request for a job-cannected disabiiity panslon. The Cnmmittee, �ay motfon duly made and seconded, remanded this ta t�e Trt�ste�s ior their a�prova! artd requested that #he entJre packet of Iniormatlon s�bmltted by Mr. Wfnsion's aftomay be sent to the Trustees. Heviowed by: l.ogal �1- Budgot ,v�Y - _ Purchasing +�� Risk Mgmt. , Nh D1S �" ACM j �i.�-+- Oth��_.._.._ �ui�' �. - - Sut�mltt�d by: City Mariayer ONgtn�tinQ Dept.� Humar� Resources User Dept.: Advertised: DatB: Paper: � Not requirec3 Affactdd partie�s L] NotitFed � Not requlied Cests: ,�-s c _: a'�"-r�.,_, Tolal Currenl FY Funding Source: l_� Capt. Im#�. ��J Oporating L� Other Appraprl�lion CodQ: Commissian Actlon: �� ApQroved l._� Approved wlcondltlons [_.� DsNed L� Cnnt+nuod to: �.., Attachmenta: U Nano L,6t�9C�S� Request Form : t . . . . , , i '' . . I�1�� . r ' . . • � • • � ! • .. ' .i '. S ' � . , . . . • � • , ' '• � . ' .. � . � '� � � � � ' 'G�;, '��1� . ;f��.^ ,. . . ..: '. .. ` � ..,' . ...... . . . Y 1 � J��J�� .�... �..� .w... .. , �� f�'. . • .111�,l1:3i� PNSOnnN Mp�rtnunR , 4d2r66'?O � 1 , ' ' . . , � .. I � , / . ' .'. J { � . . .. • ' ' . ' ��' < �� . .. . � :1 . C I T'Y O�' C T,� E A I� W A T E R . � ' . POST o�Ftc� eox �r�e CL�ARWA1'�N, FLORIOA �4618-4748 'IC}: � �onorabl� Mayar and Mem�crs oi th� . City Commissioa as Truste�s of thc . � . Em�loyccs' Pcusion P1an ' , � FRQM: Peasivn Advisory Co�mmictcc , CflP1�5: �Calcb �Viuston; Ris� Managemt�t; Dan Deignar�. Assistaat Dircctnr of Administra�ivc ScrviccslFin�nce Dircctar, �mp�ayec's ri1� SC�i�,1EG'�': PCnsion f�r Calcb Wiaston-�--7ab-Conncctcd Disability Pension � DATE: dcta6ar 2i. 199Z �, Thc Peiisiaa Advisory Com�mittce (pAC) rCCeived � aQplieatior� i'or dis�hility pensia�n from Ca.l�b Winston nn Junc lI, 1992. Ivir, �rViastocz �as been c��terAained by thc Pension Advisory Cammitcee to mect thc , requircmenis of the Pcnsioa Pla� for a�ab-connccted disability gcnsion, He was cmployed by thc City on Navcmbcr 23. 1981. �nd bcgaa participating in , thc Pcnsiou Plan an August f, 1984. Furthar. he has submittcd mcaical dacumcntauou. copics af which arc aleachcd, rc�ative to his disability which f�as bccn revicwcd az�d approvcd by thc PAC. Eiy tnotio�z madc and d�t�y carried at iss mccting �f 4�tober 21, 1992, Lhc Pc�nsion Advisary Committ�c approvcd/recommeudcd the granting of a job-cannecicd disability peasion lo Mr. Wzuston in accordance with pro�isians Q{ SCCilOR 26.35 aF thc Gity Code. This pc�asion is to bc effccti�e an, a da�te to bc dcccrmincd. Thc amoun[ of Mr. Wsnston's peusiou wiIl be calculatc� by the Finaz�ce Dcp�nment according t� thc farmala in t�� Pension Plan f�r job-connncctcci disability pcnsion at such �ime as his iast fivc y�ars of service and salary can b� computcd, I hereby cartify that the Pcasion Advisory Cammitt�e �as appxoved thc granting of a jqb�CDnIIGCLCd disabi�ity g�nsian for Calc� Winston and the abovc dates ar� corrcct. � �� ti . , � airman, Pcnsion Advisory Commiitce � , �� . i�:� s �. � ✓,1,��4 "Eqya! Emplayment and A3lirmativ� Aciion �mployer" �� , _� . . . B ;� i � # ' . ;� ' � .. . . . .. �. ,. ' ' .. .� � . . . . ' • . , ' . iS. . � . . � � , � . . . ' , ' , . . ' f ' ' i � , ' . � ` , ' . . . . •) � • ' . � ' . ' ' � . . ' . . . . ' . . � _ , . . . � ` , ' • � . � � . ' . . � " . r � . ' . ' � � .. . . . . i�.. . 1� � .. •� . ' , ' . ' . ' . e. , � • f ( 1 1 E ., . . , � . , i � ' , , • � , , • . . . e � . ' � � :� . . ��i . . . ' ' ' 'r�1'+�-�'�is�'��?i��;`!:� .i�i>!9'+f;... , „ r. ... ...<e4•..,I��.. , . . � � , , . . � . .. _ • ' . ' .. . . . F'. I ' . . . Y � � � , � , ,S , . , � �• 'li,. � . .' 1 � . 1 I '. � . . . , i . . . . . , t ' . ' , J - , . ._ . e . � . . .. , . � , , � , , � �PENSION REQUEST FORM , , , �, _��-� eb � t�s�ve�3� _ __ do hercby i�pply i'or retircm�ent frqm Lhc City of . ClcarwaCcr Gcflcral Emplayeas' Pcnsion Flan. . Q�. My b+�n��itS ds�tE i� ��'"� (Entry date i�to pcasioa pEan) My dute o� hirc is I 5� _ // — a 3--�/ �� My bi�'thday is „,, Oc.�er 1� 1q4l,� � My ,�ob c��5SifiCatiol� is i`�at,.�g,�..�.g,,� Li,'brlcer IT �d I work in the � ��r�lcs � Department. �i��c�r+-��ovt _Division. M y, resignation date is„_, -�u��, � z�—`' __ ' The Eypc af pcnsion far which I am applyiag is (chccic only anc): , �_,,,� Regular P�nsioa based on years of service _ ✓ Job-conne�t�d Disab�lity i'evsion Noq-job-cunpected Disability PeASion • My spoasc's teame is: — �•1 �°►�- � De�enda�t chiidrea u�der the age oi I8 and residing in my riaaseho[d are: �-N � - � � . (Print Ci�iid's Fc�li Natne) (Child's Uatc of Birth) i hereby certify all af thc a6avc to b� true and correct: � . � � . . {5sgn�ture/�';';'' �.Z .,.� . . (Da�) � � (Notary Publicl ' NQi`ARY P W[.IC, 5TA'I'E OF PLOit[�A. MY CUMMI55IDN �XP1A�5= OeG lQ, 1994. aDi�ID[D Tli1lU N07AitY tUOGiC UNOYAWRi[�{ts I � I � l�t' . � � � , . �f . .}' , i ' . � , . . ' . . ' ' � 1 . ' , ' . 1 . ' ' ' . ' ' j, ' , , . . , .' , . � � ' • ' . � . ' , , . ,, s., •. . .•E" , ' 1 . ' . , � . ' . ' . � . . ' .. . . . ,, , � + ' . . : ' . � ,. ' � ��i�� . ' , , � . , . ' � ,.. , � . '. . . ,' . ' . ' � � ,; , . � . ` , , . , . � � . ' .�. . , .`� t . . `. ' , , ' ' . • , iii�,".'•1." r.4. 1. • ti iir•rf�n�... � ,... . . . . �.,Rir.°^` .l.'.Vl'.� .� .s .... � � • . ' . ' . , . ' . . y ' . � ' .. ' . , . . . . .. e i.. � , . , '� . CITY 4F_ CLEA.RWATER � � � GEN�RAL EMPLOYEES� PENSIQM PLAN ' � . ' QPTIONS - GENERAL EMPL4YEE� �. . OPTI4N :#�: � Employees can reccive a lump sum payment for '. , ,' .� vacation and holiday pay and 1/� of accruGd • sick ]cave �' at the time of• scpacation frorn the City. Therc wil� be nv . ' 8% dcductit�n. far pcnsion fram this lump sum payment , � ',, nor will this amaunt count as earnings in t�ie i �' calculation of the pensiora. The last day o�' work wili be � � , thc termination date and pcnsion bcacfits will . begin � � ' � the following day. � '� - OPTIOi�I #Zt Employce can exiend tcrminatio� date by thc timc duc . (Daly ava�labie to for vacation, holiday pay, ana 1/2 of accrued sick leavc, emptoyees t�ired Tertnination date wil! be the �nal day of �xteuded time. ' prior ta �. XOII190} � Pensian bcncfits will bcgin the fallowing day. . *�fi*�***�n��*��***�*�*��* � i, � F,_C�_,� i_�n5�_o_�_� ___ �___, an employee uf the Gity of - Clcarwater, hercby a�ply for per�sion benefits �nder chc Gen'eral Emplayses' Pcnsion Flan. .. [ hereby certify that I fuliy understand the two aptions vff�red to me. i choose to retire using Option # .� and wish my bcn��ts to be calcuiated under � tnis optian. � i uaderstand that oncc this form is sigued, my decision is inevncable, � EMPLOYEE'S SIGNATURE:.:.,� ' � SOCIAL SECURITY �: a� 3 --� � � — � -? � � -- - , A1�DRESS: _ IZS t=-F7.. ��x�. �w. 3�tC�zs- / � , . � . � . � �. - - .. - � � DATE� _ � c l - �Z � 0 � � I�:�: , , . • � . . . '�7 � 4 ��It. • . .14}. . .E..: r � . . .. i .� � ;.�3.n��` f S�'r,`t:'•��:' J.,t' z ` . . . . .�,. �> . •k� . 's�, . , . , .. . •r� .vft:. �,�r,�• i,i�, :f, `r ' , . �. . � . '�' �'r ° ' . isf,,, �'5��! . . 't°. ��t� . � i , '�ie. � . � . .. ' . ' o; . . . • ' , �. i��,��s.. ��•''r. 'M1�� ' - � . 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' . . . . , rr'. '. . � . . ;J . .� �.Sr��',�,' i,', '� �`�.�'� ,=i,�`. , , , .� . �� . s. . � � . . ' • . •{)`, 'If` i it . .. r4�'.I. ,�'� . .i�. . .,E,`,.. `r . , . . . . .i1F'. ;'.y�7.+�•1�r "l; �fdi +i. � �til�, . � . .' 1�' � ';' . . � � i �' ��' ��,�'i[' ,. � �r y Za . � ' ' , .; � . . . � . , . . , . . . � . . �� ' �j'w� �I��l. � .�f . � ;I� . , o , � � ' , ' ' � . ' . ' � . � . ' . . , . �i , ; �. �.}.. °4�:,.p� 1' 4� � . e . . � � ` �� `. f.%' ��}� . �14 ��tl�.,' . 1. ��. , ;' . ' � . ( S. i ! � • • . ' . . 1 . , f �� i.�, ";,� �"s'..:n� �'. t'. -��' ;.�; '� �' . . , . �' , ;,� :r., ;r' `'. "� i, ' � ' . � . .�' ' , � . . ,� , , . . . �'1,`�' i` � ^�d. � .i�' i,' '� :.'�:.1� ' . . . ` . , . . � + , .. . �y t � � � . _ �' '�if':� � . . � . ' �' . . " : , �. . � , . , . . . , � �,�°,�y� y �' : ' i. ,'4� , {. : �4. ` :.��. .: . � . ' . � .' s • t.,:<'{�i..: _ '•.f � , , � . ' .. ?�'i'vc i '-•.�:�;�. � » . . . , .,_ .r: zI'? ' ` .• ', .� ' ; y. •r •:f �'i'1�': .: . � : �r � . . ''1 Sa,:�., .. .'��M.G.:.rA,�.�Mr�`+�11"i',-��nt�>a.%.' . , r.�:".. Yr �.0.4'.�a �i�� 1 � �4.�. . I)' � . ..'S-. ... .w...Ye/:�'f'!1�;�r'�I��Ns'.I��ri� � rj�'�"�.i:� x..� .. . :j0 7,C� E � , i 1 . � � . � . , . , ,. } � Is .vY- M�.. .... . . . � ..... . . ..w NY =�f ` � .!, , �J I • . • ",v,c.. • � \ . ' . .i ' . � �� ' . . ' , ' � , `' • ,'` 1 • • � , �1 h p.' ! `� . . ' � . . . � � 1 .«%� ' ' , . . �P•. . . , ' — � . , � i � ' , � . ♦ . � . , . ., . . � . .. .. . ' (. . ! ' � � . � . • . '�' � , �. . . ' ' .� . . . � . .. � . ' . � � . • . . " , � � � . . ' � , � .. . . . '3� � . ' �. . : 'I�N'D E,X . . . � ' ; � � � � . � � � :, ;�,r . ,; , . , - . . , . , . , ' , . '. . �: , ��' � . I. � ` 2�oti�e of inJerri�s� � ' � , `- , � � ' . �. � ', � , : : �. , '1 ' . . ' . . � � ' � � . . . . ' � .- 2. . Notice of Change�and Perr�anent Total Disability StaEus. �� . � � ; � �, , .. . . . , �� . , „ . . , . � . . , ;::`..; 3: " I,etter of,Resignatiar� to City • . . . � . , � � . � . . . � ,... . . . .. , . , .i ' .i , . . .r . ' . ' ' .' ' ' . . . . ' ��'. . , 4. Pensian Requ�st 4ption � - .. �, , � - � � , � ' � � S. R�ports of Dr. Jos�ph Sena . , ' , � I,. . ' - � �' . . "; � : � . . � � . ;. �, t �.. � . 6. Work restrictian of Dr. Jos�ph Sana � � , , , �. , . • . . . , � , � , ., . °_ � , � :;;, , � , . �. �>,, '�7. Ser.and opinion of Dr. Musella . � �, . : ;. `�. � " , � � , . , , , � . , .. ., .. ,. . . � . . � , � , 8: V�ork'r�siriction of Dr: Musclla ' . . �� . ; ,; : • . . . , 9. . iNtE of,Dr. Slomka � � � � ' . � � � . � .� , 1 � �' I0. � Work restriction of Dr. SIomka � � ' � � - . � � � � � I 1.. ' ,Functional Capacity Evaluauon � . . . , ; ., ' . • � � . , . - ' �2. 'Uacat�on E�cperE Ciricul�m Vitae � . � , , ' : . . • . � � . . ' 13. Vocational Expert �nitial Report : � . . . � � . . , . , . � ., . � ],4. : Curnent Prescnptian Nxedication .� : � . . - , . � . . : , , , � . � , ��. ��. . „ y � . . , � . :� � ,s ,. � • r . �. • rf. .. � � � ��►�� 'ir ��,� '_�"`'"� •.: , ' Q�?A�i'f'VI��V -"' • Lr1[3UK .aND ��r1P�0YM��VT �cillf�tT'� NO.. --- . fi `°"'�+'�""'0. .l��s �. , f��, � ,:,��..� C .an o� Workers' Gampensation � aifw� � ,icq �uROS�oor �ww • •r.z �usuR[ Z•iL� �XCC1�Il�C CEAtEf DS'iYC� �35� ;"a• f !, Tallahass a�ln�i 3 d r" �ae. � , �� G L� � �I �-�-t -�.`� ._., -�.�.-�,� I arr�Nrtorv: w.c. cr..aiMS o��ic� epart all dcaths hy teftphorte ar t�legrsm withir� Z4 }raetrs. A�.EASE TYPE Phanc: 7-8Da•342•174� .~ EMALOYE�i IN�ORMATION " EMPLOYE� IN�OFiMATION fliil�S'S NAM� � NpME iFirst, Miqql�, LasT1 SOCIAL,S�CUF41iY NUMBEA City of C].eanrater- ...� Caleb £. W3.ns�an, Jx. 263-�6-534L �AA11.;f+lG AdOFI�SS (Inuud� Zin Cod�i �� ;�;�;,i�•�' ME AL7OA�55 (tttcluue Zip Codel QCCUPATtQN � I0z ,r `S�,''°•ts't r..t��'^ �` Parks Worker „ :� �, ..,,-. P.O. Sox 4748 r, .;. ", Y.,°,'• , •' �' �:-'' ' :�125 F'ernwaod Street �], 5UPERVi50A5NAM� .r tiYi Clearwater, FL 346]�$� ` ,.; ;.,. �y'' �.:Clear�rater, FL 34b25 ' Howard S�li ' .t4�•� � ' - "'•^�= -•,,. a�PANTMENT NAME � � •�r• �r,�{v1� � -.,,•_�•,. Farics & i�ecrea�:Con T�1�.SPHCfVE . ' ��s r� � �LEPH�IV� C1A78 AF BlFiTli SEX 1� Ars� Cod�: Numqer; Ar�a Code: Num6rr� M ❑ p LqCAT10N �� w �,�1�klinp How lonq Nurr+ber aS houra Fer Wa�k humper v! diYf FiA7@ bF PAY ' •ma�o �d7 warksd worked p�r w�4 • • 11 2 4. C] p.,� o.v b84.59. LS P.r �oUr Cizy �ali .4n.�ex t! p;re� wtxk 4r eommissiqn. rnrsr If qorrd. lodprny or ach�t ' Q Pw Day aueraqe wewkly amount ativanp�}as furni�hwt, ont�r wcakly 10 S. Mi,ssouri Avenue • .Mdun� • � Q�.� w..k Cleaxt�ratez, FL 346I5 VlORK�Ft'S COn�P�t�t5A7falV C�V�f7AG8 8Y OlrKUr�nea ComWnV 5,�t.�n:e+..a . GIV� NAME, AOOFI�SS ANp PQLICY fJS?M�Efi OF IIYSURANGE COMPANY dfi SE�F•tl+tSUfiED S�AVSCE COMPANY. NA7UFiC OF 9USI1't@55 Muni,cina3.i�v GALLA��IE� BASSE77 S�RVI��S, ��IC. � F�OERAt. EHl�S.OY�R I.o. NuMe�a , 2953 U.S. 79 Norttt, Suite 3Qt �' ' •-- • 59-fiQfJO(J289 Ciearwat�r, F�arlda 3462� ' ' � • ' ACC1l7�NT 1NFDFiMA710N • � - • - •� • �OAZ$ ANO TiM� QF AGCIpp(Y'l'. � DA7� ANp TIME. FiR5T REPOR'iEO� _ fVAME, A40HHSS ANO PHONE Nt1M8ER QF PHYSiCiAN ;'_ '7C�2 �8g�.A..~�ox. lI• �� DoCra�s Walk-In�Cliri3c .1; � *��' PL./10E OF ACCSOEhT l5err�s, City, Cnunty, Statr} LaST OATE �i.6PLOY£� WORK�D �6�� IIS 1� NO�Ch Etidie C. Maare Comple�c �l �4/89 at 8: 45 AM C1ea�aaCer, FY. 3462I Z�� N, McMuu.en $ontf� Rd. R��RNEU 7O YIOliK Ya Na pHYSfCIAN AU � HUFiIZ�p SY �MPLQY�R ❑Yr� �No Cxearwater, ��.I14'�,IdS� £L 3k629 �� Y��• pATE NAME, AOOfiE5S ANO AHANE OP f'IOSPI'iA4, . Yr� i�No �MPL,OYtiE trlISSSOi ON@ SFiIF�, ONE (JAY dR MQf1E7 Yw � Na T �� WAS IMJUKY FATAL7 [�Yrc �No If Yrt, p�� qf pa�� $�APL�YE�3 O�SCHIPTION QR ACCIDEiVi (CiM astailc such as, id�, was ttrutk, etc.i ..' ' DESCRtSE JNJLlAY OR DIS�ASE ANL] ENpICATE � �AA7 QF �t70Y AFFECTEQ I�.q. Amnuc*Na*� ot Npl�c �mpl.ayee W�S em�ry3ng �Z'�S�l C3I15. �lI@ CO zazny COIId�.C�,pAS 1'*d�x fJna+r se s�cond ja�nt,'� racsur�d ritrs, La�d Poisoainq, sie.} � caas were hea�iex� t�aa r�ox��. �mp],ayee went to l�.f� 4�+ .. gallvn rubbezmaid trast� can onto �us�rsan ve�ii.c].e �rhen his � faoe slipped on the wet grass, causi.ng h�i.m Co taka a mis- ��'�'�' ��ra�n - step. Shx��ing af weight caused sCrain. �n ner_k/shaulder t��k/shor��,der blaci��'= blade. � ' , `'= , • � .' � �- . �' E�►iPLQY�Hs 1�qrre widi thF� detp�Ptian7 � Yra Q No If no. �KOl�in irs tornrmnts. �— �: ' , aoMM�Nrs: �; � :- " -` .-... A�y pers�n who, k�awingiy and with intent to injure, deiraud ar deceive any employer or employee, insurance wmpany, nr self-insured prograrn, Tiles a statement af claim containing any faise ar misleading infarmation is guilty af a fsfony of zhe third deqree. �L�ASE �lLL iN ALL SPACES ABQVE � � EMPL,QYEfi (Fiead and Sgn1 � , - 51 NATUFiE �R�� ' a.• . �MPLOY��'(Reaci�and�5�gn) ?+?�A Fr�r� c?ntt-�rrern _ _, ��_ ' SiCsTiATUi3Q DAT' !� L�5 F•dim flCl•1 ifi�v.6•791 � a O�I�� n, F �� *�� etror ,• Mucnr� '. �n+msRw �.579 p11FY ACR ►�RrQI#tlO7 A�IMI nc� sa u+�c K YRi I I�TUw; •u �:A. Ze�Qrt #�I �C3tZif k1y tefep�tqflC of ttleqf]m witiiin ZQ 1ta��, pt�� E �MPL(3YER fNFQRMl�TiON . �� H+4M� IYAM� S��nt Mid41t Last) SOCiALSECUF�ITY lVUM f � sr,tin or• ru3runn DF,AAR'TM _ �F L1C30R ANU �MPIAYMrN'1' S(?CWtiTY � , urvisioa o[ Wa►tcu�' C.nm�rn��tlan �728 �ncuvicw pRVa, 5ui�c 1tl4, f�orreu Iluildin� rl�lt�1117[f,� �Qfli�i ��9%'Q�i ATT�N710N: W.C. CLAIMS OF%1C�*- Phane; Z$QQ,3a�•i 74 f iMPLDY�E 1NFOFiMATION iw�,al�inrG ,4poR�s:. �rnc,ua. z�c Cqa,� P.a. Box 47�8 Clearwater , FL 3 4 0' �.8 � � �►... cov.: g� � Nu�,�: 452-553 �-°�71°^� , S�m� as Mai[inq �.'1�� $c"i�.l Aiili@J�L �.� SULI'�1 M7.SS01],r].. 3�4�� Cle3zwa�ter � i'L � 4 � �s' NATUf1E OF BuSINESS _, , , �'�" � r �..��~: :��:��'iva3c�n�Z�t= _ FEO�RAt �AAPtOY�R l.q. 1+1tlMBEA �. __ �q-..��iCi4LR(17_43Q'r �' �. • ,•... _ _. _,,, .� .... � OA:'� itNi3 TIl�C OF�ACCi�E�T �— • �' DATF A • . .. . � � .��,�� / �,fj,-i 1 - '� .� a � 1 � rLtCE QF ACGIDEN7 t5ere,�t, Ciry, Cauatv. Statol c�p�� `i�. b51 Old CQac1�n Rd. . • R[ R Caleb Winsto�n 263--9G--�53�11, ' HOM� AS]pRESS (IrrClud* Z. 7 CGde) OCCUPA'�ION �.25 Fernwood Ave. �l ar:�s Worker/Rec. Fa Ci.earrraterr FL 3�62`� SUPEHVlSpRSNA!'A� ` oward Se1i , D�FAFiTh1EN"1' NAM� • Pasks & Reereation '1'ELEP+IQNE + GAT@ OF 91RTH S�)C �r�, cna.:813 N��,�..- no - hone l- M -,. �0 �� 4'� � ❑ �. Nawlonq fVumber o! hounQp� yy�* 1Vumdrr o} dayrx RATE OF PAY ° •m yed7 wo*k�d wwk�d p�rL�mk � � � 2� $ � � (# ❑ Arr�4sY � ' � r�r l�our I! pi�e� wo�k ae CominissJon. �nt�r It basrd, 1odQin� or othRr. '�� .� 20 pa flay aw�raQ� we�kfy amount ' �dv�ntaprs farnahed: r�t�r we=kJy amount' r ❑ P�r Vyr�lt WORKEA�S COMP�N5A710N GOVQR/kGE BY ❑i,,,,,rancr Comwnr S.�f•Insur.d G1VE NAM�, AOOFiE.�S ANO PqL,1CY NUMB� iR OF INSLIHANCE COMPANY C3fl SELF•INSURQO S�FiV IC,� CQMPANY. •- • • • � • • G�4L,Li�GHER BaSS�TT SERV��ES, tNC.�=�� •. : � ...Fi.Q $OX 4840 '. i � � �. . • ; : . ' • ' � • �Gearwaier, FL 3�'t8-�ss�t0 ''' '."". ^ �--: . , _ •,•.-.: �ACC1aENT IN�URMAT(aN — — ;- — la TlM� FIF!$'i' A�J'OfiTkA ..�•_.. .:.. NAM�,.AC10RE55 ANO PHDIY� i�[L]hlBEFi OF pt1YSIClAN r.*f'. :' - -w• /'� . .. I LAST CATE EMPiOYE� I+yORKPO - '� , � ,, Wa3.3c�Ixi Clinic � _ .. .. . . , F�i�TUHNEI7'TO WORK Y�s Na P��GII►�AlSTH�RIZE"q 9��C.pYER ��a L1Ho fF Y�S, 4AiE �� y� �lAME, AaUApSS ANA P►iL7N� OF 1lOS�17AL C1,eazwater, PiaeJ.,�.as, Florida ��....�Ta 1''1 ;�_. aa�. et In w� �.�L_f YK ❑ t�io - '�Prr." , , �lti4tLQY�� MlSS[O qlV� SiltF�, Ot�E DAY OA iuORE7 � Ya� [� Na . • • � , .. .. . ' • . • h . . ` ..• . .. � rt WAi3NJURY FATA�.7 (�Yri QNo i! Ya�y�, o.�.or'o.,m . � . . • , �MPIOY�E'S OE5C1'�IPTiOfV qF ACCl4ENT (Giw dssa�ti iueh as, IMI, wax struck, �tc.1 OESCKtBE INJUf�Y . QH•'dI5�aL5� ANd INptCAT� "^. > � PART OF RODY AFFECT�❑ (r.q. A�*+w+r�tion b1 r1¢+t W2�ile II1C)inYlTlC� Sd1� [x�3F2�. J�OW�= � D3�.I. ''�' 1,, n+a*x finpar at secanq joint, Froctw�d riW. Ls�a J ��i1C.t1 p01:011inQ,�tC.I . • f:.�. , . . ..�. stee.=ing wheel of tracts�r. �a�oyee dodg�3 . .� _ .�.. :.. . _. �� .w�' .. ..-.._... ball and suained n�c�c, mu�clz. . , c��rical straiu .�to nPe?�-area , . , . . . . . , . . . ., _ � � "�-; � � . , :,. ~ ''• ��tWA7� qFclCE . . . . . . ' t , . � _ �ti•. . . � . _ � r� • �r•;iti_�S `.+, �•� :.�„ .s - iC:. �: �'!'i-' _ ..�.��_:.. ...�,._� _.��..'.�--:.._� �...._ � :.. ` ._ ;_Y "`". �..-.:_ � __.._.�. . ..� .r:- --1'��}� f:.� �.._.. EhKRt,0Y6R: 1 �qr�y witA If+fs deswipdan� • Y�s � !Vo -7t i�a, �xpl+in in comns�np. . .. . ' . . • .. . — .. . • , , . �Q�'��N7�= Em�myee seen by City ��crrse and we�at ta '_.'�Ial�c-In--Cli�ie. ,�''��`� , . • + 0 'Any ptnon wha, kncwingly �nd witiir inient in injure, deira�sd ar deceive any emptayer ar employee, insurance camp�ny, ar selt•iRSUred . pr�oyram� tiles � statemCnt of claim containing any {alse or misleading iniormatio� is guiliy ot a telony of the third degree. .. • _----, � - - -�, • • PLEASE I��LZ !�t ALL SPACES A6dVE EMPLOY�F# (R¢ad and S;gn} t�r Fu�m lll:�. 1 114NV. 8•i71 �, � � �.� �//�/�� SfG1YAT RE OATE . r • EMf'l.QYEE (Read ��d�S�g�) - �� `-'��'Tf�'� . . .. �� /.`• SIGIHATURE ATE �• � ;` . . C�R41�� C�r'.' . . 4 � � � 1 . � � . . . ; , • � ' � � � ' . . . . . � ' °' � ' , ' ��, . � � � . � � ' '1 . � r � '' .. ~, ,1 • � • • , • • ' � ' 1 • �} •' ', �� r UIVI$�1 i.11L'f1O�1�Ni / ' .. � / . .. �.:t= :-:. � �,. ., -;:_. � . waCn+�r�i[r��s ansr s'rnMn r, F�.OHIDA t]EPAR7M�NTOF LA�OR "AND �MPl.OYMEN7 SECURI7Y, '�`, �. ��'� �Y C,aRqrCti S�Nr rp niVi, q . �„�; DIVIS�ON �F WOAKERS' CDMP�NSATtON � _ � � �-8(ia•3�2•1741 (a} cornact youi local allice lor assistan�e . : :�._...'�..� . . � , � . � . . „ . .�. ,.{l.,•{; ��„•�. , . .. . ,;C ,4�'. ».. ,' � ' � � .•t.�OTiCF��JF �NJURY ' , . ' y ±'. , � �.w •� .: �.: Ae�;ort a!I deaths witY�in 24 hours (9fla) �6-304a. .•. .. .- :! � � ,r� • . �. �� . . ,• �s. . .."• •-,.. ,. �.'� �. .. �.: "... . • � ,. . , . .. . , �� .. ��•.• , � � ' ' � �'MPLOY�E !lVFO�MAT10�t --�- NAlA� [Firat, tulidtll�. Las�} Soc+al Secunty �lumaer • Ox1e antl ilme al Acc►dont . . Ca].eb ii�.s�tan • :Z63--96-534L 2/Ilf9i .+ . HOfu1 ADOH l�ndudo Zip} • • - .•. • . .. • . : EMP�,QYEE a OCSCftIPTr�N QF A�IaEtY7 - . � �.25 Fern�craad Avenue, Cler�rvater, Fi, xnjured neck Rhile, shove3.iug shel.� fox, ��rRtn txu, ]'�LEPHL7{VE �� K�, OSSCR18� {�URY OR OfSEA5E IWD 1NDICATE PAR7 OF BODY FECTEp OCGUPATIDN . {e,4. �rriputatian d right fnaex fingar a1 sc�cand join4 f�athmd r�bs, kad poixon�rx,�, elc.) .. . . 0�1T O BIRTTi 5FJ( pID YDU F;Hfl�EST i4tEpICAL C11REZ � YE5 ❑ NO �4 �fl 1 �7 �#A ❑ F 1F Y�S. t?tp EMPIDYEFi PRO�IIO� M�DIG1,7 YE5 �] iV0 �� ._.. - �.• �fa(PLOYER IhlF�RMATiON � • . Fi1��5 NItM� ItND ROaR�SS F�D�AAL LD. NlJMB�A 4AT� ANO TiM� FiRST REPORTED � City of CleazvaCer .. �,�� 59—�00�3Q289 � 2J19/9l. at 11:�0 AM P.O, Bo� 47�48 WC. CQVERAGE 8Y • PcXlC1QME�tBER i�UMBEii . • C��a�uater, FL 3�618 � INSUF;JINCL- CO. �,SEI.F[NS11FtED � . NAM�. AQO�iESS. TELEPHQNE OF r�KOH,� ,...c�.8 �3 �.. 462—b53i iHSUAANCE CQ. OR 5ERV1C� CUI�PANY W1Lf. YOU CONiINUE 70 PAY= .� SN..kRY? Y'ES ❑ Na GALLAGHEA �ASSEtT S�RViCES, (NC. � P�J�C� OF ACCI��Ai7 {Slrre�, City, Courny, Sta�e} F.Q. $oX 4840 - LAST OAY PAIa TFiHOUGH Carpes�ter Fie1d Ctcnrwater, FL 34618-4840 r � � TeEephane; {9'i3) 796�6929 .651 Q�.d CQ�cl�rcan B,d, ' � �rE nF P�,Y � HR � wtc NALAE, AOnRESS AN� 'I'�LEPHQNE WER L7 OAY G,I+AO ' C,l�lL�i�t�"X � ��A@�.�..:iS � � . S�_, g pF PHYSICW� OR HOSPITAL � N�� y � Dt0 TkE EMPLt7YE� KNU'h1NGLY REFl75� IU U5� A SAF�iY D�' g Q�,k �p,--Gi in�i� N�� _ -- APPL�MICE ?laOV�DEO 8Y Y011. Ti-iE EMPLi3YER7 p YE5 X1 NQ ry£3�0—II5 1.9 North N�r�at �{� QA7� FhIPWYEA . L�ST D�1TE EMPLUY�� VY4FK$17 • 3liEZ� •. PK wcek� rJ L'ZP..��7a'1tL' � L�/ 23 J S L � ! 1� J�� ' � P1u4 FUR Q+ITE OF IPlJIlFtY R�71Ji3NED 7C3 WOiiK �1fE5 r• NO AIITt�OR� � PC � YE5 G HO Y�S � NU p .. IF Y'ES. f'siVE OJ1TE �! Z�...�.1. LOG�TION�I�O H � .. - WAS INJUAY FATI�L? � YE5 L5C�0 ' "� /� r� � ' IF YES. (3iYE DA7� �F I�EA7}f! � (L CAT�r� r� . 1F APPlJCA9l.E7 IGREE WITH O�SCRIRTIqh! OF hCC10ENT7 1� � OF BUSIN $5 {�j,YES p k0 IF t40 A'1'7�cH E?cpWVAri4N i I�IesxliCi a�.i.. �ny per..orti wl�a. kr+nwi^9h u+0 w+tn incent to knjuro. dehaud er deceive ar�y empl4yer w emp� u�svrar�oe compar�y or sall•irrsurab proqr�m. f�es arty statemer+l o! C.um canta�u�q yry hl.se or mis�enC�ng �nlormatian is gvihy cf a Felony a1 u�e mud degr 1 �oinwded ��ee lt►eir copy at tnis nai�c�: . � .. . . . .. .. 1 Nor av�ai1a51e fo�t ai,gs�a�ttre � � f2 �Pw� s�c�+�rua� ta .w+.a�. �o �+� " wr� ��a�r�a s�c� � �• • • • • CARRIER I ATi�t� . Carrser Audit � ' Loc�t�on �' '' Service Co. # �8 Carrier F�le � ' (� i. C.x�trwerting E`ase—owc-�2. NOiICE OF DENiAL ATi'ACli�q ' . � : , ....,,... � �. . . , . . . .., � 2. Lnsi iime Case—date o( Frst Payment '='►' ., �. AWW Comp Flais • First day of di,ahifiry! / � �' +—Oate ot Frst Cantatl witf'i Ctair�ni � � G �n Person ❑ Telepha�e ❑, Mail � ,�-+voc�e Fred �ue �o M��te Pe�s.or �;sa��l;ry. Dates �avered by rrst Payment ` � Q T,T.Q. [] T.P.a.' Date Form Rec'd. � � � Catasuoph�c, p P.T.D.•: p peath , L] 3. Medicai ��Ey wl,ich became a Lost Time Ca�e. (Complete aEl information in item 2 abavej . •••- R�MARKS: � /11�.fUSTEH NAME; CARRIER �dAM�. AOOF�55 8 TEL.�AFlONE: ' oAr�: � 1 GAI.LAGHEA BASSEi'T S�RVlCES, INC. AO.tVSTEFl SIGNAtURE: P,O. Box 48A0 fi Cfanrwater, FL 34618-d84a • ' ie�ephdnv: (819) 796-fi929 LCS fam OwC•� 1��1 EMPLQYE� COPY � ., . _E�: � . . .� � ' , , � � ., . . . , . , . ' �, . . � . � . . � , .. , . � , . . . . .i , . . , . 1 ' � , � . . . . . 1 ' . � ' � , . . � . . , . . . , ' ' . � . J, f • � , , . . � . • . . , . ' .I . . • . ' . � ' ' " . � ,• .. . . , ' . : ' � , ' ' �� ,� � ` .• , � , � , '_�. . . .. , �6; . ' . . . . . . . . . .E . , , i.� . en.��.'. _.., . - . r�e..... r �.< r.,., . , , , ... .�.. , . • .� ,,, .,� �. . . .. . . , .�� . Y�` .'� ��;�, . �`�, . . . . . • , . . � . .. � . r � j, � • y ' . . ' . I ' tr • � , ' = The I�m oJ�ux pJ . � ' � � ' EdwafdD. Cartron ;' • �� " , � CarlsQn, Meis�ner, � . . � . : � . ;°��Nd�°" ~ Y Y e�� DQ�SQT�. � Aeee1A. Mclsmer� � `1 � . � � Wtlllmn R �Rebb � i. ��,P�. � � � . � • � ; . _ . �� R ��oR ; , , , . , .. -a��a �,wr�td - . � � � c.�„a�t � � . , . � May 13, 1992 � � '� Jon C. �Viazcin, Sr. Clauns Representati�e . , � Ga]]agher Bassett Services, Inc. � � P.4. Box 484� � ' � � ' � . CIeaxwater, FL 34b1g-4840 � ' � . � � � ' ' �e: . Err�p�oyee: � � Caleb Winstar� ' . � . ' Iviy File �: , 4�&8 � ' . Employer: � C;h+ of C[earwater � , � DIA: 7122/89, 3/12190 and 2/11/91 Dear Ms. Marciri: � � . Pursuant to my conversatian wxth you on 1VI.�y I2, 1992, t.�v.s letter serves to confum that � you f�ave agre�d ta accept my clier�t, Caieb Wi�nston, as perntane�tly arrd totally aisab��d aL this pc�iat, pertdi�g ihe outcome of the �ocational xehabilitatian assessment which will be scheduied sometime in the near fiature by ypur vocatioaai rehabilitation d�partment, I will be cpntactiing .� my client and infonning him to disr�ga.r+d the job seaxch x�equiremeni and that l�e will b� �ceiving payment for the back pay periods beg'inning vn Apri115, 1992, pr�sent anti continui.ng. �' . ,�; •r . � Very truly youzs, � � ' , . CARLS4N, iVff�TSSNER, WEBB, DODSON & IiART, P.A. . . . r/ . .� _ , Casey , Car on . cxcra� � � P.S. Enciosed is Mr. Winston's Request for Wage T.asslTemporary Partial Benefits and Work � � . Sea:rch Report fc�r t�e perioc� �€f2S112 thro�gh 518192:• . . ! � - � I . � I . . Responrs To: 0 ❑ ' � "� 2S0 Bdthrr linad NariJe -Suite !03 7d14 Masseeluueiu Avenur �, �'` �+. q �� . . Cleorwarer, Flaridn 34G�S New Aart Riche�. Flarida 34bf.i �" � j 3� � d 813-44.�-1 S6I 813-8d7-2737 . � � F�iK $l3-d49-0?58 F'AX 813�S5-9T': �"�''-�-� �ici. � - i � ' . � . .. '! . . ' � • . � ' � , ' r • i •1 • ' z ` ' f � � .. . 1 ' � . . .. . � � � . ' � ' ' � � ' t � , .., � ' ' . ' ' r , . . '1 . . .} . ' �'' . � � ,_ ' .1 . i-. '� '' , � � ' • ` . .. ' .4: ��5�� . . .. 'y:. � .�L.. . . , ':i � , .'k'. .�i � �' � i • � � . . �: . . ... _ . � � � , i � , � . ,, , . i� ' � • � sr� t,v► o� OJ . . � � � • „ , ��0�.� �E'�.SSrl�.'xr ' R Y �V'�bb, T�odSOx� , � � � � , & �a�; P.A.. � � ij . • . al �( . � . � ` . . '� 4 ' , . ` , . . � .• .n' .i . . .' [ :1 ... ' , i , �y' • s�ne 8, �992 . �3. Michael �Laursen, � � Human Resvurc.�s Dir�ectox � ' C�ty. of � Cieazwater . ° � P.O. Box 4748 � � � ' C�earw�ter, FL �dfiZB � � ` ;" -� Re: , Employae: � . �ry �� : . Empioy��: ' Clai.m #: DtA: � Cale� Winston �ss � cx�y Q� c��c�r 263-96-534i 7/22/89, 3/I2f90 & 2i11/91 F_diwrd D. CarlrAn . larrtes� 4i: Dadron r.'r:.�y Han Pau1�4, AfeLrmcr� WrUlum R Wcbb Gucy !G Ca.irun *Boarrf Ccrd,Jfed - 4fmfna! f�rw• Dear M�r. Laursen: T#�is Iet�er serves to confum that my c�iectt, by tiis signatuze t�Iow, hereby formally z�,signs #'rom emplaym�nt with� the CiCf o� Clearcuater as a municipal wori�er in the �arks and Recreation Depa�tment, eff�ctive i�nmed4at�Iy. ��rther, it is my cuent's undecstanding tf�ac the persoruiel o�ficer will cantact � my client tn discuss his applicadoa for disability pension retirement. Th�s �signa�ion cames as a dir�t res��i of my cliet�t's p�ysical inability to �erform ,�ob d�tics. as a Fnunicipal work�r in the Farks and �crea#aon D�artm�nt for ths �ity Qf Cdearnater. � Tn submitiing his resig�ation, my clie�t is na�„�iivin� up a�rty rights that t�e �as under th� Flarida Worke�s' Compeusation Statute anci mserveS thc�se rights na�+sthstanding tivs t�esiguatzon. My cl'sent is cunently treating with 7osepli Sena, M.D., and will contini�e to s�eceivs medical e� and t.reatment for his i.njude,s �re�ated to t�e abave-mentione� acci�ent. This msignation is gzv�n recogaizing that his �mploy�r is unabl� ta px�vi�c ium with employment within tus restrictio�s and Umitations. � 'Very k�v1y yaurs, C.E1.R�.SON, Iv1EISSIV3��, V�F�B, DODSC3N & HA�T, F.A. . � �� . Casey . Carlson �KClc�k�. ec: Jon C. Marcin, Sr. Cla.ims Representativ� Galla�her Basseti Se�vices, ��►c. R�spond T'o.• � � ❑ • �Sd Bcicher �iaud Nonh • Suire .102 : bl q Massachuscas �Svanur Qcarwaur, F7oridc 3�fd�.5 Ne+v Porr lllchry, FlaNdc Ja6J3 � • 7713-443•1561 813-847-273? FAJ� 813-�W9-O3S8 F,lX 813�SSS•9TI2 e _� � �F`r� • � , � .. . . , � . . ' . � ' . . . �. . ' � � ,r• Ii �� . ' , � . } . . ' i 5� • 1 i ' � ' . ! ' � • ' . ' �I.�. . . • . '' , ' ' � ' r ' ' . � . , . . � . , � . � � , � .i . . . ' ' . ' ' , • • ' . y ' ' i . . . .. ' . . . . . � . ` � ' . . . . � , , ' . •I� 1 . ��.. `, ' � ' . . ' . � . . . . . . . ' � � s . �. . � .. t . 1 . •' . • . • . . . � ' . , � ' . .r � ` . . .,:1. � � � '. � , � � . ' , • , . , e� . � . , . ,', .� ' I ' �. � � . .. .' ti ,�'' ` : i ' . ' ' . ? 1 • � . . , • ' � ' ,, � , ' ' . . . � . . �',i i, � . . ' • ��' • ' . .. � ' . :I ' � , . . � ' iy qe,.'<L* ! � ..� , : v ... � ... . . .. . . •, ' � --Y'+1' '•A1�1•. ..... � . ... :,rv�.:,:5rldtS'v.r'.:l:Jl..�. . • , . .�., . . .� .. .. . ,..., f,.L ��'s� ' .., s , . .' • , e �� , .. � � , , , . , . • . . . � ,� ' , x r . . ; . + �*+w , � ( � , �'t � � � • . ' , �t'. . ' � " , � ., o , r+,� , , � ' , ' �' � , ' , � • i � . . . . .. . , . . r � ,�� HA'�iE�� the above and agm.� wlth the contents of this letter. �t �s undecstood an� � .. ,.. agre�.d that � am resigning emptoym��t� 'as of June � a,. �, 1992, with the � City of • . �. ; Ciearvvater as � mnnicipal worker in the Parks and Recreatian Department, d�se to the accidant, �� .• inludes aad r�lated restt�ctions, limitations and pezmanenGy that T have suftered as a z�esuit of . � th� acci�ents t.�at occarred vn Tu�y 22, Y989, 11�arch. I2, 199q, and Fe�zUary 1i, �991, whil� � �, � � . � e�nptoyed for t�e �City � af Clearwat�z�. � � � . � � , �� , , . . . . � BY� - - : . -.. „ �. �c..�� , Caleb � C�Tinsto� , . ST.A'T� O� Fz:ORII)A . ) , . � COUN'I'�C flF PIlVF�3.AS � ) � � � . ,� 1fie for+egoing instrument was ackndwledged before m� this /! "'f'"day of 7une, .. 1992, by Caleb Wi�stan, who is persor�.ally known to me or who has proc�uced ' -�L ��+•�=--�;. .� - � - - . � _ .. � _ .. � _ �. as identification, and who � . di rio take an vat�. � _ 3 � �y Comm�ssian Expires: tvox�cx puHUC, sr�re o� �t.o�tn�, iHl' C�OMMLiSlON E7�[iL�S: D�e. 1Q, 14M: . �0l+IDED 7'aRV NdTARY tlJatdC UM1CtiK'R�kc V � • , :� e ' , .�.�-�...a. K � Notary P��lic .f'i r r� �J E K. f� R�. H l p 19 ��ta Nam� Qf Nota� typed, Pri.nted ox ssamper� � 0 � � � . , � , I �'!; . r . '. . . , . , , . . . . ' . � ' . _ , � . � ' . , , �, . , � � � ` � , ' � ' . .. , � � � , . ' ' � _ � • � ' � , � ' , . ' ' . ' . i , .. . . ' . , . • . � , . . ' . . , ' • � ' . �, � . . , . •. , � ' j . ' . . ' � � ' , . � . ,4; �}. ,f.�le� ;r�f. ' . . . , . . . , . f. �1". . . �..*,;•, .. �... .�,,. . ,wn3F" ... •�e„.. .... � . � . � .... .. , �� . . ' . � . � . , . � � , , ' � , � . - . . � . , � �ITX Or, �LEARWATER � �' � . � GEN�RAL EMPLOY�ES' PENSYUN �LAN ' ' � ' � . 4�''I'X4[�S - GENERAL EIYIPLUYE� i � � OPTXON #].: Employecs can rcceivc a� iump sum paymcnt for - �'� . vacation and holitiay �ay and 112 of ac�rued � sick leavc � ' ' at the time of scparatao�t from the City. Therc wi11 bc no ' ' 8�o dcductioA for pensioa from this lump , sum payment � Qor wiEl chis amottnt caunt as caruings in the ' .` c�Icufation of the pensian. 'I'he last day of. wark wiil b� , � , thc termin�cion datc and p�asiaa bcneFcts wi11 � bcgin � , ' t�n failowing day. . bPTION #2: �mplaycc can extcnd tcrminatioa datc by thc time duc (Only avuiiable ta for v�cation. holiday� pay, and lrl of accrvcd sick leavc. employees hired �'crminatio� date wi11 be the �aal day of cxtcndcd time. priar tn 101119Q) Pension bcnefits will 6egin the following day. »_ , ��*��***�*�***w*��*****� � I, r4 F� ',n5 �, an' emp�og►ee af the Cicy af � Cloarwater.� i�ereby app�y f�r pcnsioa beacFts under thc Geacral Emplayccs' � Pcnsion P�an. .. � . � . �. � I hcrcby ccrtify tha[ T fully undcrstaad t�e twa optivc�s offcrcd, to mc. I c�oosc i to rctire usin� Uption # � and wish my bencfts io 6c C3ICll�3[C(� undcr this opuon. ° � � I undcrstand tbat ar�cc tt�is farm is sigued, my decisioA is irrevocable. � EMPL4YEE'S STGNA'rURE:,, ( � � ' SOCiAL SECUFtITY #�:,�a6 ,3_— _ `� � �� '3 � I�- _ _...� ' A]�DRFSS:--125 ��_.. ��.-�. C'.Cw. t3�{�zs ./ l - , , �, � . . � � DAT`�. _.w..�.,.. - �—_ � � - gz. � � �� , ; , . a�` � . . I:i. r..;. . f . , 11,- ` •. . . '. �� . . . , .i� .. � , , . . . . . . . 1 ' . j' , . � , t � . , . .�:i� ., '� y` . . ; . '. , o ' ' . ,,i, . . '' . � . � . ' , . . . .. �, , � :� ' � ' ' � , . . ; , ' ' +� � �'1 • . � i . J ' . . . 1 ' ' ` . • , r, � � . � : . . ` ' , . � ' . . ' ' . ' '' ' � � . . - ` ' � . � � , . . . . � ' ' , . . � ' ' ., . � . , . . , , . � , • � . � f � � , . , , . • . , . „ r . . . " ' . . ' � . � . � . � . � � . , ... • ' . � . . ' � � . � � , • � . . t � . � . ' ' � i . . ' ' I ' . . . . � . . � . . . , ' . . . . , � � ' . � f.~•�`Br�ytA'i�'i.,��i5y:�1. �1M , I � ,�r', .,'� . ,',. � . ' ` ' ' . '' . , � . .• 'i ' . � . ` ' � , [ .. . . . . i ... .... ,la;�rlr.��•. . .i..4 r..�. . � . �. , ° . •1 `;F . �s �'� 7 '.� . . � . , , . �• . � � �. +°=�'�.° �"'� , . • , . - � �� , • � , , , . . ' , � � ' ' � � . � � � � ' `T:i�y. .. s. ._x . . . � ,. 1 � • ' •� ' , �• � • , r • . � � ' ' � , . ' . . � . . • � � � � r . . � � � � � .� � ��rxvRiz�T�a�v To ��L��s� � � . - , . .. . �. . . � � . , 1riEDXC�►�, �NA REL�.TED RECORD5 � � �' � '� ,� .: T. �,al p!� Vt1;Ms!�e�:. an a�plicant for disai�ilty pcnsian undcr • r. � . , . . . , ��f � � provisions , of thc Emp�oyccs'. �cnsion Pan aF thc Cily of �Ica.cwatcr. i�crC�y , . � , at�thflrizc ,,., �f�� o�.pl... ✓t/t . ��- .��: !�= . . to reicase any and - � alI :ncdica� aad relatcd, rccards . pcn�ining to mc io thc City of Cfc�rwatcr's . . .� , ' Pension Ad�isQry - Cnmmi�tee. Pcnsion 'I'rustees, 1'crsonncl Dircctor, or , � . ' � . authorixcd cmplayecs or agc�YS thereof. � , .. , � � � � / . . , �� ,. ' . . . � � . . � (Signaturc}� ' � '�. ' � � �-11-RZ, , � ' ' � . � � . (Datc) w� � f � h� .�.c�+,-�.. �{ -- — -- . - -- - - — Notary Pubiic My comwissivn cxpires: .:. �� t."'fAAX PUBLIC. aTA."C'� OF l�i.ORibA. . A�sY C�MMISSiOM E7[]'1RES: flec. 10. 199�. �OPiDCD THRU NOTAf.X Ttl�uC UNU�CRVIRi'CLp � • � , ' , . ' , • . . . f � ' i • � I� � � � . .. . . . . . , ' '; .. , . � . , ' � � . . � . , . �—. 1 � , • , � . _'—_ — _ _ i.`--- — — _ , ,� � I ;, .... . , . ::z . . . . . . . ;; . ' ' , , : , . , ' ' � . , . , � . � . . . .. . , , �t . . . '` ,',, • , ' ' . .. �,. � �. �.. , � . . . , , . . . . ,,. , �. � ' . . . r' . � � � ' . � . . � ' � � . � � � ' � ., ' � ' � � , . � ', � � . , � � . , . . .. �� . � 1' � ' ' ' ' , . . ' ' ' , : . . �;�, � , �. F ' '. .A � . � `' �' ' ' ' � ' , � a. • � .I . �� '. � , . , .� . . .� i• �i � � ' .� . . i � . � ' . �. �Ri�c''f5�°6'1�t��1'x' e r . ' � � . � ' . . � 1. . � /"; .�i .1., ' ' . .• . ,. . . . . . y a .. ,. .. . • . .. . ' ' � � . �� ' ' .. .'�'' . i , ., . . . . � , • . , r' , . ,,,,,, . . . � � � .��1VSION nEQUEST FORM ' I. ��- �4on� do f�crchy a��Iy for rctiramcmt `� � from th� City af C[carwatcr G�neral Emptoyer.s' �Pcnsion Pl�n. '- � My bet�e�ts date is (Eatr� da#e into pensioQ .p,lan) . , . . . � . .. � My date af hire is a� R' 1 � � My birthaay is� .� Oc.�he� to� 194G, � . �. MY Job cla55ifiCa.tion is �_��c� � n�,..r,. ;.,-�3._., Lt`�r l[ev' [T and i work � . � , in tha,,.. I��ralcs , , � Dep�rtnzent. ��cw��o� b�v�sior�. �' . M y resig�afiur� dat� is ri'+= � z�`—' . .� Thc type af pcnsioa for whicla i atn app�yi�g is (chcck onZy onc): ' Ke�ular PrnsioQ tras�d on ycars of servicc • ✓ Job-con�r.ctcd Disability Pcusian . � Nan-job-coc�aetted I3isabelitp I'e�5io� My spouse's name is: —+� p� � � � Dependct�t children under t�e ��e af I8 aud res�ding i� my �oessehold are: . --Na- " (Print Child's Fuli Namc) (Child's Datc flf Bsr[h) ., I hercby ctni£y aIl af the abave to be true and correct: � . � , � / ' (Sign ture� Z � ,�. . , (Datc) � — — _ ��--�^-4- � _ , (i�£otary P�cblic) . t;orARY ��a�.�c, sr�� o� �r.o�sn�. MY CUAiM155lON EXPIR�S: Det 30, 1994, ' EONDED 711RU NOTAAY PuilL1C LIN�EAWACT�RS � � �. , I ..� Q , � d . ' ` � . . . ' . . . , , . . . � ' 1 . . . ' ' , i . � . . ' � F� , ' � � ' ' � . , . • • , r i , � . I ' . . . . � � . • l .. , � � . .� ' . . � � .. . . . . � , � • . . . , ! , � . !� .. • . . . ' .. ' � • . , ��` • ' , ' � ' � , ' = 1'�� ';::t'�'�+F.e.e..rs.: e �r . .�.>'i .^f.::�. .t' r.. ' � . � . � . . '�'i:1.�' ,� �� ..._•.� ,''.?��;;;'.,,. �.��.7:;'`. . . � , • .. �.. . • . � . . ,; , .�� .� , � ' j • � •j � r. 3i• �� ' '�..' ;�Y ,i � E �' � ,��_`' �1i. �, � '� ,�� •; ' ' ', ! • ; , � � ,. 3� � : rJ 7�',�a..� � I'!�' .r� � . � � , ; �� : ' i �i � ',lf� .�� SJ+; . �I �� .' 7 � � � ' • � � • i ' : b.t !• ;z�,.r; . �,� , �� • 4 i. - � � �, � ; �'• t�� ` :, ;n�.�r ,.,••�. �� . �f t.i . � j �;.� i = • •., .h.t'..� .� �' r i' t• I !' , e . .:t.�l' �� ; . � �� !r� ., � ;. !$ (, � , , . . ,,., : , i ;� ;� ,;�, �ii (� �7t }� � t � 1• . � , • � �'j,i.�. �' �1 �f��#. 1. � R I { �:�'��y � • � �..�r+j � ;�;.�•;• � 'Wi onr Ca�.eh� Jt1t1a 79� �,992 , � �{;,;<; •��! ; ��,;}��}}; �, IT��i � '• ' j'', ;� �� , '��i�;� �'� �.� , s �� i: ; r: � i , �� j . . �� ,� � ! , � �•�� rr��.�:5,� 4'��i fiE� i��+J��l +. C'� � . � ��• ' � . ' ��_. '� �• t ' , i . t �:�� Ca �eb��,hae noi:ed coxit3�nued neck p�i it wi L•hout ��ign%ri.c:�n �,�. '�� ' �`;-'�� 'C;� • , . . . � . . .i,f, '`,r ;,I , di � omfort�. � . x dn £ee1. L•t�at hig cli�cat�o:ti� �aF. iierr�aat �d � ';'� .' ;f • 'a�±� :i �r , �I� y � a �e a• i . � tS' ,t �.,;�, df 1�anc3. unresol�sd_cerv�cal str� ii� i_ rela� d� ixsf . n, �he;� �:,:;�,,, ��;a�'''�t jo� �: in,�vey;��rhich�;p�curred , 3n Janu�ry c��' �.99I � xesull:�.n�, in a�= �'�:+�}t� ;'�a;'�`�:'�; tw�,`Xve' per�ett�. d��aiaili�y to tre b��d�• �� a who�.�', T�id f ': .''°,,��1, I�';r•, i pat�ient'also`• 8u�ta�.ned an appareiit l�ac:l: stra�n as NR��..;1..1 ' ,'', �, =•i+:� ; ��, ��± Th�.'s•` pat3ent�: currc�nt �.i.r�i�atiorc : .�re �� avoic� li��ang }na i '' . " •;'�:, ��_.� ` qr�ater'th�ar��t�:�nty. podnd� ancl to :xvoi.d excessive �,=nd�,ng �, ; •.�`.; j ;� .•' an� �txisting. �. � . . , . . � �� . . �:�;� iF �i! •;� � .} :'�,�!'' ,� � ' , f• . ' � • � � � �1 . :1 �•"i I. ��j�+�� , � :f� �i� ]i': ;. � ±.. ' • : j ' ;i ' �i.�•':i ,. �:�; •Jo �ph`'M. ;Sena, M.D. . . . ;� •'�`'. , , � � � ��' I;'.�f , (ci�r�tiaied but no� read�) . . : . . . . �� : ••? .i ��.Ji; t 1 :. • ; . , � � . ., , ';�� :'E� i � JM5 t kef ; � • � � : � • , � • : j� �:� .,'� � �� E �:� � , , ! � • ; ' '.+�f . � '� �` � � I: ; : . } r `. � � ;� .f � i ,� '� j �j �' ' � ' � � 7 , 1 1 • � • • „! r,� t �,f �!� . � • ' � . � ' ; , � . ;j , : , �j : . .� j , r . �� !� � .. . • :+ {; ! � s , s � y j � � . � . :� • .' l�i; i h � : ' I , � j 1 �� .� �' s �!'� � : �; � � : . � _ f � ; � . : � i: E� � � , � , , f i . :i . - r ' •}1 �1�: t t+' ! � .j� • � .;�� ;' .� �. � ; . 3 = . � � �� i , � , � F , 'jk� i i ` . � I : , ` 1 � �: r• + ' ' . �, � � I � �• � ' i . t . e i � `.::� .'� . =i�� ;; . `• • • � �` . � j . ; : � ��• T'� � �j ; �;.E',� :, f � _ � . • . . ti � . ,I , `' `',,,.�� ,�� ; '+3 �:� �;� .r _ ' i i E . � r'' # :.��. ��s �� ,'" ��..t ..•,, y • .��,�� , , �. � � � i � �� .i:;.';!� '.f"' ��.• �s . ..I : s• . �. . i '' � 1� .� �i � . . � � �c:' <�• � . � '_ .�.; f s , . .'� ,,. �� ,Y :. ; � . •el . � -, : . . � , �. � � : i! . . . ;. i ,..;, • �, .�f •*!•; . t , � , ; ' � 1 : � �i:� !'"� '�.! E� . :t�: ;' '' • �'��'�� . , • � , � � � E.s�•: :� � •��';�I i'� �, f �_ ±• � ��+ • t j:. 3 t' � •� �L/ { � l� � l E �`r•�e .�i..� ii � . , .'' `'�ij' .,!4Y'f 1 �� •��j�l . : �S• ! i ;• , 1� IN. �.`..lii± j 4'i •:I��j M :�•r �:. C ��. i �i =;j � t ! i� . i ! �' '��ti, � �� ' ..ti��: � !� ' ;� a . � • ��•� j �� :��.�ck � .��' • � � �: ,,,.. ±: . . i'�� ` . , , , ' . j' . . i i � � r•�; � �:;�;- I .. :',:i,r.'`;�p r '�� t� _�� (, '� , , ; . ' i � r' i � .� ` � . '�'f , . � t. � �'' �'' ,��:�'' ::•Fa'� ,. :, . �� : . . , � , , � , i .,. !. , j , ;` ad'-; : ,. • ,�, :� :, �• � , i � � � .� ;, � '�� '' �t,��S' +3 'r '� 'i'! ' j ci ' i i S ` �:}.. .��l��'� •;• I;,�#.�� ; r' '.� ��' " � I • `1 ` ` ' ; i� ; ;,�'��! � �?�'� * .�t'� 3 • , � : 1 � � ;..•�•, . . t � .� �.t� 3 . . • ' � �„' ;.� ...i' �� .. ..�,�.� � �. . 3 � ��, . . ; • .,,, �, .A.; .,� , •,µ,:�'�'., `,: ;� ,l.� i .. ; , : � �. ,; � � �` ; `� �� •`, •�y � , . � ' � . . . ' � !y= � �'' . 1� ' � , ' �r i i•� ��i �,. •��1��'. ; ' ' . � . f � ,�� f I;;�r:LI� '•j =% �.� �'' , � .s . , . ' } ' � ;i . ,Y��+��j � • ,�' ��{ � i� . � ' � . . . � �, � ~ �� { . '•� r � . i • . . 1 �� . � ' . t� . •�J' ,4 �i , � .. . ,j ;; : . • . �r � :� , -: � r� �' �,�;- .., � !I �;! .. . i :,; r ;;3�..' r,' � .•. :.�; � : �•. • , . 1 ' i ' � • a }C: �'�'r� :f• � � � . �' t . r� '' ��s�t'{ '�'�:'r.'=: �• � { �� f � � r : . • . � . 1 ' i��lr� .l:i '°• . . .�-�t j �,` , . ' ' . . I � { •3 . ,.1�: i�. r•i:nl t ��;,: � . j'� � ;f . :;t,��l�:�i� . .. i� ,� � ' . � i � 'f • . ;iN:•s*•:=�`� • �i k �, � � . ' :1 ., � ; f;;K._;;••;,. . � �� f � r'- s • �� 1•ti'1•i/�;' I � ',: ' . � • , �i� s ..; �,��;�`,'.i„•. .:j �! , _ , � ,� , .. '1�'�.; ; ��f I r .. . • , ` � i j� . � . ��:�:��t�� ,,.�. . • :� �, � i 'c.• . : � ' ' . ' .: i=i, iy; �� 'r �,. � � + �� . � . � � . i . , .2•�;=r.•� r,t: I tii!1 ' r � r +_. ... �:.R1�:�1 !� • • . , . ! '� ' . fi"�it . . �s. . . . . , . ' • � � � . � .. �C��L�.'�rr,� ;;i�. , tiY Y7. ��'1==. � C Y T Y O F C L" � A� W A T��. ._. -.,��,-�� ; . . '�`'L""'�` • . PQST OFFiC� �qX i748 �.�f: rf�,�� . �• . :.':�f� r�� CLEARWAT�F�, F�.OFili]Q 34618•4748 '-�f i,i'��i � i ..✓ r; , '1'f! (.� �<'I � . . . T0: /��„�'�',L ., _ _ .,_ . ._ D�T�:— / `� z-�.� ,,._.� SUI�.TECT: Request far Medical Services - F].or�.da � Workers Campensat�.an (FS 440.13) EMPIAYEE NAME: E�-�' ��"'�'� D/A •� -- ��`�-9/ � k�LQYEE SOCIAL SECIIFtI�.'Y NO. You arE hereby requested and autha�ized to provide services which are medic�lly necessaty �o diagnose and�or treat the above-named individual as foll�ws: _,�_,__, �_, � ..., �, _�.. _ -- - e -, � - f�-- - -- We are encYasing aJ.], medical notes in our fil�s related to the in3vey of the abave da�e, �hp e�ployee has b��n instructed ta bring all X-Rays to the appointment ior your zeview. IP medici.nes are requiz�d and prescribed as a r�sult of yvur tseatment oz diagnosis. the prescription medic�nes may anly be obta.ix�ed fram ' ' . I� medical supp3ies, duxab�.e medical equipm+ent,•orthoses, prosthesis and oth�r medically neces�ary apparatus are.required �� and prescril�ed as a resuZt Qf your �reatment and/or diaqnosis, t.hey m�y be obtained onlX with 'o 'a ova of City of CleanratierJlridustria�. Nurse, Phon�: 462-6756, �po�,,,camnl�e�ion of ,your ser�rices . instruc�_ the__pat�en;�, to .�etu�g a ea e us 'a u se. Prepare an approved Health Insurance Claim. Form and submit it�tc the address shown � above, c/o Indus�.riaZ Nurse, no later t,han ten �10) days from the_ � date oF this lettex as required by Florida Stat-�zte d40.1�(2). � Failure to camply �rith the above may result in ns�n-payment of claim. Si.n�erely, �;`�,.. .. d.�� NanCy Degne=� R. N. xndustrxal Nurse cc: Jahn� Eastern Company, Inc. SHC?UL13 TREATMIENT �iE FOR A CONDITION NOT JOH RELATED� IT IS 'iHE F.HIaLOY�E'S R�SP�NSIH=LITY TO PAY �IIE BILL. � � � � . �� . . . �.. .,.. _. • �� `,^ �` r � . }' . . � . � � . , , ' • r.� , ' . � . . : , . . • . � .. ' , � ' , '• . _ y.� F ' . ' ' 1 , , . . ; . . ' , � . . �tP`r,' ' /, ,' , ,, 1 , . 1 a� • , . . •� , ' ' . . � � � � . . � . ' , ' . . . ' � • f ' ,at' ' ' �, ' ." . . , • i � ' , . .. � . �,� r' � , . , ' . � ' � . i ' � . . ' • . • . ' .. , . . " . ' ,� . , �. ,� � , .. . , � �� - ' . . � . . � � r' ' ' 1�' � �.ii: tl:. . ,�r; , .. . + � ' . . � . . � - . � . . ' . . I � . . . 1 i', � . � . .. ,1. , ; j � ��, '.i � . . ,ti � � �� + . . x' ' 1. ' • ' � ' � . • � � . • � . , . • `' � ' ,. i ' r �� . , ' , i . . � � ' r ' . . , . . ; . , '- . " i � � . [. " . � ; . , . . � � , � - � , , .1. � . �' . . � ' ' � � � . � • . . . .. ., � , . � , . < . , ' . � . � � . ,r.', .� , � � , .. :f5 , � . . . .. � , ' . ' ' ,. ' . , . , 1 , . � . .i ;K1"a'.i��]�i.�rl �l'',v�t�S1�AA�. ,i� � •��r�•. ' v'�• I ), '�`I . � � . . ' � �, � .. . � ' ' t . r' . j F.... .i. ...,...+�M�r:i!i]�nl�'wi'S� "` ... r' . SrF� .1 C.'�ii t. #u� � � � . . `�� . {� ' • • �1. � ' ' ' � � , .. . .� �. . ' . . .z . � '-.:, ' . .. ,.,..,�.., , . . , ' . . .rc.., , f • .. ' . . � . �� f , � . . 'r. :,•;.i;: �• � , . , . ' " ' rj,' .. , �t ..�.•r.•.:' ', , , �!� � {� :.::. ,'r , . ' � � � � . , : ':,it'�,� ,`r . f , �it'. , , , ,.: r •� . . � l� . • . . . � . . ��1•.ri:. • . ,. . ' r. . � � � . tff.3 �: ' , ; l 1 � . . . '. t�/=,'::: � '!J '•'••'sj.:::. �! �, .. , .� . . :h;�:i;., , . .:f , • 7� . ' . ' ` � ;'tlrr'r. , .,.. t i • � , :� � . 'r'�:',;�'; ` : �!f , , �. . �: r i:i :;i : . . . � � � ' . , ' r.. 1 . r. 1 ;f ;: � �'� ''i :�� . . x.:_ •» , , � , ' , ir�r'�.. . ' :i: f� � o.. .. . � .1 ,� �t . YPI.' � �• . ')t � � . � . �� .. , . : , , . . , •y�f�'., ' �/� •::fl.�l�C .r.{. , . , Zi , � . : rrZ : , .r ;. ,' , �, • � :'�� f: , . ',:_�: . ' . � ' . . . , •ty ' . ' ' ' . ' :r:ry; � • :i �fr •'.�:s:S 'i ': � Sz. . . . �.v': . . • � ' i , � : :�: � � . . ::ti . . � • � ,FS � • . . - ' ' :'f,.;�;. • ;�: . . r:r . • .:•Yi:: . •:; a . ' •r. :•.: .. . ' , . • ' � _ ' , ' '; :i fi:; :;.r . . . ' . � ' �• lfl :' . , ;' � ' ' ' �c'• ' ti• f'rr � � � � • . , , � �� . , � � . 7aLYt•. � ;'j . � .�. . , . ' ' . � � �Fff:.f ' � ' . ' � iY . ' . ' . � . . . . ' . �.�� '. . . � '1 . •' jl�f:: �.:':. � � ' � . . .,�� , . ; ' . , ' IIl:.^,�Ff. . � ' i.7 , � ' ' ' � . � . ' . . �:/t.l:.':.' � .'.�, J. � :!.• � �'•, f�l ' � � :r�fptt:.:` • . � . � � . . . • ' . � l; t .:.•. •'.:'!' . ' . , J, . ' ' 7� . .f•'�:. t ' ' � � � . ' � ' � •• ^Pt� .P , ' . . . ' �' , ' � � � . . . ' ffi '.. . - + ' .�• . [ • . � � . . .L' . �^?,• .. . ...... . .. . . � � The Orthnpedic Centcr of �STes� F7arida �sss s� �c�n. . Jas�ph M. Srna, M.D. saao �ne sn�r �x sus�a 1at ' • . ,. s�m°, aA4 Pto� . 5a�oe�, Ft�u► 3� Sr. Frrtrnusc, Ft�aaow �17p9 �::: P4►o� tEt3) 39�.�731 Phanr (613) 3S0-ta7L � N�xe + %� . .. �"," � Au .. ;� Ac�u • b�n , � '" ZZ.'�1 � _ � � ro��a�.� OI�AL IQ MG ' � � D�s�, # �i� : ,$IG: AB Q 4"6 HRS � PRN P�1N � . � � � d �� AS 18492�45 , ;� . rr, � . ' X' ' t i 4i , , 'r.i; . .;� :� , ' _r, . . rt} , 'y, Kri. _ .. . .. . ' ' , � : ,;' � �• , . �, - � , , . , ��' . . . � �., . , i � �:, . . . . . ' `- , � . . ., ..: , �. - , , � , � �--. ' /� � • �1,r�!! `^ '• •� J ,,�`c�`; ` . .s�' . . , C Y T �.'' O F' � C L E .E�. �. V� A� T � �R .,...;; • :_ . 4�-;; ��,; , �; P�ST p�FICE BOX �748 ',�.�. . . � CI.EAf�WAiER, FLORiQA 34618•AT48 TO . ,_ CcJ_/S�,l. �.�. , - — -- - DATE : .1��I'i 2 � ��9�I . _ SIIB.TECT: Request for MedicaZ Services -- Florida� � Workers Compensation (F5 4a�.13) E"HPLOY£E. NAME • ��-� ��.��.-��a--�- D / A � „ /1-- S'/ �.�........� �FLC3YEE SQCIAL SECDRITY NCJ. . .� � � You�ar� 2xereby requested and authorized ta prova.de s�rvices which are medically necessary tQ diagnose and/or treat the above-named individual as follaws: . � , We dre enclosing,all medical nQtes in aur files re�.ated to the in�ury ot th+� abave date. The emp�.oyee has been instruct�d to iaring aIl X-Rays to the appointment For y�or�r rev�,ew. If inedicines are requir�d and presc•r�.ied as a�e�ult aE your treatment or diagnosi.s, the prescription aedicines may on�.y be abtained �ram Joel N' 3'ex�rv's. If inedical supplies, durab3e medical equ�.pme�zt, or-thoses, prastheszs and ather medical�ly necessasy apparatus are required and prescribed as a resu�.t o� yauz� ;�#�xeatment and/or diagnosis. they may be obtained only with P,3;�,or aAp�oval of City of Clearwater/Indkstrial Nurse, Phone: 452-6756. �,�eitv of Clearwa�er/��iu��,al_Nurs�. Prepare an approved Health Insurance Claim Form and su�amit it to the addsess show-n above, c/o Industrial Nurse, na later than tan (1.0 ) days �rom '�.he�. date aE this letter as zer,�uired by Florida Statut� aaa,13(2). Fa�.lu.re to comply wi.��h the above may result in non-�ayment of cZaim. Sincerely, �� ,��.�� % �� , Nancy Degner, R. N. Industx�ial Nurse cc: Jahns Eastern Com�any, I�c. sHQULD TREATMENT BE �"oR A co2tnSTZoN NaT JoB RELaTED, xT �S THE �iPLQ1'EE' & RESPONSIE2LITY TD PAY THE BII,L. ' � . �� ''f.t, :i .�' ' ' . .i. , , r , ' . . � . � !� i fs . , i1. ,. : r' .� j'. .1. i � , ' � i' �^ i ;a, . j� _ ,'- i: '.1,' , . . . ,. ' . . � , . , � • ,. . .� . � ��., ' . , . ' • . , ' ' ' , , . , ' ' .. , �r�rt� ` , .,.•'. , .� , . ., . ,� �' ° ' � . . , .' ' , " „ ' , . . ' . ,. . ', . ' ' - . .. . i' . . . , ' . E�i ^.r ..�1.; ,', . .. s ' 'y � ' . , .. � . ' . ' ° ` . . .� � , : i . . , � _ ' . . ' ` 'f �' ,�' �i� � 3 ' �'I�t . . ' , . ' . � ,. t . . . � , � � . , i 1 . . 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'.1.7 � � � , f •�� j +'�{Z;t.r � � Gj 1^+ �S r � .1.�� [YS1514'� , ' � � . • ' • � � • �,•ritt•�+�r jr• :+• n,+!{� > ' :�� { ! 1•} �1'v1iy: .ij:i..i�l 1 <i';i,L ' • � , � '::�. . !; � tt '+ 1 , • � � � .`. . . �� . . . r',.;; , . j i�-i .�I � �:.. � i '�' .� i: Win�finr�. Ca1Qb ,1..r14.t_�rY 15. L ��'� • I ; '. • �:; � .`'� � . . . � { . . .; , r'1'' Tha.A , is a farty 'f i.ve''y�ar c� 1�� m�� c. i��F�n sust�in�d �.n j u.ry� an �:' , , March .i: , 199�. �ppr.�rt�dly a� ri��i: �.�rs». the p�t�en�.w�s . . shov�ling wh�n• h� nr� ��d on��e k� af F�� in �I�e cer-vi.��i ;�spin� ! . are� �nd a,�tdden �enC�ata.qn ��F ��u.11 »��q �r'brn th� n��4: intn th� ri.ght shoulder anci ci+a��i�ti t�o? ri�hh �zr-ati t�a r� �pYp.L t�eto�� h� • �lbow. He ha� �ompl�ir��c! :�-f �onk:,r��.tr�d 'F��in as a�e11 �� '. pare5�he5ias of �th� aiikeri.c�r a��+�ct :i•F i,h� rir�hl; �.�rm �espa��e �nn�inued att�mpt� �t consnrva�i.�� rlti��r�,�y a.ncl4id;ing s� . ,,., meda.catiQris and p'hysic�I i:lz�r�,p�f. ' . ._... : ' . Ht r3�.d unr'er�o r��a�i-al,uga.�; ��1r-F;--��+ ;�ei �N�I L �,s �ar�:hr_p+�dic • . evaluatinn and nr-urn 7urnic.� 1 p��a! �!r: h�.an .. H� haa 1=e�n� seen fay � b�th Dr. DeSous�, a ne�tro?.��r�a�t:. ��,��t' 4r. �'S�i��7.1,�, a '' . neura�urgenn �nd �ar th�ir a�ii7ia47!a., i �•��uid reca�r,rn�nd ��ha� ' yau contact thr��e dnc�or� ��irectJ•,•. H� ��ci +_ind?r�ao t1�,I , . scar�ning, af the.cervical 5pir+� wli.ici•� r��nrted a di�r �'� ., :, . herr�i�tion at C�—C4 impinq�.na pn l:!-�� c��r�l asaect c��f i�he ,;. �• :� 1. cord as well�'�s h�rni.��ti.on r�pnr�r�d •at r��--C� �nd C5--C6:,.�.I i; �; :��`; wou}.d agree w�.th Dr. P1uaQ ! x� �ha �; ��.i��ther ev�luation �could ; b� �.�: , ascertained wa.th a CT m��t��ram. I•ic, has had LM�s pew�-farmed,. .;,:.;,, w�hi.ch report �videnc� c�f �.arac�rr.�+,�-l. ��nervation sugg�stive . � ��f �:�rvxr_al radicul�pattiy in, t.i� ��ti�d•-c�rvical izv�1. _, Nerv� : conducticn p�r-fs�rmed w��-� r�pnrt��i wi.thin nc►rmal ].�.mxt�" ��! ;,;:�. ��cord xng to Dr . OeSc�us�► . A 1 i:l�a�_t!� fi �.T �nyp � oa r�m �a�s 1'd : be ': �'� , u�ed for fwrther evaZGtatic�n, sin�:e Fl,i.s p�tien� da�� 'r�ot. w�.sh; .':;: to cansider surgQry, h+� .i� �h�rc•Pc�r�� r-pluc��,n�t �o �av�,ta CT�'.;. s'% myel�gram which is of cnurs�,� �ii irtiv��ive pro��durFr capa�Iei�c�f�s �r;, causing same di.scomfor-t �nd of cnurs�:r. sarne ri��;. � : ��,.��.�'i .i, _,t�' • ; :,; : , ''+• �:�t � .:• ,',_ �1 i � •j..: .. �' . •� r �i• : E� '�j!•�j�l1 1 •eLl' .'J: T•.� j � �� . Y X do feet that this patient h��s r�:�c:hed maximal medi�al,�� •. :.1. improvem��t a� I��st in ►-�Ia�ia�i �o �oris�rv��iv� ��F.farts: ;;iIt'�.�'.�`'� i.s passa.bl� tha� s��rgery rr��y hal� � mE�rnvE� �tpo� hi� s�atus ar�d ',:;. again surgery would pa�e =ome ri��E; ca�f wars�ning o� hi:s�:�:.'='��. :,.` :...:�,. � conditien=. ccr�plic� ti�ns �r 1��•r �r im�r-r�vement. C�rYi�al ��i; ;�;; my��oyraphy fo1J,c�w��c: by CT �cr,nnin�.��uld tae perf�r-n��di�;pra;or•�`.;';�� ta ev2lu�tion -For �n�enki�:l s�iraical interv�n�itin !.i.��t}��s;�+;4:;;�;•; patient. i wcauid n?.ar_� �hss p�1:?enj: with ��ermaii�n�� partial ',;`.4;� disab�.lity �s � dirc.�ct t-��tLt o�F ha.� W��r6•.man's i:.;.�ap �injury;�at� .'',f' �h� level a-f twelve per- ��n�, �,� ri-�� l�ady �s � wl�ni�- ' !�''' ' � ' ' .:"; J�s�ph M. Sena, M.I). . �. � .. � . ' :� (sigr��d a.r� my ai��nC.� �❑ �::�:nid �- !�, ? ' .'s�:��";�r:.rr:C�� . -, -;; ��IS/s��d � ' ' f •,r �'�;�� , �, � . . ,�M1: + �T ' � i��'1� ' V/� , . � . • ' .. 1� ' ' .r.:�C . ' '�,`�� .i,'�.�..jl �i�/�i try/�i�liC"X° . � . . ' � � a., •� „{ !.• � ' ,� • i ; •�t:� ��:j4 �# �'� �� L�� t ' � � , � f �,' ?��'[ �.�ih7 �� i,t�;i•f ��i, . ` � if 'i�~�i. . ' , • !,� �i � ��.i1;;Y.;�• ; ' ' :� �. �� .� � .. . ' � t��:� . a�; : .S .., t' � . s� 1t ., � . !. , . , . . ..s ., �t ' . �;� °� . '�t r ,,��:.'+.�l: t .� � . ' ' . . • • .. ,, � .. . , ., � , ,r . . .. . . . i . .,' , .� ,`I . . � . � ' '• '',,f. . . ➢ ' . . ' � . �, . . . � . � • ' . � , . . ' . . . .• . . �a1,�', �M7i ;1 � . ., . .. , � ., ' ,.. . � . . . . � . ' ' ', V ,. , ' .. ' . . . � �.F .. � � . � � . . . . ' , . . � " 'f' `'' ' ' ... , . ' . . �f . , . .. � ' , . � . . , ' . . , � .. 0 � �� ' 'F �' • .f1 . .j '�i., ... . . , . . � � • . . � � . , ' , ` . .. . ' ' � ' ,.. . .. ' 1 �1 • ` •, . ' •�t ,. � . � . � � ' � � � . i . � � ! . ' .. �a . . ' . . . ' � . '' i� � - • • ';' . • �.% } � .1, ,E��', � `. . .. . . ,' .. . , ' . . . �. ' . . � .' � . . . . � , ` I' ' '��'' , ' • � ' .'. '.1,�� ' �,Irr � , .1 . . 5 .,` .[ ' . ' . � ' , . ' • .. i. . ' ' � •, . ld' �5,•.. a 11:. � . � , ' . ,��I'�' . . .. "�� 1 . . . ,� . . " .. ` � . , ` '�� .. ..t ; .. . • • � I ` . . „f ��. �r.+: �` �7� T <�� ' ,k �f . . ° ` 'r ; � . . ' � � , � ' tiS�'�' ' • ` ' �. • , , , , • , ir. e�s 11,�' �'. t ,. ��1.9 .'y .i,_'.� . F' � .'r. � '� `:3: i' .��; .�i'�:i�� '�,`' ' � ' . • � , � ' . '. ..�i ry sce ' c' ' ., �t: F„ is t �!:",• �/�, .��°Y � . �r•�� .- �� .....�.:.l.rw.^ rAf�L':. ,, i�i+.'�w.. .. . � . i .��1.• 11� , • e �� . ' ' , i . {I�p..... � 1/ , •I��..1�.`�ta.. .i ._. . . , �� . <��.'3 � ! f 1 ' . . . � . + " 7 ��,Y Lr.� 1 /' C,r'� ti/C..r�.�/ I�r I�` . � � 1 � ' �. �, r . � r. � ,' ' , , . . . . ' •� �^r � ' � 1 . , � , � ' 1 , ' � , , . . . 1 . . � � , 7 . � . . . . +�': . E� ' , -��-. � ��ti• �� . . , ,. . , ' , . . � . � ' . �� . � ' ° ' , .� . � ,. • Cal�b, W3.n�ts�n ; . � , Ma�ch '2�, .199� � ' . � . � � ' ,, � � .�.'l � . . . . , � : �,. T��i:�-p�t-�-�:err�'�s campl�.�nt� are unchanged. � He continues to � � � . - � h�ve �neck� pafn, H� dves nt�t feel, .cap�ale af -re�urrr� .Ea .- . � ' ' , .previaus wark.. H��»i�••�far�lidht.dur�y^anl��'"'to �avoid e>tcessive � � •�, �Niasting and Z3.��.ng ob,�ec�� af gf e�ter �han' fif��een p4�incis•. .�� ;�.� .�. I do feel �h�� his patien� has reaehed the po�.n� of ,m�k,imal ~ � ' med�cal �.mprover�ent �s af Ja�uary �S, 199Z.,-"He does � no.t wish i�'�� :' � ko consider ,surqery �� thi� time. I.have eKpiainecf h:lm� tt� � �;� ' �'h�m �fi�t ��he risFts and ben�fits,�a! �ttrgery. � He ttnd�rst�nd�� .' .� ttti� k� s�irq�ry .i� ns� g�,��rr►n t�r kn cure. • . � . , JaSepii M�. �S�n�� M.D. . . , .. �� ` ' i d � c t� t�d t�u t nc� � �read ) � � ` �� • � . . � � . . JMS/svd � � ' � , � � . . i. .. . . . ; . . � . � � � � �E�c»/ �:� � , . I:� . � �. . . ��. ' �� ' � ; • ' � � , � � . � , � _ . , .i a � M� g ��c,^• � , . ' , � : � • ' , ` ' , . , . .Z+ + � , � i , • . . . ' � . .. . ' ' � , ,,�� , � � , ' , . � , ' � . � ' : . ) . . . � . . • ;i. I • . . ' . , ' M �: ' , I � . � , � . � . � , I '� . ' . ii . . ' .M � � . ' .` , :. ' � . . , . � , .. � i , . ' ' .y . ' . ' � ' � .., ' '�� H�'`,.:7��..� ! � .. � .� . : , "Rti''iF"'IiS/�;`��`'' � , i . . � - . ' , . . ��-1(`.G` . . - . • , , ' Ar",�7 � � �A�z . j ' _ , ' ; ' , �t��:��r� C :,�.!oa.P!' S . , , �C • . � � . . , , • � • � , , . �. � , ' , , ., . � � . • t • ' . , � ' � . � . � j . .. , , , � ' . � . � , � � � � ��• �- .. .. , , .,. „ �. •� � . . . , � . . . . . • ,f � � "� . . . _, ,,; �` � ... �� .- , � ' 1� � f � ' ' � . ' , F • � ; • •. ' . , ��► v�.�ti�'�y �' �� C I� T'Y C) � C� E A. R�V A. T I�- R � ; . �;.�� u.? . ��.. ....``��.,;�;�� ' , . �asr a��rc� �ox ay�o , , ,r,�� . :,."•.�••.,, ...,_,, . CLEAE�WAT�R. FL�R�DA 3.46iti-47A8 �r'�r : �:.��• , . �.Y�r/ t , � .�.:�TO; �./v. _ _— ,3 - - DATE: _�� .�ly'' 1�-'' ` - .,.,. . � SIIII.TEC'�:� Request for Medical Services - Florida � Wor.kers Compensation (FS 4d0.13} . �r,aY�` N�rs�: C� �� ..�.�'�'"� n�A �. r/��i �IAYEE SOCIAL SECt��t�TY Na.� • You are hereby zeque�ted and authorized to provide services which ar� medically necessaxy to diagnase and/or treat the above-named individual as follvws: „ - - �„-�`�-r�.� ,_/L-�F;..: � . .., �.^...,..� . We �e enclosinq all medical notes i.ri our files r�lated te the injuxy of the abov� date. �-�*+tayee has be� ins�ructed to ' bririg all X-�Rays to the appo� s�� '-y�- rev�iew. If inedicines a.re required anr � sult of your tre�,tment or diagnosis,, the .es may only be obtained �rom 1' �Tg�; If m�dical su lies durabl► �'�� orthoses . PP , � . pxosthes�.s• and athex �edica �'""�'`?`'• .• .t�s are required • 3nd prescribed as � result of yu�..,. �, id/ar diagnasi�, th�� may be obtained only with prior,�a�pru.,�� .�f City of Cle�rw�tex-/Industrial Nurse, Phone: 4E�-6756. �a ,�itv of C�ea,�„w-a�,e,�,�,�ndustrial. Nurse. Prepare an apprAVed Health Snsur�nce Clai.xa Form and submit it to the address shown above, c�o Industrial Nurse, no la�er than ten (10� days from thE date a�' this l�ettex� as required hy Florida Statu�e 440.13�2), � fiailure to comply with the above may result in non-payment of claim. � � ' SincerQly, ' ��.,�-.��..�._.. �' �_ Nancy Degner, R. t1. �ndustriaZ Nurse cc: Johns Eastern Company, Inc. . SB�ULD TREATME�IT BE FOR A C�NDIT�ON NOT JaB RELATED, IT ZB THE �L�XEE'S RESPONSIBILITX TQ PAY TH'� HiLL. � 41'�. • �� . . � . � ,'.' � ` �, � � � �., � . ,. . � - � � :, ' " „ . � � • ,��' . � � -, � .�',. � " , '.. . . � , ' -. � . � � .' . `�� • . ��... �. . � -� ... ,..-�. ,: �� , , ' ��;.y. - � • � � r �� , 0 . . . ' � ., � ' . , � X � � , � � � Y, � .I�. �. � � � � � . posr OFI�lG� nox ,�.a � CLEARWAT�R, �LOF13pA 3AB18-4749 TO • � � �.��. I I��..�� DATE : -� '� �:L � _'"' �r't SUB.7ECT: Request for Medical Services -- Florida Workers C�mpensation (FS �40.�.3) ' EMPLOXEE NAME• � � � -�-�'� , D/A .� /.�~-' �l% EMPLC?YEE 50�^IA�, SECURITX NC? . � You.are hezeby requested and author�zed ta px�ovide services which are medically necessary to diagnase and/or treat the above-namEd �.ndividual as tol,lows : , � � �f�u-r___�e._..r..s—�... • . We are enclosing all medieal �at�s .in our �iles related to the injuzy of the abave dat�. The employ�e has �een in�tructed to bring all X�Rays to the appointm�nt fox- yv�tr =evz�w. if inedicines are� requir�d and prescribQd as a result of y4ur treatment or diagnosis, the prescrzpticn medic�nes may anly be obtained from Joel_N! J�r�y's. Tf inedical sup�l�.es, durable �nedical equipment, arthoses, prvsthesis and other meda.cal.ly n�cessary apparatus are requir�d • and prescribed as a r�sult of your treatment and/or diagnoszs, th�y may be obtained an1.y wzth prior :a��a�ova�. of Cxty of Clearwater/Indus�.r�.al Nurse, Phor�e: 462-6756. to Czt�r Qf C1eaz�waterLlndu�trial Nurse. Prepare an approved I�ealth Insurancs C�,aim �orm and submi.t �.t to the address shown above, c/o xndustrial Nurse, no later than ten (].0) days fram the date of thss 3etter as requ�.red by Flor�da Statu�e 4�40.13 {'l) , _ Fa�,lure ta comp�.y wa.th the above may result in nvn--payment of cJ.ai,m. Sinc�rel.y, � . � �".��.� � �'a� Nan�y Degner,�R. N. � Tndustr�aZ Nurse cc: Johns Eastern Company, inc. SHOIILD TREATMEN2' B� F�R A COND�TI:3N NOT JOB RELAT�D; �T IS THE Fi�PLOYEE'S RESPONSIBILITY TO P�,Y THE H�LL. .. . . .. .....,.,..._.•� � ' � �w�rew� ..�..� I � �� .�� . � ' �. � � . ; ' ' � ' . ' ' � ,. • , � , r ' - ti . . . . . . . . ' o . .� ' ' r.,�'�, ai� .. . , . . ' , � _ . . �..v. . .l�>.a ... . , , , • � 0 . 3 . ' a r ' � � . .�w � .R . O .Jl." � � .i.�f t R � ■ f f JL r+1. +;J A L . ' � , � " � � POS7 OFFIC� BQX 4y�1� ' � ' � , � CLEARWATER, FLORI�A ga618•4748 TO : L�.�! �� - - - DATE : - � '� � ' � � �.�� x� i T r �r SUBJEG"S: Request �or Medical services -- Flazida � - Wazkers Compensation (�S 440.13), . � �% ► EMPLVYEE N,A.ME., � --- �"..r�-r��i ,�� D/�I�.�- — �/_--9/,_... .— � EMPI.,OYEE SOCTAL SECURTTY NO. ' You are hereby requested and authorized to prov3de s�rvices wh�.ch .are medica�.ly n�ce5sary to diagnose and/vr treat the above-named �ndividua� as follows: ' � , . :,c..c�.�.� �� We are enclosi.ng all med�.cal notes iri our files related to the in3ury af the abov�'date. The employee has been a.nstzucted to bra.ng all X--Rays to the anpointm�nt For your rev�.ew. � � I� medicines are rer�uired and prescri.bed as a result of you,r treatment or diagnosa.s, tkie prescription medicines may only be abtained from J'oel N'�Jer�y! s. If ined�.cal supplies, durab].e m�dical equipment, orthoses, prosthPSis and other medically necessary apparatus are required .�nd prescribed as a result of•your treatment and/or diagnasis, they may be obta�ned only with r•�ar approval oi City o� � Clearc�rat�r/Industrial Nurse, Phori�,: 462--6756. Upon com_pl,etion of vour serric�r.. instruct the patient to,_r�turn to �it of C�earwater. Industria� Nurse. Prepare an approved Health Znsurance Claim Form ar�d suba�a,t it to the address shown above, c/o �ndustria�. Nurse, no ].at�r �han ten (l0} day� �rom the date af this �.ett�r as required �y �'lori.da Statute 44 0.�3 ( 2). Fai].ure to camp�y with the above may, result in non-payraent of _ c�,aim. � S�,ncere�,y, f' ' � L�' -1 c `, �% � . . Nancy Degner, R. N. ' xndustr�al Nurse � ' � cc: Johns Eastern Company, Inc. � S$OIILD TR�ATMENT HE FqR A CpND�TZ�N NOT JOB RELATED� �T iS 'Z'HE EMPLOYEE' S RESPONS�BITa2'Z`Y T� �AY �'HE BII,L . "�qual E�n�loyment and Atlirmative Action Ernpfoys�" ' �i.�r.— — — � � ; ,., , , . . , . . . . ' ' . . ' ' , ,. ,: ' . • . ' 4 , S�, ( ' . . . . 1 . ' ., + ' , , ' . . • � , . � ' . . . . .� ' . . .• � . � " ; . � � .. . , • , � � ` ' ' ` � ' -1 • , � ` • j , � 1 • . � . ' . �r � I . . � ' ' , . 1 . . � . . . . . . • . � � . ' ' " � ! . � , t ' � � ' . � . � . . ' .. ' - ' ' 1. . . . , . e ' . . ' ' . , . . � . ' ' � ` • r r' � ` ' ' . j . . 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Rg=� •`�•� Ca3.�b Win�ton --v�- ��.ty o� �I.�ax�sastez :, .i,;:��.!�;�`E�;i ;:-;:�'� , . :'. ; . � Data of � t • ch 1.2 1990 , ��;�`��''lf;.. ,'�.;�,�r"; ► I ��oSd n . 14�r r -t �:�••:• �� . . � , �i '� �a i]�ar .Dr. sQnai . � ;�.- .' , �,;�;'•.�:� ., I" mm �aw .handling Hr. Winston's sbavo-caption�d'�,��workar•a.�� oQmpens8tiott' cz�im on �ha�.f v£ the Ci.ty a� C�,eqrw�t��:. ,�; �� :, ''�� . � .� •,:.. ; ..': •: ....•':. � �tecgnt3.y Hr. Winston � s attorney contacted ae and ad�i$ed : that �� i�IY: ;:~ Ninq�on #.s understandably re�c�ctant to undvrqc any•typ0 ax'gttrg�Ctx3,,-; , p�ovedure tar his back p�rabl.em� , particu3.arly in ' v�.ew o�. hia •;� - c��eb�tia condition . . � . � ' .: • � � � �. ' , � ., . .,. . .. � ti::'�st I�t �t3�aG x�q�c�d� Mr. W�.ns�ton wc�uld l�.ka to �ee �h�ather� or ' �`' c prt��tia .�r�a�ment may o�fe�/x h�m sam rc�3.ie .-T t� a�•� �' t � �� C{vale.� i�l� �'�.t yr� e�� I�eie�%� �'t'ja{�j „�[k�� ' � � � i. �ir. n�ton s�111 w�.she� to r�mai,n unc�e� yaur ct�..re � as.` h,�s�:'pr��a ',,� r 'tiareating ph�rQi.cign, however, he would:�.as �aentioned� lika�`to eee;i��:�. ��chirr��ractar �naa anything to otfer;�im �,n th� way ot:�r�alief. •��'f�'��; G� � . :. 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I�. �N" A T E�-' R. , � � . r� P05i QF�iCE 90X �7�0 ' CL�ARS+VATER, FLOAlDA 34B78.q7de To : � � /�C �-� - oAT� - � -- � a --- y� �� SUHJECT: Request for Medica2 Servic�s - F�.orada Workers CvmpEnsati.on (FS �40.13) � FMPIAYEE NAME ; „ Cl.,c��.f.- �Lf..�.��c_ _� � D / A � � i ,2. � J/ IIKPL�YEE SOCIAL SECZTRIT�Y N4. You are. hereby requested and authozized to.prov�.de services which are medica�.�.y necessary te diagnose and/or treat the above-named indivi.duaX as �o�.lows : . .�.,. C'�IL ��r.�—L�e.-�..�a ,��—f . . We are enc�.osing all medical notes . in awr files re�.ated to the in�uxy of the abev� date. The empxoyee has been instruc�ed to bring a�.l x�-Rays to th� appvintment for your review. - If inedicines are requ�.xed and prescribed as a result of yaur treatment or diagnosis, th� prescription med�.cin�s may only be obtained from Joe,�. �r' .Te�rv' s . I� medical supp�.�.es, durable medical equipment, arthoses, px�astlxesis and othez medically necessary apparatus are required and prescri2aed as a r�sult of your t�eatment and/or diagnasis, fihey�may be abtained only with prior.`'ap�roval o� City ot Clea�wa�er/Industrial Nurse, Phone: �462�575b. to Citv_ of_ C�.eazzvaterL7ndustrial Nurse. Prepare an approved Health Insurance Claa.m �'orm and submit it ta the address shown abov�, c/o tndustriai Nurse, no later than��ten (1Qj days fresm th� date af th?s �etter as required by �'lorida 5tatute 440.�.3(2). � Fai].ure .to camp].y wi.th the above may result in non--payment of cxaim. Sincexe�.y, . � ft', .�,i�. ys�-� � %� , �7 Nancy I3�gner, R. N, rndustria]. Nurse cc: Johns Eastern Gompany, xnc. SHOIILD '1'RrATMENT BE FOR A CONDITI�N NOT �TOB RELATED, IT I5 T$E EMPLOYEE�s RESYONSI�II,xTY To PAY THE B=LL. , � �� - � . .i' , � . � - r':. . � ' , . � , . . , . . . . .� . . . . �tr.n Ni':.i�"'�a� v'�i.'' ` ' '.y: , . ' . ; . a� . . . . . , ��.' � . . . , . ' ' . , . � • �. . .� ` 'i ` . ' L1 . • . . ' . 1 � .. . . ' ;' � . , . ' [ . ' . . ' 1 ' ( ' • t. I' . i� I . . " . . . ' . . r . . . , .. . � . , � .. . . '�. �S' . S ` ' � . . . . ' � . . . f. � . . . . . . t . .. . . . . ,e e '1. . : . �.11..��' � . ... . . . • i , � . - • " . . ' ' ` , , . � � i ' i . ' .. . . , '% 1 ' �'I, ' F ! '.r � ' ' � , . . ; .. . � ' . . '. , . . . . i. � � � . ��.:, . ,'' _ � �4 ��`�� 1• 1�''�. �� ` . ' ' � ..- , . ' ' ! . , ' � ' . �. , } � ` , it � � . � . . . � - , . . , � . . V `ri;` ' ' ' • :. F. • ��:.. ` , � .i . � � , . .� . . � e ' � .� . ' . .. . . . � c V'., . • � � �. . • . . � � ' . . . , .�',;'''� ' 'I�' �j. ' �. .i .o . � . .. ' . . ' ' . . . . ' ' , , � � � r r ' • �.5. �,. .� , ' ;�;! �� ' � � +' ' I , � ' ' : ' �� s , � �t`3• �}. . . ' , . : ' t, ' . ` ,. ' . ' , ..' ' , , �;" . tiy�': , , , . , � �(' . � .'. ', • • +'. , " . . , (r' �s'� ' , . .� �+'��'• .. •�1� . . ; � �_ ,��5, , `� . . . �., • . ' ' . , '' ; F . •. • _ . ' ' , wk: ,�,r•.s: t,��t.� ..�,,, ,,,,,,,,,;,:,�;,..W�+r�az:;'; �s,�._r:�`".�;,t�rt�a• ' . ,.. ' . .. .,. . . . . ' ; . ., : ,..Et��.#y.';rr�+:.e. . . , ^ 4` ` � . , . .. ' . . . .�s, , � i'WR ?7 .' g?. 11 � in � � FRC' ; �C1�L, l i'Y CF1t�� SYSTEr�15° '�n �A5D258 .. PAG�. t3fl� , , � � i . . � � � �• . , • � . ,• � ,' ,. . . � � " : � , � � .�j:�.. �,....ry�f� . . . r . ' ' ', .. � • ' ' • , ' � � � . • • � �T��' F 1� � s•' • ', , , . , ' . � . �..�,.' ' . , • • : ,•�,.� . . , . , . f ' �� i �; . - ' : • . . . , , , . , , � ;'�4 � :,� . . . , . . . . . . ' . � . s 'f •� i . . . . . � . ��ti • � � i 1 , � • i� � �� ' . ' � . • ' . 1 , l • � � � � �� . ' � . � ' ' . - � � � � � . . � ' � . . . � ' � � � . . �,;��,�,,: Win�tan, Caleb � . ..1=el�r�tary 1�� 199� � .. , ; ; � . , `, . . � . ' , , ; • , , , .,::,. ; ; . � � � � ' � . � !; �-� ' C�leb's necY pair� can�inue� �a �J►��1 �s r�di�ular �ymptcrms �c� ' • " �� • i� t�he upper �:ttr�m�.ty. It �.s di:f•f �cu�'� �a evalu��e s�rength o� ��. ' ; ��'�. .�. - � the upper �x�remi�y as he nete� �r�carbatiar� s�f p�zn with � � '. :� ,' ; �. �, cantra��'xon af bicep�, �r�Geps. wr�. �� f I e:;ors F at�duc�or5 . of .. �:::,� � ` � � �he digi�s and. grxp s�r°��gtt� but strer�g�t� �hraughout is .�� - s''- � ],e�st 'four aver fiv,�. � &�c�t!se. nf �c�rc�fu� con�:ractian�� he "'� ; ' . I' , . . .. • pat3.ent camplains v# �aiit �nd ��herefvre i� is di�F�icult �a . '�. . '. . . evalu�te, car. ass�� hxs stR-�ng�h exae�ly vr'asse5smen� .of '� ' '- w�al�ness. He doe� rtot wi,�;h �a cnn=�d�r surgi��7, �.n�srvention � { _ � � at� this t.im�. � � . • . . . � . , . ' � " • , . ,,, ' ' • . . , . ; � . �, . � Jossph M. S�na, M:D_ � � � � ' '. . � Idictal:�d but n4� rpac�3 � .._._... . . � JMS/svd , � ' . . � .. .. j . , , � � � . : ' . � .. '. :: . . � � . ,; , . - . . . . � � •. � , ' ' � � � . � . .: . . , .. .., . , ' '. .'' �;. . , , . . . , . 7 . ' ' � • � � . ` � ' � • ' • S• . ' • ; ., . 1 ii . � . . . , . . . � . '{ . � ' • . . � �i. � • I . ' 'f�. t ' , . . ' ' • � . ' .. '`•,• . ' . . . � � . � �. . ' � . , � .. . � � • y' . , , ; • - � • � � . , � , . . � . .. � � ' � . ir � , _ - . , � ' .. � ` ` � . ` ' , . � ' • . .� . �� ' ' _ , t� • � ' ' , �. .. � , ' , ' , ' . • . � ' . 1 ' ' . • . , . • ' , : . S' , . � .� . . , � . , . . , . � �; , ' , , � ' , . , . , . , . � ; . , . � � , . , i• � . , � . • . . , . � . '� • i � . ' � , . �' k � , i� . ' �� . . 1 ' ,� ' , • r . �, . . I;� It � �. a�-., -._... .. . ` }. ' v �• . � a • i • I ' l i . �� i . , . , � ' � . . �r�c�. .., , . . _ . �.��, . .•,a.':ii� .. ... . . . , . ' . . ' � ' . , �;1F+� ,� `53 a 1 i 1` ��f 7tJA� I TY �:C�f-;E SY�TEl1� � f � . � , Winstan, G��T�b �s�-�, Mht� 1 ~•''rc�'. ' v •.. .. . � �: .r r�'^4aQQ?�� ,� .T«+nt.►z+t'y iL"-+. 1� r: > �a��.44� ; , �.~. , � : ; ; . , +: • :; �c r �,,5.��• � . ... ' Ti.,r �' , . ...#.., . • .. s � � r�' ' :,,�'; 4� • .1 S. . • ' � ,. • This is a fot��y fiv� yQa� �ld r��.la �ci-�n a��:��n�d in�ury on •' M�rch �.2. 1�19Q. Fepvrtec�l.Y �� t:i��,+- i;:;.me� the p��.�h� was '', shov�ling 'wh�� he. nnt�d cros�t; o� p��n �� hca cervital� sp�.ne ;'; ;' a��a and ��ucid�n ��n��-s �3.�tn Uf ��t� lxny frdm the ri�ck into •�he r' .. righf 54�aulder�'and down th� �+-iqht �r•m to a levQ; i��law �hP . �lbaw. He has cc�mpl�ined =of ca�7t;.t��!�cl p�in a5 well as ,' par��hr�ia� of �lae' �t�tr�ri�r ��a«�c*. �i' tN� right �rm d�sp3.�Q , .'� � � . can'��.nued .attemp�s �t Car�serv�tivF ;:�,�r-apy 3ncludic�g � • • • meda.catifln� and physi��1 tF,r�t'�p�- , , �, . , .. - H� did undergo ne�tr-o3c�qir ti•»rh:—L`r� �� 11 a� artheF�da.0 ,� �; evalua�ian anci n�ur-o�ur-gic� L�va.l!�r:ti.nn, He ha� br�en se�n�..by .. � tioth Dr. DeSa�sa. a r�v�trr�l.a�ist. •�r�� r_ M�sse� l�, �. •' ne�tra5ur' ctir� ar�d sor rl-ieir C ini.an� � woul� r�cvmmen� th�t , g � _ p _ . .. yau contact the�e doci:ar�, directly. Ffi� rli.d �tindergn MFX scanning . s�f �he cerv},�al �pi�� wnict, ►•�,pqrtiQd a d3.5G h�rnaatz,on at Ca--G4 i�npir�gi,:,g an ± ��c ��r�tra� asp�� t�af th� � Card a, wv�.l a� hQrnxat-iQn repOrtFv ,,�sf_ C�I�C� �nd Cti--Cfa. I would agre� wi�h ��r. j•��scll�a �h�� ►.irth�r e4��1�a��i,an cou3d k�e asc�r��-�a.ned with a CT •my��or�r�m. b•ti� Ft�s h2d �MGs rer�ormed which repart evidencQ af •�r�racpr��s�a3. ��n�rv��,ion ��gestive dfi ��rvical rati3,cult�p��h�� ?s� �_hn r,id--+,prvi��i l,�vel. Nerve �c�ndu�ti.on per�orm�d �er� rapor�:e+� 4!1 ��'IZn norm�], limits �cevrd5.ng ko Dr, DeSG��. ��1�,t�a�tc:F� �'�" nyelogram cauld be us�d ic�r fyrther eval.!«�i.nn; �i�ic� thi.�s� patient da?s no� wxsh tQ �on�ider surg�ry, hP is �herato�-e r�iu��n� '�o fi�av� a CT �sy�logram which s of co��r�: �n i.n-Y�[.i've pracec�ur-� c�pabi� vf c:�us�.ng some ti�sGOm�faw-� a�d �f rc��.tr�� me risk, x do 1��1 that �ha.s p$L•x�nt has r��.��h�d m�uS.mal me�a.��3 improvemen� �t �I�a�� in re1=�.i,or� �:r� can�erv�t�ve efforts. It . is passible th�� surgAry m�y hAl� im�r�v� upon his s��ttu�s �nd �g�ih surg�ry wcsca3.d pas� SC]Zi�� risl: c�t ws�r��ning ofi his . . �onditiqns, cnmpl ic�ta�vns er• 1��k � f im�r�verneni:. Gervi�al myelv�raphy follnrred k�y, CT �:��2�1�it►±7 c�uld t�e perfarrnQd •prior �a evaluat�c�n �or po�:�nt�,�i ��srr�i�.�� in�prven�i.on in �h�i<a'•. � patien�. 1 wv�tld �Iaee th�.� pal:i�h�_ �•r�.�h a permanen�. par.ti�,l .dis�bi.li.tv as a tiirec� r-��-�iI t n# i-i�.s Workmar�'S Comp inaurY a� �.he lev�l o�F 'twelve p�r ��nt: tr� ttr� ��s�d,v as � wh41�. Jasepi� M. S�rra, M.a. (sig��d in my absenCe l.❑ �.�ln�d cf�l�y) JMS/svd ' . . y n P Pest•�t� brand (ax transmittal memo 767t �� er n+�s�: .` L F'T10Re I/� / � �,,, / ,�jG/ � � (C� � " �'r�-G � � � F�x � � r%%�� 3 3 . • 4 r . ' •�:�., .; : � .� • .f � ■� . , .� , _ . , ._ . .� . ' . �-- . .. . . . , . , w � , + ' , , r"`+ . , � �y � �` � I , � . , � , , r".. � � C. I T Y rJ �' � L� A�R W A� T�.R . w � � pOSi' OFFiCE BOX 47qp � ' CLEARWATER, �LOFilOA 3461 B•47aa T� : /J.�✓_ ♦ � f]ATE - l' '-~ •5- - 9 � .,.,.. .-- - SUBJECT: Request for Medical SQrvices - Flor�da , � Workers Campensation (FS 44Q.13} EMFL� Q'�E� NAME : �-�-- �� D / A / -� •� ;- i/ ,� F.t�II�LClXE� S�CI�3i� SECURITY N� . Yau are hereby requested and author�zed to provide serv�ces which are medically necessary �o diagnose and/o� treat the above-named individua]. as foilows: ,,.,. _,,,, � .¢.��.<-�-�_�� ,'�- --�r r . . We are enclosing al.�� meda.cal notes in our �i].es relatesi to the a.n�uxy of the above date. The employee has been instz�ucted to b�-ing ali X-Rays to the appointment for your review. If inedicines are requir�d and prescribed as a resu�.t o� yvur tzeatmerit or diagnosis, the prescription medicines may only be o�tained from �Toel N' Jerx�t! s. If inedical supp�,ies, duravle m�dical equipment, orthoses, prosthesis and Qther medical3.y nec�ssary apparatus are required and prescra.bed as a resul.t of your �reatmen� and/or diagnvsa.s, they may be obtained on3y with przor±'apnrova? of C�.ty vf Cl�arwater/Industrial Nurse� Phone:;�.,462-6756. U�n completion.of vour servic�s.•instruct th� tiatient to retu�n to C�.tv of C�earwz►ter�7ndustrial N�x�se. Prepare an approved Heal�h Insurance C],aim Form and submit it to the address shown above, c/o Industrial Nurse, no later than ten (1A) days �rom the dat� of this le�ter a� r�quired by Florida 5tatute 440,13(2). Failure tics camplX with the abnv� may result in non-payment o� _ claim. Sincerely, ' � �', �'� ��. .�? �r . Nancy Degr�er, R. N. �ndustrxa� Nurse cc: Jahns Eastern Campany, inc. SHOULD TREATMENT BE FOR �i CpNDIT=ON N�T_JOB RELATED� �T xS TH� E.`4PI�QYEE' S RESP�NS�H�LITY TO PAY THE BILL. • "Equ�l �mploymen! and Altirmative Actian �mplayer" ��.' � � e i i � � � 5 i � � � . ' . 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POST OFFiCE 00X"4748 GL�ARWATEA, FLOF!!DA 34&18.4748 za: .� . ,c�a�.c.�.� AA�' : ��Y ,� 8 7592 SiTB.?ECF: ReQuesr far tied3eaL 5�rviGes =�Iozida � � � iiark�rs CompcasaCion (£S 44p,��} . . . �'' EMPLOYEE Ne�MF : ��--� �i� _ .^ _ .Y, , �_---- b I r1 � w,/.� � J�/_ �iPL4Y:�'H SOCI.�L SECL1iiI�Y PIO: ' � � . iou are hersi�y requea�ed aad autborf.zed ta �pravide �sezv�icea which are atcdically nccess�ry eo diag�ose.artd/or rreac cke.abave-aamed i.c�div�dLal as • �o L lavs : . , � - �1.��..�� • � �We are ettcicsing all csedica� aatas in our fi!es related to rhe injur� af the • �bove daCe. Tha employee has beea i.naCructed to b�iug all X-rays ea �he appaiaC[aerst fnr gonr r�viev. T� medicin�s are reqn�,xed and pr�scribed as a reault of qoctr treaCmenC or diagnosis, the prescrip[ian medicines mav only b�. obCainad frorn .74e1 `�' ,Ierrv's. If mcd?caI supplies, durabie ¢�cdical eqaiptaenc, archoscs, grost3�ases aud ocher mtdicai�,v .necessary apparatus are requi�red and Arescr:Cbed as a result af your �rea[menc and/ar diaguosis� chey �ay be obtaiaed only vith prior a�arovai n£ Ci.�y of Cleaxvacer/Zadustrial Nurse, Fhane: 4bx-b756. UQoa comvlet�on af vour services, insCru�� the oatien[ [o tecurn Co CiCv of - - - - . .. ...., C1earWaC�rlYnduscrial Nurse. Preparc an appz�aved Hea�,th I,nsurance Clai.sa Form and submit it to the address shown above, c/o ZndusCrial Nursc, na later thari tca (ID} days fram datE of this lettcr as requiz�ed by Florida SCatuce . G�►O.i3(2). Fail�rt to �aatply wich che above may result in nan�-pavmenC o� •• , clafm. Sincerely, �� `-��`� �� '�. . . . �Tancy Degner, R.N. . �ndustrial Nurse � c:c: Gallagher�•Bassere Insvranc:e Service�, �nc. � , SS007.� TREA�HT B�" FOR A CaHDITI4N NOT J�B 1tEL�TED, IT IS THE EHPLOYEE' S RESP�2i57BZLITY �D pAY THE BIx.L. � . � "�q�ai �mpiayment and Aftirm�tf�e Actla� Errrpfayer" � � ' . 0 ° � .. , , . , . . ' ',' , . , �, - ' . " � • '. �. .' , � � � � ,_� . , , �� , , , , , ' . . � , � � I. . .. . . � . ', � � , .. . � � i, � � ,; �f��t. . .. . . . � . ' � �' : . 1 , , � . . , .. ` I. � ,� :�. � . , , .t, •� � .� ' � '` ' ' . ' ' � , ' , �. . .. - . , . . � . , . ' , � . . .. . . '' ', j ' . . , ' .n n,... .�l7 . . , ' ' ' . . , ,r � . . �t• ... . . ,. � . . . . �. , .. � � � , � ' , ., . i � � . ,.. . ' ., . .. I � r F ' . . . , ' . � .r �' � � .' ' . ' ' . ' . . . I' 7 � �� r+}L , . , • . �0 3E CC;LpL� �� 3Y A�::...•iDI:iG ?�YSIC��+`{: � � �c,ras;.s : � ' • C. �r r t , �, �-,., I �..-� ��P�--�•1.►-i.�,l t1�7 c- � �• -�.a r,�.» , . r1 "� . s►...... 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' . � I. f' • . � . � ' , ' , , • � { � • ' ' . . .. , . . ' . . . ' . . , I ' . . ' t. � , . � ' � I� � , . . , . � , . . ' , .l . .... . . � • � ' � � � ' ' � 7'he Orthapedic Center of West Flarida . � . . . . �. � ' 9555 Sr�tNOtg B�va. larsph M. 5cna, MD. 5680 4�ru Sr��sT Noars , ' .' • 5urra 101 � Sutr� 2U4 NoRrn � ; � ' , . . Sr�x�rouL �c.of�so,► 34642 � ' ' Sr. F�r�usvRC, Ft�a�a�. 33?09 � • , , . ' Pstaa¢ (Si3j 393•2732 � PkoN� ($13) 398-4879 - . . � � . v. � 4 , � '. � . � ' ' � N�►t� � , AcE ' . '. ° AttURESS bATE `� � � � ' • 1 � ' . , . , � �� , , � � y • . � r i' ��_ . '"� rT ''�`�' �-' �'..e.? �%4—t,� Q�r �°�fg r, � . , r �Itu•�. . .,s . ... , . . T�a�s ' M.D. o�., .tis�sagus . :i. � _ . m , ` . . . . i� , F � � ' ' . , � � , , . . . � , : � , „;�.S..�s... � ,;a.. .:.....,._ .rS°. . :�'., ., .. M � 1 � I ' � ' c z T � . ., i , . , ' . . , � ... � , � � ` � � � . � , , . . �. , p F C I.. E A R W A. T.-. E R , • PQST oF�ic� sox �e�ae CLEARWAT�R, Fi.OFiIDA 34618-4748 To:_,��'� � � .. � . nA�s.� /� --��..: .�I..� .� SitBJECi: Reque�t for �fadical Scrvfc�� - Flori�a � Wark+�xs Campensacioa (F.S �►�.13) /� ' , �; SPLOYEE ii � : � � �/�.,�-t��z-Z�.� -' � D / � ,..3 -- / a ��'/ Ei�I�Li]YEE SOCZAI. SECURITY N� s �. You are �ere�y reyuesCed and authoxixed to pravide services vhich are , [aedical7.y neccssary co di,agnosa and/or treaC the above-aamed i.ndi.v�dua� as foz lar,�s: � � �'• - .�s..�-�..X.�-� � , We are enclasiuh alI u�edical uates fn ocsr Eiles relaced co th� injury of the abave daCe. � Thc � ca�slaq+�e has been i,as Gructed ta bri.ng all X-rays to the appaincment �ox qour reviaw. . If snedicincs are re�u�red and prescri�ed as a rea�ult a£ yaur tr�atmen� or diagnosis, che presczi.pcian medicines cnay oal.q be abcained fxom 3oe�. Y' �� ' If inedical supp�ies, durable medical e��fpraent, vrtiioses, prosr�eses aad othez meriz�ally aeces�ary apparatus aze requi.xed attd At�scri.bed as a resulC of your treazmeac andlor diagnosis, tHeq may be obCainei3 only vich prior at�oraval of City cf Cleazuater/Industrza2 Nurse, phane:� 4b2'-6755. �� U�att comoleti.on of vour services, fnstruct the atiant to res�srr� [o Cfr� oE C].eaxvater/Induxtxi.al �turse. �'repare an appxoved He�altit Lnsurance Claim Fera� and su�mic it Gn the address shavn a6ove, c/o ind�zstri.al Kurse. no Lacer �han ten (IU) day� Fx�m dacc of this 1�tLer as �equired by.�Florida SCazuce ,,, 4�40.I3{2) . Failure co co�ply with tha a�ao�e may result i.n non-gayssent of c].aim. . S.incerely� � . �� .� , ��.n' � � Nancy Degner� .N. 7ndustrial Nurs� � cc: GaLlagher Bassec: Iasuran�e Services, inc. SHOOLD TRFATH�2iT B� POA A CaNDITxOH NQT JO$ g�.S�D , IT I S THE F.t4FI.0YEE' S �ESPQN5TBiI.iTY TD PAY THE BILL. �,�,� . �1 .;' "�qua! 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' • , . ..�_�c::[l�-. ,'�4Ai .-'i` `cFi . .� Rr.Fi �d..:;..7 ?t: ` ' .'a��,�� '', . . _... • . ...� . I �� ' :F�-�;�(ti .�y-,-` l _'G � ! + . . , . . . • •,I' f ' r . ,1. � ' ' , ' I . � � . ,� ` • � 1 ' . , ! . . � �� . , . . .. � , "3 , . . ' ' . . `' i � � ,. •' s ' S�'•, ,� ' � , . .. � , ' r : ,, I � ' � . � .. . • . ' 1 . . . fl+ . , r � , � . . ' � � � . . . � , ' . , 1 . . . � . ' ' ' � � . . � , ' , ' � 1 . �:;;� . . ' � Wins�r�n, .Cal.e�i � � . � , �c�ober 7.8; �.99�. � , . �'.,. , . .� • . ' • ., , . , , � . , ' , ', . � , � � . �'1 . .� . � , ' . � . . � , . . . . = i. . . . . ' ' ; . ,�, � �:Thf.e' pa�ien�s campla.�n�� are 'unchanged and my , . ,' � - . , ., �_��'.'.�, � � recommendat�ons• for.. him � would be fo p a ..to� �Q�'• ' . � . ; . r. �•Muse a. o o - er� op ni.on. � ., . . � . . , E •w. � , , ,� .' ' � � . . , ,� • . . , � � ' +. . '; � .. , � . Joseph..M. 5ena. M.D. . • ... �� . . . . � . , . .' . � � � . . ( dic�a�ed .but not � read }. , . .,' . � . ' , '. � � '�, . �� ' �'MS:kef . �. � , ; ; .. � � , �, • - . , � .. . ' ' • . . ' ' r : . .. E ' .. ' . . ... ��• ' • � , . , ' � ' � ' � .. . � '. ' � ' . . . � � . ' ' . • , . � � � • . � ' . . � ' . . . , o ' . . . ' ' . . ' ' . ' . � . . 3 . . . . . . . . ' .. . . . . i . . . . . . . . . . � . . � . . � . >. . . t . " 1 � . . 4 ' � . • ) .. . . ; , . . . . ' ' , ' ' . ' , ' � . . ' ' . . .. . , ' • ' !� ' ' .. ' . i ' , , , . ' . �� ' . . .+. � . � . . f ' ' . , . . ` . ,. '. , '' . , . s . . . � ' , � ;; . � .. � ' • ' � .. ' ' . ' � " . � r � • . . • • ` � '' ' � � ' . � �i• , . . ' ' . � . ,. •'�a ' , . I: , � � . � i ' „ t , i . �� ' '. - •{ . , , . .. . . - ' . . -- ... . � t ' � ' . .. � . . ' 'j � ' n ` . � � 5} . � � �1 . . . f , � �'�, • � ' � . � . . ' 'i. � . ' ' . , � . '0''S� � . . . . . . ., � .. •�.' '}'; ,a�. ' � . � ` � I� � • r ' + � � � � . . . • �i � � F , ' , . � � ' � . � ' , . + • ' ' . m ; . � . ', � ' � �� I 7C Y ., , � � . Q F �• • ' C L E A R. W A. T�� Pt�ST �FFIC� 80X �748 CLEARWAT�R, FLORIDA 3461�8•474q ?Qi �irc./. .�rU�(,,,.... DA'I�:_.._!_ � � � �� ' 5ilE,i£CT: R�equest Eor ;iedical Services - �'lorida . , .' S�ot�kers Caa�pertsaciarz (F.S 440.2�} ��i�'t,pYEE N�ME: t...ic��.r� J-�.c�,-�. �-•,� n!a ,.� r� �..,. cMPLO1fE� 54CI.�i. SECi1RITY N�: You are hereby requested and a�sthori,zcd ta provLde servicaa vhich are mediCally n�cessary ta diagn4se �nd/or [reat the ahove-aamEd individual as fol lc�us: � ��1 �a��'�-C.�d. roL. � '�✓ r � . i3e are cnclasing alI �edi.cal. noces in our E1Ies relaced c� the injury o: the af�ove dace. 'iha e�aployee has been fnsrrtscCed co br�ng aIl X-rays Co tt�e appoinrmenc for your rcvie�r. � If inedi,cines are rcquired and pre�cr�bed as a result af your Cxea��ent or diagnosis, the prcacr�pt�on m�dicinea may only bd obtained fra�n .�oeL V' JarTV's } . �, If �cdical su�pite�, durahle medical eqvipment, orthosas, pra�trieses aad ache: caed�caliv nece�sary apgaracus are required and„�pr�scribed as a resulc oC your [reat�ent atzd/or diagno3is, they �ay be ciscai,n�d„ anl.y Wi.th prior �pproval a� City oE Clear�aater/induscrial Nursc� Phone: 45Z-b756. • '� � Upan co�nletian of_vaur scrvices, instrutc Che �atient to�racur� ko Ci.cy.of ClearwaCer/Indu�triai,Nurse. Prepara an approvtd Haa�Ch Insurance Clafm Fora� and sub�it it ta che address shawn abave, c/o iadus�rial Nurse� no lacer chan Cen (I.O� daYs from dace oE Chi.s lettnr as rtquired by��Flarfda 5tatuc� - 440.13(2). Failur� ta c�mply aich the above may reaUl.t i.n non-gayment of . clai.m. Sineerely� , , �t. �}- �.��,��r� � � . � . Nancy Degner, R.N. Industrial Nurse � cc: Callagher Bassec[ Insuranc:e Servi.ces, Inc. SflOQY.D TRF�Z�lEiiT 8E PdR A COt�TDIITOH t�� .�OB REi.ATID, IT �5 i'HE �i'IFLOYEE' S F�SPONS�BII.ITi TO PA'� THE BiLL. .r:i � ,.. �: , ..►r{� `„�; �� .,�ue�af Employrrtenl an� A[!i►m�live Aclion Employer•' 0 d , �,; :. . � . � . . � � . . .,, . , , , . „ : . , . , ' , • , , , �, �,. , � - . . � . : . .. • ' 1r , . , . , • .. „ � .� , . � ' �, � , . � • , � . . ' • ' ' , `rl t + , ' • . . ; ' ' . .. • . .. . ' ' .�� : , .•?. • , � � ' ", . . � ' . . • ' , ' . ' . ' . ' � . . ,. . , �� , , � :'riS: ., '.e's �t?.. , ... . . ,• �.,r+�:i.^._'ek�`d!>1.�tr. ...., ., � . ... � . . .. " � . . ' ° � � •1. . , � � • , , .. . . , , .� ,y� � . . �` , r . . 1 � ' ' �l �i ' . , . 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' . . � , . . � ?; , �, ` � '� Winston,� C�leb ' , , � , :' September 27 � I991 � , ?' i �� . �, . ` ' ' ; . �, � � ' ; , . . , , ,, . , � , ' • '�;1�: �., Ca1.eb is cans�dering. myeJ.ogram and�.I �have exp1ained tv him✓ � ',;� � . . � . tha� there are' cer�ain].y r�sks ��.ncluding i.n��cti.on, • � ' �� , seizures, patn, headaches, , ep�.nal fJ.uid Zeak and, mar� and h� °' �;�,�• �, • . � Wil.i conaider �he above, • He underetands that su�rgery �is , � {�'� . .. . . not a guaran�ee ta , cure,� . � . , • • . • ' . � , • , . , . , .. . . . � • . } . �=, �.The�patien� is using a� cervical coilar part-time., ,� ' ` . . . '. , � � •�';� '. Joseph M. 'Sena, .M.17. , � ' + ' . � , � � � i . . . - •(dic�ated bu�:�. nu� ;� reac3 ) ' - . � . - t `� . . . ': � �MS:kQ�., , , • � . . , � , ' . . � . ,. ��, �: : � � ., . • .•'_ . , ° , . , , ,,. ,.,, ., •. , . ,,: `� . . , , � � '� � '. . � � � � � ;. � � � . .. ,` � . , , . .. , , � . , . . . ; ; � . . . E . r . . . • . . . . . ' � ' ' � S ' ' . . . . . . � , • , � . , . . . , � . . � i � ' � ' ` ' , , � , _ ' ' �, � . , , ' . . ' , > , . `�, ' ' , ' . I .i ,: I � ' I I • . ' � � ' .. , . , ' ► . . . � ' , ' , x ' , • . ' . i ' . . . . . [ . . , . .i , � � � � � � . , . . ' � , , ` � . � . .. , . � . . , ' . ' . . , , . . ' . � ' . . . ' . . . ' , ' , � i . , � ' . .,' -.. . , _... . . . � , ... .. . .. _ . i y� .�. , , . . . .' . '. . . � . � , ' t . , . . ' , . � ' - i � � . � . .� ' ; . . , _ , r t , . • , . ; � . . . ��. ,, . ' '. - . � . , , , � . �' . � .' � , . ' . , � .; , . . . , . �. . : • . ' • ��. , , � . , .�•� .�b.... . ' . ....._ , . � ' ��: ,... � ,- ' . ' •, .� . .� . . . � • ' , e� /�� ' � . + � . f . � �� ' . , ` 1 , ' � � . , � C T 'I' Y . U � � C L E A. � i�V' �9. T` � �. �" � P�OST 'OFpIC� 80X 47�8 � � , � • CI,�AF�1NA'f�R, FLORIDA 34618•a7ag ' TO s r....J.+ ! � ��r'✓ � l}ATE : ��°�' �f / � . , � • •. � ' SU83iCT: Requeat far Hsdi.cal 5ervices - F'lorida - . � Wor!c�r� Cac� aasacioa (F.S 44�,7,3} . j E.cPZ�a�E Hu�. ` ?�6 � �i�'�•�-'.5�� a 3�%��'il � . - .� � � EMFLOYEE SOCIAI. SECiTRiTY ND: ` Yeu ara �creby rcquesced and auchorized to provide serv�ce� Wh�ch are � ,medicallq necessary ro d�a�nasc and/or c:eat the above-named itxdividual aa � fol lcsJS : � � �.,��-G� /��c� . . �+'e art encl4sing al.l medical naces in aur Eiles rciaced ra ehe injuxy oE the � a�ave �ate: �he em��,opee has beeA inscructed ta bring all X-rays eo che a�pointment tar qcur revicv. if inedici,�es are req�ired and prescribed as a resulC o£ your treac�ent ar diagaosis, the prescripcion madicines may enly I�e obcaincd .f�acn Joe.L �i' .��.T..L`.�. � IF m�diaai supplia�, durable mediCal equipmene, crchoses, pros�hesas aad acher medicxllv aecess�ary apparacus are required and„presCribeB as a resulc of your treatmeaC and/or diagnosi$, chey may be ohtained,.anly vith prior aaoroval of City af Clearvater/industri,al Nurse, Phone: 4b2-fi7Sb. lipqn camol.eCion of vaLr services, inscrut� the oaCicnt to recurn Ce C1�y of ClearuacerfIndusrr�al Nesrse. prepare aa appraved Health Insuranc� C1aim Fot� aad submit it tQ tht address showtt abqvN, c/o Endustrial Nurse, ao Late: chaR � Cen (IOJ days fram date oE th�s ].e�ter as requirecE �y�rZorida Scatute - 4[c0.].3(2}. Failure eo camply wi,th ci�e above may result in non-pavmeac of c3,ai.m. Siacerely, . . ��"L�+�/ � Naacy Degaer, R.N. �ndustr�ai Nurse cc: Ga��agher Bassett Ensvrance Services� Inc. . SH�ULD '�RE(�'1�fEN'r $� FOK A COKA�TZOlt NOT .70it RELA'I�, I1r IS THE EHi'i3OYEL' $ R�SPOttS7EII.ITY �0 pAY Ti�:: BILI.. .�� . "Equ�l �mployment and A!lirmalive Action �mployer" � .. . � � , : " , •. „ . , . . . . .. , . , , , . <_ . �� o . � � . n; ,rr• �.•,. . ,..., . . � • . • ., , . , , � .�- �"- . . w + , . , �. . . t ' I , ' �r s �� L .. , ;0 3� CC:"°:.�:.�� 3Y ?►��:.y�L:�G ?vvSiC:::t: �L�C►jOS�=: � , I . . , ti. � , . �E'L��.KS : �� } �� a � � � n3i..=: i0 Z::UtZ.`I �0 .��'.GvitZ ][%'°_". � L=' Vai � '�+r��V? � �/'"' . � .;AI.? :0 ��.`� '0 L�Ga� �l3'"'i'_" :�5i.�CC�G�5. �" :iE:C: r3n�i�T'�'i?.:ii i5:/� __ �( "' �� " �r/ • _ 5 �G:1c�J : �L.':i5c � :'l: e�it CD4or �-�r n : � Su -p � s -.�... `: . � . .�'.�Vi, � ',R'�' . � ' : } .. . .� 1r � ; �+ .� - , ' � " • ' � � � '� ' . ., �, . , , � ' . • � i. • .• ' � . t ,`�� .' . . . , . ' 3 . , , . " , . . . . , ' . . . ' . .. ' . ' , .. . . . . r' , � . � ' '', � � , . ; ' � . ' . , . . . • � � � � '� � . ':�:. .. 'r ,�. �. � � ' �. . . � � i • � � � `', ' , � + ' � . � . . � . , '` � � ' � � '. . . . II . . ., , . • 1 . ' . .. . . . , . . �' 1 , , � � � , . , .'' , - ' .1 _� . . � . � ! • , aA . .. . � , � . � , . .. ' ' ' . . f . ',J,, ' I'•'.?' .$. � E ' � . �1 V . . 1 ,'� • ` ' � ' . ' ' • . ' . '. � ' ' . i . [ .. � . . . ' . . . i 1 . . . � i � .'Yr. 1 . .,r . . . , ` , . 5.. ' ` . .. � . � ' � ,. � ; ' � � }. '� 1. . ' ' .. ' ' . , .. . . ' . ' , ' , .. . , � +, ' ' � � .S ' �. , : ' . . . . • ' � � � � i . . • . . ' ' ' . . . ' . ' � � � ' I ...r.��r+.a...... � � . .��..r.w�J:Nh.1'i��iS,.+!'�yiFZb'.ji'i11r�.1�.... � 1• ' . �'..__,. ,.. . , i ... . . , . s I.��, S..Yk�..�. .G. �. ,.. e. . .�. � . � � � . � . ' ' ' � , . �.� .. � ` i (+ . � �. � . . . � . , . ' . ^' ' . ' ' . ' : .. . . . . rI �) . . , , . . , . . , , i . _ � � ' . , � . . ' , .i . ' ' . , ., , ,. . . , ' , , � . � , . ,` � � � Win�tvn, Cal�eb . ..Aa�r�ust 2B. 1991 ... r .��1�eb can�in�ues �n nwte neck, p�in w.ith radi�t,ior� �o th� � �' �. right upper e:ttremxty'. We i5 nc�ting lnw bacl� paa.� as w�l i. ; ,•.. . H� ha� h�d r�-r�ys a�f the ],�.�mi�ar ��pin�. The�e �re nega�iv� ` , fiar �ract�sre� nr d�slo�atinn, ' . � . � . �Jc��eph M. Sen�, .M.D. � . � , . . . ( d3.ctia�ed but nv� . r�ad ) � . � � � , , �. . . � ' ' � . � • ., � ' , JhiS/svq , ' ' , � ; � � � ' . , ' � , �. � �. �' � d � � � � �. n-��c. � (�,-�w..-� .s' � � ,...:;� , _ , , � . . , , ��".-t-�- .� �. c.�..�,� . � „�--� , . , . � . �J ° U �� „� � � � � . �- � �--� . t� � � � � . �-�� . � � �-�-� . �-� . � �..,�} L,�,,� ,� �..�., � rt, � ru � �.�.,.�; _ c..� ��., �..,,�.., �� . � � . i . � . t.. `�, � ? ��...,, ° � . �-` � �.. ,,� ► t�-� . �.,..�-�� , . . . , .. � � G �-�r` f t �''..,�.,� vs,�- �-r 0�-�i � �, � � � -� �, �,,.t �1. � ��•...i,--- , . r . � ... � � `w l } �� -f �` � [. �---� � � �►-,; ..� til fi�-.{ r'� � . . r . : � � r�.. . l � � � , . �. � � . i • , . . .,. , _.. �� ' � 0 c� "{' . � �. . . '" .. . . . , . , . ' , . , . , �, - � 3 . . , . , ' � ' � � . r ' � � . . � � ' � ' t ' . ' � � � . . �. ' . , ' � • ' �So` , , . . ' . � � - � . . ' . . � � . . . � . . .�.' , . . . . ' , ' '' ' . . . ' • . � • � . � ' � . ' . . . , . 1 � � • , , � ' . . r.n.,� . r. .. , . . _ ..,,. � .'�''F'' =i�' . i �R�. . �. � . . � ' . , . '.. . . . , � .. � '� ... � . . . . . . + . , � . . �^ 1 r ' , � � �� i ' � . . + � . � . ' . ,. �� . C I x' "X� � a F C�� A.� R W A T� �� ' . ° . i'OST OFFIC� BQX 4748 � � • . CLEaFiWATEFt. F�,OFili7A 346t8•a7a9 �. Tn: �i�', � � - �a�: Jtfi. 31 I99� Sti8.1�CT: Ae�vesc for Hedical Servicas - Florida � . � uorkers Compensa�ion (FS 4t►�.�i3) E?iPL(}YE� N.1il� t C�C��.�-� . L�it�,t�a� D I A -�.! �-- �I EM�L�Y£E SOCIAi, SECi1RIiY Nd = '.. You ara hercby requesCed and authorixcd eo provide servicea sahich ar� � ' medicaliq necessary to dfagnose and/ar tre:c chc above-named iadivfdual ss follo��: . .G�-f,�.��i�.._. � _ � � �:e �r� enclasing sIl �sedical nocea in our file� xelated to the i.njury 'oE che abave dace. '�he e�sployec h�s been instrucCed [a bring all X-rays to Che appnia��zene fqr your reviev. If inedicinea arc required and pre�cribed as a re�ul� a� yaur cr�ac�ent nr • diagr�osis� rha prescripriari medici,nas m�y qnly �e obtaiaed �rem Joel V' Y�r � �--�-- . Y� �s�dical au�xplies, durat�l� medical tgnipsaen=, arzhoaes� prosthase� aad acher credicxll.; ae�essary apparatus are reguired,. and prescribed as a reaul� at yaur � Krcacmc:iC andJar di3gnasis, thaq may be obcaiaad only vich priar appraval of Cfty nf CLearvater/iadustrial Nur�e� Phon�,:. �62',6?56. � U an camvlcridn af vQyr �crvzc�a instruc� the � atierst to retuz•t� to Cit a£ Claanrdter/Indu�tri,al Nurse. Pregare an agQroved Health Insurance C�aim �orm and submit !� to ch� address at�ovn abo�re, cla Lndtistri�l N�srse, na late�r ehan een (l0i daya froca date of Chi� ler.cer aa requi.red by Flnrida StatUCe [a1.0.13(2) . F'�aiiurt co cnmp],y wi.th Che above may re�ult in naa-payment of � � claisa. � Siucrrcly, . �. �,,�-�r..� �r , �1, ' ' . � Nancy l7egner� R.N. Industrial, Nursa cc: Gallagher BassetC insuranc:e SGrVicea� Inc. � � SHOOLD ?REA7�fEti7 bE FOR �► CO�ITIO�i NOT JOB RELATED, IS iS 'If� EHPLpY�E`5 RE5PC1NSxHII�IZT Ta P�AI TI�.' SII-L. , "Equal Employmont and Affirmalivv Actio� �mploy�r" � � � � ,. . � • . , . . , . , . . , . �' . � _ , , ; � '. , . . , ° � ,' � � . ' , �� . , � , , � , . . r . , . .. , , � . , . . � � , , ' , , • , , . _ � .. • . . '; � :. ; �� ., �.. '. ,. .' • . . `, � ' . , i. �, � ' . " . , , . . , , .. . . . . � . f , '' , ; . , . . �. r ... ..1,... � ..' . .� •1�.. .��' 1i�6!'�'. . � : . . . • . . .•. ' n. . ' , ' . r ' � ' ' ' ' . � ' �.. ' . . . .. � . . � 1, , � , r � J�� • , . l � . . . � + � , , ' � ` - • • , ' . ' ' , . , . . � . � � ' ��Q. �,'�', . . �0 �E �CCW�L�+�a 3Y �+�:..VDI:IG ?SYSi.C:;�Y: D�G:i05iSs . 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ATTENDING PHYSICIAN: ' , . . . ; . C .� . ��..--. . ' , : �� ' ❑ZAGNOSZS : EL Lc ctc.- � �,?G � t. � ,�c . � . . TFiF..ATMENT : ' � . � . , . : _, • . � �� ..�� • . � . , � , REMARiCS ; � . ' +-11 ABLE TD RETURIv � T4 REGULAR DLT'I'Y'? "�`� IF N�T, WHEN? � i . � /��r�� .- � �L �/�Jci �i � ABLE TO RETURN TO LIGHT DUTY . L-�� R£STRIC`SZONS: - .Cjl��L• Q.Lr ��3 ��E• ��7 Lc.��{u:�c� NE;CT APPDIN EN IS_• � � • """ - . - , . , • � .•�+�STGNEI} : f � � /_ . � _M. D , LEASE RETURN COMpLETED FQRM TO PATIENT ! � ' , 0 ;t��: z i� , .. . ` � , • ' � • ' zF'• . � ..}. . . � a . •• ..t' . >s . �i��'�i: .rG�,.t fr�,7, '.�}.l'� �1� . ' ��lie � . . ' .. ' � . ..,. , � ., . .f�� . . i �.�. 1+.� ' ' .i� . .,, a.� . � , y, tE' , . , -..li .' �» �i: :�l�: , � . " . : . , � . . 1' ' ,. . ' . . . - ' . • � . . s� . ':� .`t_ ' . ;" � . , " e.':' . '.' . 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' ' . . . , . t�. � e .r . . � . ! . ' . . 1 . . ,�••I-��.. � . . . � ' . '_ ' ' .'�! , ,' . . ' ' � . . . , � . ' . ' . . , '��;i•�� ;1;�� a.F' ' . . � ' �i. � .v .� � , '' � . � - ' � � . . � . � ' ... , � ' � i . ' ; • ' , , .F, �, .: . , :: � . . . �', ,. � . . � , � ;. � > . . � . . . , � . . . . � , S: f ; ��; . . , ,! F .. ' . . .. , - • ,; � , , • . i ' �5, .. , ' • .t.. . .e• ._ �.' ' ' .. ' . � �;`r. . � •.7� , , , � • � �:`I �. .. � ,� ' , , � � ` � .�!' ' . � ' ' �• . , r � , t. � , ,' , r , ' . ' ' .. . ' .. . � - , Yl- ' ` ' r' . . � ,� i� ' �� , . 1 I •• �� "[ . • 1 ' , .i . � � �, � .1' �.. . Winstcin} C�l�b . : � ,��Jul�y 3�., �.99i , � � . ,• . . . I . �' .; ,. e. . ; _> .. ' . .. . . . , ' ' . � , ; ,. ° , . � �.. : . � - ' . �.�'. �� _ . . . . . , ; f � � :.C�leb's �ymptams con�in�e' as.'per prev5.aus� va.si�. ,,W� ar�� .' . � , �.�.'.�. . ��;,,-:.. ��;. '•• .await3.ng a' �eLirvs'u:rg3ca 1 cnnsu 1�ation .. Hc a.s con tir��.ia.ng ar� `, :�� , physical therapy,'r�. H� 3.� zinabi� to erfivr^ 1+� , . ` , . ' , . which' wer� signS.f�eantlY„vigara�c�.� We will' see. Careb �back i.n� • �, ' . � . . . S.�Y. " W��I; � S ],fiB . ' , , ' . , . . , . ' . , , �oseph M: 5eri�� M:D. . - , ' � � , .. . , �: , , � , ( dicta��d but not read ) , , , � . „ . . . � .. , ;�. , . - JMS/svd �.� . .. , . , . � . • � � , ,' . ' , . . � •'. , ' - : � ,, . • ,` � , . , � . � .. .� ' . � , .. • . �. 4t , , • . . . . ' .' . . . � , , . ' . . . , ,� ' � ' , . � . � . ' -r . , . , � . . . � . � , , � . {�'' � o.. � � '� 1 . . .. . ' ' ; - • _ ' ,.. '. +� � ,' . � . � . ' . ' � . . . � . . . � : . . • � � ' . . � . . . . . . , � . ' . ' , . ' . . '/ , ' � . , < . . . � � , , ' ' r , . ; , � l , „ ' �� . . .. r' ' . , � [ ' . � ' „'�. , ' , .. `- ,. . . . , . . . . ,,,,,�r � ' t�ia'��y��l ��r � . . . ' • � . . . , ,. ' �Tt:• .n;.�t: • . .�,:i� .f�i� . , ' . � . � . � � . � . ' � . � • • . ' F . .. . . . . ' . ` ' .� . 1 ! � � � � . . ' ' ' ; . ' . . . � . . . � [ � . I i ' . , . � � ' � . . . . . - �. . , • �. � � ' . • . , ' , 1 ' I ' � ' . ` � , � . �i , .l,� ' � ; , . . . , . + , . . . . ' , � ,., � � . , : . . , . . � � � . . . . . � , . ' . S . e . •t� i . ' ' t i 'i . . . . . . � � 5 � • . . . . . . . � � . � • � . � . � � . . , i . . ' . . � . i � . , ' � . ' � . • r . � . � , ' , �, 4 . . � . � ' ' . ' ' � ' 1 . , ' . . �r •.. . ! . � . .. . . a I . . � ' ' '� . . , • ' 'i ' 6 • 1 •• � � ' , . ',�y`1�r'1��<.'i.; 'r!yy? �y !F lf' � i � � Ct . :i • , � �. ... . � ' • � ' 1 �' . . : ' ,. �17: �� '�; - �. �� rn • � : .1,'s . -r. .,��f .E;�:: . "�''I�,. . . . ;�..,,: •i,,.. . , . .�' ' '=t�' .. , ��; ..' - ; ` � , ' . . ' , . . ' � � , , � ' � .�' ' � • . . . , rS';!%� i,i'a, i .. . , � . � r . . . . . . ' , . . • . 1 ¢�:,� 'tF�'. ''E1' �+?'r' , ,� � "�� , . . � . ' , . . . � . . . � ' '.i' '.I � '� . �� . � ' i r.. .. , .. �.�..�``�.'.[ .i, . ' ' �� ° .� . �•�' . . t , . � ' . , . �� . ,. ,' � , � ' . �.` � . .... . '.� , iS ' 'FI� •�3' ' 3' ��•+3f . . �.. . . . . . . . . . . ' � .. . . . . . . . . . . � t ��P.�,1' �' ?.1�' . . . . 1 . . . . • ' f. . . . . .' •r' . . � . ` �} � : f. 'i , ..'S,' ^' ' . . .. • . . . , ' � VI f� ` °3'i"�� '�' ' ��'l'. . - . . , . } �� ' ' .: . . . ' . :f � . ` ' . ' " �: ,.S:�F? �'p�i. •'ir .'1' ,• , . � . • , , , k . . ' � . .. ' .. . ' + . � " . 1 �i. . 1r. ,. .r�� ' ;irr" 'v� . ' . � , - � ;�' ' . �. , ,�,•%� , "r'. E i, r; . „ . , '' , . � .. -. ' . ,;" �.�: < �'s.�;� ��' . . . � . . zr �F .i�, .�{; .v`'',a{ . 's.:'�.: •�• . • , . . . , , '.,r ji • , • , , '�:1• rt:•�' ,'�f•:.�,.'� ;:� ti:y' , ,: � .�.i;. . � .. �A' . (5 � . ' . , ' . � . l� . � �' , • ..t••"�:S '�`. '.f 'v .I•v "f � � `,� . "•� � � .i . . .. . . :�r . . . � . . �.,r.t ,., ��.' � it• .: � ry��.if.. � , . � , � � ' . . . . ' l�: '' � i,'..� -i ..i;: ��`.,+.. `I. -{,' ,1� . , � , /�f9'.;: '�jJl. � .! . i "' •.1': �rwf'}•,,,' ' . . , r I . ,. ' ' ' • , 4.�',�� ',i� 'i'= .'ie e�� ,��'�si�.• S'�i �� ' • . . ' . �^" ' . � .� �, � . ' , . � . �s'i� "�: ., .a,.;--��. ' . , � ' . . � � . ;:�: ,yi�. :.t . • , ' i . . . , . . ., . „ . , ,��f�.f�p; � • � 'e: , s . ,E � � • . . , . � . � . . rf �� :as �i. , :'f.` o i1.F., � �"�s.'� .f. � ��'�. . �. . , , � � ' , . . . _ . t' .�.. S. . . . . . . . ' .. �t ' '✓i�' �s.. � -r;;. � . '�. , . . � r .�., . , . • . . 7 ' �' '� ,i e i � '3':�l�..'<' '.i?,o-�:: . , .9 ., �. r , ' . „ . �r 'J .'� -:{�;' �1�MkAV' ;a.t,i:tn:.�i�;�.;!.i<`�}; �i,,��;' �e,:�: �:n.,�� :i� r .r�; . .+ �� , FFiqtfrs�ri-,,.�,,,,, .. .s � .;I.d��uiJa`'>.. �t;:......�.cda;: .,�. . ... , . . ., . . 3.. ... . .: . ,. ., e` , 'cu:. , . '.L��S .. "' , :�. � ,., , r . � - �`� .1 . . . � � . . � . • . . . ��''':: _ _ .. . � .. . .,.,..*a ..f' . . �. . . : . , . � ' • � , , � , . . , . . � ,.. .` ., . ', • ., ,. • ` , � � . ; . ., ' - , � . . ,. , . ' . . . , .; =E , ,, , ; . , , . , � . � , �'_ .� � . � ' ' ' � • , , '.. . , - ; , .. , , : . •' � �� . . . .� • . , �' s . ' 1 , ', � . . . . : . : . � . ' ' � � . '�� ' � , , .� . . � �• ' � ., � � Cal�b,' Wir►��nn ' � • � , ' July ],2, 3.99.L � �: , . , , ' ,. , , , €� : � :. . � , . `� �� W3.R��on ,c�nkinUes ta complai.n df neci; p�in? r•adi��,ilar � ,: ; . , . �ymptams �prim�rily, �� tihe rigi�t upper extr�mity.�� He ,.is � :� � • f'`' '" •� c�rrently out� fram .work. � He� i� giv�� a prescr�.ptiari. �For�. ;, •;• ', ` � Rtib�xin • a�nd wi�l 1 con tinue c�n � IVaprosyn .� We wi l 1 see Wins�r�n ' �• •� � _ . , � � back in� •Fnur week's time '�d che�k his pregres's. He wil,k . � � . '� ' �, , �antins�� nn' physic�].� �herapy. H� does have an appdintment. � � ' �with•:a neur.r�surg�on:. If conserv�tive �herapy �fa��s� •further✓ .' . � ' �options . �wi 11 b� distussed wi th him . ' , • � . . • ,J�aseph. M. Sena,. hi.D. � � , � � , , . . � � � ' • (d,ietated �ut not r-ead ) ' , � , , . • . : � " , � JMSl�vd . . . , " � . . . , . , ,. � .' ,� ' ,, ' : ;.• , , ', ,, .�, .. � �' . �. � � , ' ' � � � ' �.' • . � ' . . . � . . � , •' . � � �� ..� ,. � ' ,.�.. .' ' . , ' - .. . ; .: � � ' „ ,1 .. , . , , , ... < , . , ' , . ` , ' ' ' (. . � � , . . .. � . � . � � r, � , , � . ,. � � ' . �, � �. � ; ., ' ,� � • . ,� � ., ' ' ' � .�' - � . . . . . �. , . i• ,, " , . � .. . ' . . . •. � ,� � � , � .. . .' . . ' . . - � . , . � .' ' • � � � �:, . � � ' ' �� , ' � ,. } • . ' , . � ' � ' ' � , . . ' , - ' , : . �. , ,' ' . �. � . ._ . ,' , . , . � � , , . . . . � " ' � ' ' , . � � . , � . . � � , . � � �. , '. . , � ' � � ' ' � � , , . . � • � � �+' . . , � , . . � � - . ' �: - �, � � , . . , • . ' , ' . ��, .. ..:: . , . ' �. . . ., . . � . � ,-. , ' . , ; , . . ' . . � . , �,'� . i� s', i � .� . � . �.I':; • . � � . . 'i,. . , . ., � �ei .. . �` � ' . � . ' � � ' -• . - 1 ' . ' � ' . � . . . . .. . . .. ��r - . _ . , , ' . � . . . • � ' , , . . . . ' -{' , ' ' .• ' . ,. . ' • , . , . ' ' � , ' . . . . . ' . , '. .�. . . . . . � � ' ' � � • . . . ' . ' . • ' , . ., . . ; . ' ' � ' � i . �, . , , � • : . ' ' � � . ',�.' ., '� . �. .:ti .... . . ' `, . . ' ' .� . ' . ... . , " . . .� . ' � i �- . �' �' . > . i ! , f . ' . . • . . ' ' - . � ' � � . . ; ' . . � 1 . � '' 3 }' `� � . . . � , ' . , � '�' � , ' � , ' • . . ' , . � • : . . . . 1 �i ' . . '� ' . ., i� ' , . � . r ' . , ' . 1 . � • , C; � � '.� �'r r. .� : . . . ... ' ' ' 1' i � . . 1' ' , , . . . . 't .SY'tfe�' �'r;`�a �l� ' ' ' ' � . ' ' � r � .. . ...� .�. ,... . .. a.w . ..'.r. ',1: . .'.)'�. � 1:'l.w s._ , � �. ... � . , t , � . � ~ , . . , � � . .. . , �i � ' , . . ' � ,. �i r � • . ' , - . .. � • . � . . � , ' � � � . . • , ' . . ' t r}�3{�� ' . . .. � . • . . . . ,� • � ' ,!�i;{ . ,�., 1 � , , : � . , � . � �t��r�: t, ; . , . . . . . , , , 3;'� .: � Wins�vn� �aleb � . t1�y �., ].991 � � � . ` . � r� : . . . - . � � ; Caxet► �antfnues ta na�e n��N. pain, rad�atxan af da�scamfart �-n ''+� �he r,�ght arm �nd farearm. F i.� c�an�xnuin � h�' 4 '� � . , � �r# ' • °. for hern�.ated di.sc and i�s pla�ec4 an Volf�ren ifi lieu f � ,�j.�� • � oc�n. . e a.s p ac� , on �t bi.d with meals �nd mi1S�:. � � _.:� • • ...,..�..r.-+ � . � . . . ' . ;� a7C75@pi 1�'i ■ SQflc1 y ("� . i? w' , � ' ' • � (di��aEed tiu� not r-e�d). . , '�;� � .7MS/svd � • , • . . �'��# � • . . • , , ' . � :�;;: � � �z: i .v� � ' i ' ,�� h � , _ . , . ',.r�i�ir'j��.� ? . . �'_" «.. F'� { (p � � i" � ! /� � ��C..L. � (�"JZ•'i% C�C�-t ` . , , . , . . � . / ?r'� , � „ • : � I �� /�/ a� � I/� t: ^� 1_}..�.�C � .E � t. , �' . ��f,,� - V . , —.. ',. �; ! f ` � n �.c�c� � :..; ��,.c..%Z,�c.1-t.Lc.t..y �' � - � � . 1 � � �v,'�v � , , / � E � � ' . , . � � . ♦� ;;��I . • •• ♦1� ' �-i�1 • � � �� . .. � ; � , pt�". �-#�� ' �,�(��`;� P� �- c�.t.�� .,_Q , ;; 1 � . . y_ {J . �. . �%L/�...1 _' . �•-}{ � ��`�-t� ��„ s:�„_L� y vl-c}�""�- �—c� --, � xi u =f d4� -'r `. (/�� U . � , ��✓ �"�'_l G�J G Y 4 � � � ! Z �� . �r.� � � �, . 3 ��-y� � � �.. � �} . q . 1- � . , � . �� J�. � h.� . o � c hl ,1,�,� � �"'1'e+� f V'T f[ Wi �•~ �'{ n�j �v-t � � ��j �.L � � �.�1-�L�.- ` . , � 6 .�� . � � t . .� �--� �te.�. � z. �� .•-� � � ��cj �t �t.._1 �J`�--ti-� . . � �, . . � . � . ' , � ��Y - � �� . . ' ' � " , . ' •��;e �' �`' .� �'f�.� .. .' • r .. 1 i � ,1 . ' . . 1 .. . . . . � . � .. � ' . t ' . ., ,. . .. � ��. � i� �J, � • ' . ' . . '.� .'I 1 � . ' , ''- ' � ' ., � � � � ' � � ' . , � ' . . ' 'F I . � • , ' • ' . � !� . , � , ' � ' .. ' . � . . •,r . . ' ' , . . ' . � . , ; . ' I � � . , � . . . . . . . . � ' . • , , . ' i e � . . ' ' .. ' . . . . j . ' . . . . �`� 1 ' . . � . • � � . . '• . ' • ' . . ' ' � ' . 1 ' ' � � . . � . � � . . . . ' � � 1 . ' ' 1 ' i! . '�" t1 �, • .. . ' . i . . � � � . ' � �. . . , , . . ., . .1 ' . � .. ;��',1 � • • . 'i '. �; . , • • � , f ' � � . ' , � � ' , . r F ' � .�. }f � � . . 'y.'';: , � . �t' ., . . ' ,. ,' ; ; .. ' . , ' ' , ' • . � . . .. , . , � . . , . • • ti� ' ; ' , , , � , � , . . � . . � ,. � � , . . , :' . , :� 1 , .,' . . .. �, ,? � .�tf4t1:..:�.el..•e.i''t..ic • . . ' 1 . . •. '' - r• � � ��1-.i'}=;� ' ' ' ' . , ' ntervl�a5'.`4�r .+ wv..��h �r�a� .r.. ��P'i'KY:.:ti.��Y . � . c ." 1.>iil�'r . n. . . .� .. » . �.... .. . . . . . . . «.f •� . .i � '.i.� . `1 ,.. , �.. . , � .. � . . ,ir � ' . . ' � . ' ' . . . . ' � . . � ' . ' ..'1• , . � � . , . . . ' . , '�, � j ' . , . • . . + � . � � . , � � . . � . . , � ' . ' � . � • • � ' ' , � �� .�r��. , ' , � . . ' � � ' ' . � • . , ' ' t . � ' 3�' ` . . • . , � ' � . ' ' . � �! . . � , . . •��I . . ' , • . ' � � i �' 1 �. . . , � . ' � � ' . . . . i�l . • . :�.� � . • . , • i ., � � . . ) r � � l�linston r C�ileb . Apri 1 17 � ].991 . , . � . . , . , , - . . . . � ' , � � . . . � � �. Cal.eb� is' n��ing �ec� pai.n with �some r.�dia�i.an ta th� upp�r � ,;:�.j' .. e�c�r�mi�y. He i.s'�placed on ].3ght ci�.t�y w�,�h�di�►qntisi�_ af �� 'i':�. .• h�r ' ated vical =da,s�. 6ie wil l see him �ack in .two w�ek's �. . ' t�,me. He is tUrrentiy cantin�ti.ng phy�a.c�l therapy. He is � � .. ' ,placed an �ndvc3.n as we11 as Flexeril. � � ' ' , �Jcrseph M. Sena, .M.D. . . , . . idie�ated but � not re�d 1 ' � �. , ._ . , ,. . . , 3 JMS/svd , . � � , . � � � � � ' (r� 1 '^j'�`^ �J ' �5��- C,�-� �'�-�.-� �_¢~"f l � . , �� . ' • ylj,,,.�.. �I�-�....�J , �.it+.-J� r ►�►.�i"� ��.--..� , �`'.� �r��-.,. � CJ � � , . � � . , aG Q�-i. � �- •-�-�- �`^-� �^-� � �r d -�lr � � -, (�'-� b� w-� . � � 1 ��+.7�^�f ° _ (• V l.�l� � �� ~� t �/ CiY' � � W1 �. F , ' � � �.-� �.-, �. � �►t �..�..� �..�, r�,, , � t . � . •:, � . I#� • '� . � - ! "� V'�+�� V z� J � —'7„'�`�'��1 1 C� ��,f J -.�r��,`^u � •i. . , � . -�:yj�, --..r,�...�}; : �.. .,�'`�?; � ; J �; �--_ C.�-�-�.--� �� ...� � � C.�� 3KO� �-�� s...,��-�-, '! `: , c,:.}�-n.l� �-�.��r � � .� ti.,,..., �. s �. � l � j �,_,"_.�-�-, � 7 .. �-- , � s � �J ; , i�e�. �,;: tn�'r-' •-e ��1 i1 �—..J � �,.a.�-� w a}' C r. _ C,' i �7 � ,.Q � C.r.. +c c� !!' 3 . . ' � � ' . . ' � � N� � . • ' .. ' . .� " � rf . . ' ,. � � . � . . . , ' 1 • � � - � � . i� ' ' • . � . . . . ' . ' . � ' , ' e ' � ' . � . . ' • '� : � � � ' . � . I . . . . . � ' � ' ' ' � � . � . • , 1 , . , , � � q . r ' � , . • � . , 1[ r . , . � • . ' :1 � � . ., i, . . , . . • � s • , . • � � , :1 � ' � . :,I.�. . .. � � , , . � , • 'r. . ' ' � ' ,. ' � � ' � . . . ' , . ',In-�?,' .�_��._ . �.. ..:�i- . , -,. ,a� , �. � .rC � .. :t' � . . . . . ' , . . � 5�"� ( �'F' . .. , . 't. . ,. i �„ . � � . . , . '1' , s • I } . . ' . ' , � � • ' . . � � , . . , � ' 1 '� .. . , � • . ' � . f�.� . . � � , �.� ' . � . ' ' ;r. , • � ' • .� •, ! . . � _:�� Sat,��i . 1 � �r`.r��.� � � ; �tt � . ''��.� � � ' Caleb, Wine�on � � , Apri�, 05, 1991 � �• .� ::'.'.;> � �. � , , , . �i ��.; . � . Thi,s fs a, 4�! year o].d �na�e �aho sustained injury to h�.s neck . ��'-F , �trhen ehoveling a� vrork Kh��.e �:;o.rking for the City af � �� Ciearwra�er. He no�ed sensatian af sudden'pul�ing in the � �; � neck fe].t across the righ� • shoulder and down the right arm �� ': � i . � b�lax �th+e l�vei of the elbow. He compiains of cont�nued , • ��,', ,. � neck pain and notes �ome parESthesias of tha anterior aspec '��.;; . o� �he right ar�. H� complains o� increasing pain x3th ..,� motion of the neck. . . ��On physi�al exami.nation strength of tihe bicEps,is dif£�cul� - � � to evaxuate on th� rigitt bu� is �a� l,east g+ secondary �o � , �' �.. . 3ncreas�ng pa�n. ,xith extremes of � forceful contractiion, i . ' � tr��e�s l�.kewi,se. Streng�h �oP �he Kr�,st Elexors, �' � extensars, abc3uc�ars of the digi�s ans� gri,p s�rength are ; bila�eral,],y intact. Reflexes are diffa.cu�.� �o evaluate � ' secondary to �he pa�ients inabiliL•y �o relax. . ?Ctays af �k�e cervi.ca�, sp�ne ar� revi�wed and are nega�i.ve , £or k'racL•ure or dis�ocation. There �.s straighten�.ng a£ the ❑erv3cal �pine not�d an ,latera.� view.' �Crays of the ' ehouldex ar� perform�d to�lay. � � ;�� ]Craye of �he shouider, AP and axill.ary v�ew c3o no�, reveal evicience of "frac�ure, dis].ocation �z s�gnifi'can� L, degenera�iv� changes. . ' ' Jaseph M. Sena, M.D. % (dicta�ed bu� na� read) j JMS : k�f � " � :�� c� � � `� � �l � ��-� � �-' 1�`.^.��,,.�. � •`�: , t�.�.'-L� �`.,.a`�� C-� ° �.� I- c e� � �'� l � .� w�._,4 , ,�.�•�-.-_ a,�..,_ � ��-c.�.,� . l�� 1� �� .�1- �F v� �- rI � V� r� r.�c.� F�-�--�`- _ � •�-t. ��T'� � ! � �,�->,.-i �'J f �s. � �'�-„ � iy�, ,�-.'A CJ'��t �L l l, ...�, �'`--�- • , ' , � �'ti � ��;� � `l I � �� `'� �.�' �-c_.._ ��" C.a -�,,t �,,�.! (� � S � �-�u� i � � C .� ` `� �� ' � � S e 1.. G-� C_�-�-�`�"�,1 �,� �i e: -i-� � ` �- �"L �,�„ � . L R- �` F � : -1� y( � r%' �. � �� O' 1, �� 1rE.' ��:In,�--. �[ i'L'�.Z ! C•. �:. .� C`E l. -C v-� �,v u � '• � � '� �'�' �. s � , . , . ; � � .. � . . , �. ` ' , .. . , , _ • . : ' . '. . ' , � . . . . � � � � � • . `' , ' . . . ' „ ; , . 't 1 . , • , . . . , ' . • � < ' � _ � � . ' .. , � . . � , 1 . . . . , , . . ' ' ' .� ' • ' , ' 7 � ' ' � ' • . ' i. / � . . . � , � , � . � � . ' ' . . ' � , . . , � ' � : .... � . � . . • . . . � - , ' , ' • . , ' . ' . , , . a _.�.,��. � � • . .. . ..�I.�r�l.�ibF. . �.jie+:5i' ..r..� . . 1 • :1, . , . ' � . ..,� , � � 'r I ' . . ' � ' ~rr` • ' . ' �.rti . h . � , . . � ' ' ' � . � , f ' � ' f . . _. . 4 � , . ' . � t' , . C� T Y C? F � C L E A R W A. T' E �. ' �, � � � � , . �� . • � : � � � ', . pOST OFFICE BOX �t74B . '` - . CI.GARWAT�Fi, FLORI�A �'•t618•4748 e . • '�0: �s :..��.� �• •-a � • DaTE : • .r.�, `" �l " �'` , ...._. Si1BJECT: Re�quest ,�o� Medica3. 5ervicts -�,Florida . �7orkars, Gosa�casa�ion {FS 44d,13) . � ' , , . .l�f/ •'''�`--- ' . ��iF'LOY�E �iaPiE: �t�G�� -.-�-y ' �Id_ `�--- /�-� 9/ � EMPLaYEE SOCx�L' SECiJKITY N0: ' . You are herehy raque�ted and aucharized co prov�de SCx'V�CGS v�ich are medically aecessary to diagnase and/ar �,eac ehe abQVC-named individual as follaWS: � _1�--Q � . S�e are enclosiag all madic��Z noces ia aur �il�s relaced to the injury af the above date. Th� cmploqee has been inscrucCed Co br:.ng al.l X-ravs ca the appoiacu�euC �ar qour reviev. � � Tf �skdic�nea are requf.red aud prescribed as a rasult of yo�:r LTeaCmeat or diagnosis, ci�e prescripC�.att med�ciaes may nuZy •be o�catinc� Era�a .Tae� V' . J�r _�, s • � If inedical supplf.c3, durable raediCal equ�Ermcut, orthoses� proscheaes and ochc: medicall? nacessary apparaCus are �equirad aad prescribed as a resuls af yaur � � Creacmenc and/ar diagziasi.s� they m�y be a�caiand onl.y �ith prior aroroval o� Cicy of Clearwater/IndustriaZ Nurs�� Phcae: 462�;675b. Uo�n co¢tnletion ef Yaur services, instrucL the aCienC to return co Cit of CZearvaterltnduasr�al Nurse. Prcpare an appravecf Heaith Insuranc� C�.aim 5orm and subc�it iC co the address sho�t� a�ove, c!o Industrial Nurse� no lacer chan Cen c�a) days fro�a date af Chfs le�ter as req�i�ed by Flar�da StaCuce , ' 4b0.13(Z). Failttxe co compLy c�iCh the above may result ia non-gaymeat of clai.m. " " �_ �..�-� c.�— . Sincerelyt . :�l • � ��.�� y� � • . Nancy Degnex, R.K. � . Industrial i�urse cc: Gallagher Bassetr L�nsurauce Service9� Inc. � � SHOULD '�REAZ?lENr BE F�R A CnNDITION N� .IC1H RII.�,TE�, I� I5 T'F�: �TI,OYEE' S , I ItE5P4N57BiI,xTY TO PAY T'i� BILL. �7�SC� x z -- ' , -f: . . ' � �/I.2 Gua,.� ►�+.tao e.eQ�Glt �. ,n ,(io _.,.,.f,�_ . "�qual �mployment and Ailirmative Action �mployer" . .�.�..,. , _ . , . . �`. .3. " ,}. . � ' . ' . ` , � . � ' . , 1 : F � . . . . � ' � . � . . . � ' . ' . I . � � ' ' � . . . ,� ' � ' . . . . ` .. • • ' , . � ' . • ' . � • [ � , , � 1 ' � ' ' � . � � � , � • , � , i. � ' , � • ! • . � ' � i , . , • � I , , r . . � ., , � . I . . � � , • ' ' . ,. , . � ' . ' • • . f � . . � . . . ' ' . ..,. .,. ,, . ..,.. '.'�F41.ti,:i�. .�5.�...,e , . ... �.'i . . � ''� .•. .' . . . , •� � • + . ' • , . r�' ' ' �, +.1 .. ~ � � . . . � • i . �• � � �~ . • � • � , '., . � �' ' �, � � i � � r �a�� , . , � . , � . � -4 3E CO:�?.r..-�..::.7 3Y �:' �'..V�I:IG ?s'.SICis;.2i: ' , ' � "JYaG�;DSiS: ��- ��" J . �_hy �.� i : , r^ cZE..'+.i►R.ECS: — �/"�� __ C_� �-' `�Yr �—� • ' �� -�- - - .L�I.y i.Q �=LTA.� :4 L�G:.'L;s2 '�[Ti`.'^. n' :i0 i � 'w-i'i��T? �18 Y.: ='0 .�.,'�. ; �t .*t � 0 I. � G'ci _ � {J�'" - �..,. �E5��C.?CNS: , �", ` r � �. �— � .`iE.'{: �i2°flIV'i:'.r:IT �S: .� � •" � t �� s;.�.t�D: r � W. �. 7T :.2��G .�.r.TuLZit �.7:lD� ""'� J :(1i�f "'O � 3"' :'�;"' , . r � ' • � ,. . „. . , .' f � . . .. � � t i �'. ��« � , . �. ` 1 . ! � � ' !- � .i , I C�. E A R, W A. T E R, PqST O�FlC� BQX �7�0 CL�ARWAT�R, F�QRIbA 3a6�e-a74s DATE: ��/'z �� Z T i sVHJE�T: Request for Med�.cal, Serv�ces -- Florida � Warkers Compensa�iot� {FS 44a.13) EMPLOYEE NAME: „_...�( _v? /��J G�I/�'.'�-�'�� DIA ti 1 r'�2 "� �'l � EMPL03CEE SOC�AL SECURYTY NO. You a�e hereby r�gue�ted and authorized to prov�.de services which . are medically �ecessary to diagn�se andJor treat the aboue-named indiv�dual as falJ.ows: � �i/!r-t. (/I" . We are enclosina al� medica�. nvtes in our fi.Zes related tA th� a.njury of the abvve date. The employee has been instructed�to bra..ng a11 x-Rays to the appaintm�nt ior your review, ,If inedzca,nes ar� r�quired and �rescribed as a result of your trQatment or diagnosis, the pres�r�.ption medicines may only be obt�ined from Joel. N' Jerzv'_s, If m�da.cal supplies, dura��.e� m�dical equipment, arthoses, prosthesis and other med�.cal�.y necessary ap�aaratus are required and prescribecl as a zesult v� your t�eatment and/ar diagnosis, th�y may be obtained onJ.y with ri.or'a�ppro_yaI o,� City of Cl�arwater/�ndustria3, Nurse, Phone: 4G2-5754.' '(Ipvn c�mp�etion of vour serv�ces_�_ instruct th� patien�. ta_ return to Citv of,clearwater '�ndustrial Nurs�. Prepar� an approved Health Insurance Caa�.m Form and submit�it..to the address shown above, c/a Industr�a� Nurse, no later than ten (l.�j days from the da�e Qf this ].�tter as r�quired by Florida statut� 4�0.13(2). ` Failur� to comp3.y wzth the abvve may result in non-payment o� ci.aim. sincerely, � �� , � .,�,,�%�- � ncy Degner, R. N. � . ' �ndustrial Nurse cc: Johns East�rn Campany, Inc. � 8HDULD TREATMENT BE FOR A CONDI�z�N NQT JOH REE,ATED, IT IB THE EMPLOYEF.' 8 RE�PONBTB�LI�Y TO P�#Y TiiE BILL. � � , � "�qual £mploymenl and Allirmative Action Employer" ' �;F .�, . ., 'i: '. . ,. . , , , �. ' ; ' ' ' . . ' � � ,. , .� , , �S � ' � , . � � , �r ' . � . ' , i�! . � • � • . . � . ' . � ' ' , � ' . . �! ., . . 1 � !1 � ' 1 ' ' . , . ' � ' �. . . . . . . • . ' ' , , . f � � � 1 � . . . � I ' ' � ' ' . . • ' . 1 � , � . . . , ' , • � . . ' ' � .1 ' ' • , � I. ' ' . , i � � � ' ', � . ' �. ' , •, � � • . . . i . � . �, . . � ' � ' ' �� J .' , I . , ' . ; '; ' , , . . ' . . � , : � � . � . '�t.; .. � , . . - � , � i , .. . , ,� . . , , . ". . . ' ' ' .': ,. - � . . . � ' � � ' , • ' . . � , ... ' . , . , ; , , , , , . ' . , � , � _ ....� ..., _ _� :r,.�.:.�::��:� .-'j�f' �r7�,;r��,�..... � .. ,�p... '�,. , . , '3`,. �., .. � . ' . t � , • . ' ' � � � , • ' . . , • , ' � ' . . � . � � � . � ' � . . �^^ : , 'Pag� �!z�, ,� . . . : � �Td SE COMPLETED HY.ATTENDING PHYSICIAN: � , , , , , . , � � . � ��A�NOSSS; _ �� `' ��-�-�/� -- , � - - • -- .. - , . . . / � , TREATMENT: �� /��•u-� ' � REMARKS: ABLE Tp RETURN T� REGt3LAR DUTY : `` �`1 �f A� IF NOT, WHEN? ASLE T� R£TUFtN TO LIGHT DUTY� ��5. , RESTRICTIQNS : ��Uo�� /_ �f ��.. �_ �- o � � � • NEXT APPOYNTMENT TS : _ � /Y�--' .. _� / 1 f .. ' , SIGNED: 0 0 'PLEASE RETURN COMPLETED FaRt4 TO PAT7ENT ...... `. ... . .. ,. . : . .. , . .D, � ' . .' � : , • , , � . ' � .. ,. .�. .�, ,. . • . � , t ,,.. � , ,� . , . , , :. . . , � � � s . � �U1Ca ,...i7 � �1t�.ELLQ� c�.1�. � c... r �dr�., Jn-,.� . • NEU�CILQG�CAL. SURGERY ' � T31pi011�t�t?'Lr /tMl.'RlGAIi . �4� CdREY AV�UE �ouwor sr. f�CYE4i5qURG kIEACli. �L.�RidA�37C6-{�1t3 NEUACLGaiCwL 5ufla�qY • , 'T�a-�S'�iONE C[s18] �G7-4593 .� May ].5 � 1992 3o�ept� M. Sena� M.D. � The OrthoPedic Can�er o� Wes� Flo�ida � Sui�e zox 955� Secuinole' Bo�Ie�a�d • ' - . S�mi.nole � �'L 3 �64� _, � � RE: Cal.eb Wins�an Da�e o� �xam; 5/8/92 � ❑ear Dr. 5ena» , � Thank yo��very m�ch fo;r re�erring, once again, Chis 46 year old. zigri� handed, hl.ack gentl.eman for a£ur�her second surgical opinion. _ As yvu may recal.�. the patien� aas originaliy seen by me on . Novpmber 4, �991. Ak �har time, he gave a his�n�y o� an injuzy on the job uhich acc�rred in January ].99Q crhen he Picked up a gaxbage can and deuelop�d numbnes� invol�ing bo�h arm� assac�.a�ed trith �anstant neck pair� radiating to the head. He suFfered a second on-the-jab in�ury� on tt�e 12�h of March, �991, uhen he �a.cked up a 3oad o� shells. Fo].loving the second inju�y, Lhe parxent uas back at uork anly far:: one veek. He ha�s beer� incaPa�it�red by severe neck and �.ow ba�k pai.n despi�e �he admini.s�ration of appropciate medxcation and phy�ica7, thera�y. � reviewed an MRI aF�the cervica], spine obtained in Ap�il 199�, uhieh I �r.oughti �vealeci •• @4'xc7ence of a mkaZ�ne disk he�n�ation �at the C9--CS l.eve�. as we�.l as disk he�na.a�i�n at• the CS-C� Zeve3. mastly ort �he �eft side. _ " This patien� had �eVere xmpairmectt oE �o�ion range af cQrvical and tha�acolumbar spi�ne, which Were not associated With signi�icant .muscle �Pasm �n either the cervical or the thoracolumbar region. Othe�wi��. hi� neuxological. exami.na�ior� �tas saithin normal l�.mits. The'pa�ient appeared to bc overWeight. He had a pa�t h.is�ory of insulin o�:�ender�t aiabeCes and hyperten�ian. , . � thouc�ht that rhe patien� mi,ght ha�e �a��en�ed wi�h ' syu�ptow� consis�e�t ui�h�•:unresolved c�rvical and lumbosacra�. . , . . . . , � � ' ' ' � � � .a . , ' � � ` , . � s� . �. . ;...+. ... i . � . . � Jase�h tf. Sena� May 15��I�9� P�ge 2 , RE: CaJ.eb Winstan � f� , s�rain� and recomraended �hat� Eor'aake of campl�ten�ss� a CT myelograui con�c� be con3�.dered to c3arify �he diagnosi9 in a more ' defini�i.ve and objective fa�hian. . � �he patien� re�urnea to my of�ice on 1�he 8�h o� May, � x992,� aitYs.vir�ual�y the �ame complaints. He a�aked �har he dxscus�ed �he p4�sibi�ity of harr�ing a CT myelogram W�.�� h�.s fam.�ly phy�ician b'u� sras adviged �a ' de3�-��e th�m i.n vieu a� th� . accurrence of a caraiac arrhythmia,.�uhich haa de�eloped'in tt�e in�erim. . � ' �3is . sympt,oms a�ce sro�9e� pa��zcuiarly headache� a�d ].aw hack paa.n a�sacia�ed ai�h pai.n radiaGing 'dovn �h� 1ef� leg aggcavared by �h� Yalsalva'� mane�ver� . Neurol.ogica3 examina�ion revea39 i.ntac� cranial nexves and normal gait �ith �he paCient being able ro ualk an heels ar�d'toes srithout dxf�zcu�ty.� Huscle �trength i� 5/��throughour, and �here i.9 no evidence o� mu�cular atrapt�y. The stsetch C�f�.EsY�3 are �ymmerri�a�., and t3�ere are no patho3.oyica� zef�exes. Coordina�ior� i� no�mal. Sensa�ion �o pin �rick is c�ecreased o�er rhe iet� arm and ra.ght foreaxm and vibrarion is stzll decreased �hroughou�t the ].�f� arm as we�1 a� ove�r the le�� side of the sternum. Range of motion of cerv�.cal spine is as impair�d aa it uas wh�n I or3.ginally 3au the patierit�. Range o� motian of �hnraco3umbar 9pine i� al�o o� �he�sanne degree as an November 4, ].99�. Y��r th� patient has no zmpa�.rment �f �traight l�g caiszng in �ithet �he supine or sit�ing position bilaterally. it is �ti1� my imp�ession Lhat the patien� prese��s ..wirh fi;�dings c�n�xsten� uith unre9olved ce�vical and lusn�osacr�il � straina ui�hou� �vide�c� �� raai.culopa�hy.. I do not be�ieve �haC �hia paL�en� �.s a surgicai candidate at the p�esent �ime. ' F3ecause of tha long standing nature of �his patient's symptam� as�oca.ated v�th MR� abnoram�.itie� in the c�rva.cal s�iner i� is � a�y op��.on that the patient i� mildly par�ial.ly dzsab�,ed. He should be 'ab�e �o return �o Work� at 3.caa� on a part time basis; tor the time'being wi�h �im�tatior�s as �o bending, squatting, and li��ing weight� not gcea�er than 20 pounds. , . ..; ,. , .,.. � � . • , .. . � � . • . . � . . . � .f . . . . . • . . �� it;3.:'+ .. . � . .� , . .. ; , , . � . . '' • . ' • , �' ' , ;�,' , . . � '. � . . ' •, . � ' . .. , ' , ' • ' � • ' ' • ` � . I�', ` � . � � r � � .. � � .1 . ' . � . ' ' . � ' • . • . . � . .. .h' ." �4 F' . ' . F��. . � , , • � . .� ' � .' . . ', , . � i � 'r��' ,'�1•�..a " ,'' �.t .. . . '•f:1' ,;�I . , , � � ' , . � ' . ' I ' .'� � ' �5. . . 1i�� . �'; 1 . .. '' � . . �!. � . . . . . . � il ' . . . , . . � ' �� . ��fF� . i ,�,� . . �i :.. � .1 �Ej ��;l. �1 � � i t. ' . ' .' `' � I� ' � . . ' . , ' , ' I ' 14 . � .'r`' ' . . - . � .. . � � ' � , • . . . . , ' ' . • . , r ; . , . ,'i` ..,,��F� � ' . ' . , , .. ' .. . ,',f - ' • ' , ' , ' ' . . � . , � ' , + ' `i, n�.. !!1• ` . . .. , „r.e�xa'i�wz� 1ii4t�'}{;S"fltx<:. +-.., ,. � t . . ! ... . ' `�° , ,'�:' E. 1y;1; t��.,.rP.. ' / .: ' . � • ' : °�� . . .. . . . . . , . ..�.,. I.e � . � � w . � . � . . , ' ' � ' � , . . ; : . . Jo�eph M» Sen��r r. � ,: � , �� , , , � . May� �5. � �992 . , . � . ' � - � � . � ' Paye 3 � � . ' . � � : � � , �. , . . , � . � '. � ' � RE; Ca�eb Win��on � ` . ' �.. � . � � -� � ' ; � .� r , - , . � � . . � � � ' � � � � , . , � . i� • � ' ' � . • ' � . � . , , � • , . ' ' , ' . . . ' ' ' . ' , , , � ' ' . ' . . . � �• ' , . � � Tn u� o inion. �he . � � ' . � , y. p pa�ien� • may he ab].e �o benefit ' fra�i a� �.° ., houte �xercise ,program but, probably� no EarmaX therapy i� �ne�ded. ; I.� �' � �� '�� z� ° raX QpinS.on thak the� pata.enG' 9 pezmanen�, da.sab�ili�y � � �� cating �is . �a percen� af �he boay as �a uho7.e. � � � � ' � . . . , . � • , ' PZease �.e� me knou if z can be o� �urther as�istance With . t �;� '�he 'managemerit and/or eva�uation 'of ;th�.s paCien�. Thank you� I :. . . . again. fo� yauc ka.nd � eferral. , ` . � • , , � . , .' ' , • � ., �@L"y �rUlj► x'011r3 � . . i. F . ♦ '� . , . � � /�;�� -� . . � . . . , ;. , ,�� Ro�arxo A. Musella, MD,�FACS� PA . • , . � � Clxnical Assoca.ate� Profe��o� ' � � . � ' . , Depar�ment of Surgery , ' . ' �� • . � Univ�er�iCy of south �lorida : � ' -� (S�.gn�d�. in ab�ence �o � � , � � � ' � . avaid de].ay. ) � , , . . . , , , , . . RAM/ac ' � � � '� • ,. , . � � � �. , , � , ' . . 4 11 , , I • ' , / �....` .. . . , .. . : . . ' .. � . '3.';y� .1: . ' , • . , . �' ' . � ' � . . . . . . . . , , , . , � � � ' r . , , r. , • . ; � . �� „ . . � ,, . , . . . ' . .. . . . , 1 , i � . , . • . . i . . . , . ,' • .� � ...�.i...... � . i . . .-. ''.R:� '1.� JIf.F3,"�.5[; . �. . . .. � �� nY 1 ' (/ i e �� ' . , J� . ' � . � . ... . . �a/ . . , � . . , , , � . ��.� . . � . ' ' . . � ��r+ �� , , � R. A. Ml15��LA, M.O., F.A.C.S., �.A. � . � ' 2�7' Car�y Rve�tue � � � ' ,�� tti �' � St. Petersburg Beach, Florida 33706 � � ' � (813j 367•459� , :o �� ca:�L��:.� 3•t �::=:lnzuc ��szc:::r: � , . � . �T��Yn��$. � . �`__,L��'�,�'/!�1—��.7 /�� , � y C��-` .� � . . � C.� s - � . . . .- . _� �:��:, � : ��1� � �....:__c� i" �� _`�� L� �� j �E.'iARK J S . �9L4 :Q ;�E:Lfit,v :d �G:,Z..;A �1l'�':". ..,. —_�!'! � _,,,— --., . .,.,_ �..r �roT, �x��? .— ..�.__ � IILu��C~/ �iZf'f�/'Ii'G-,/�__ __ �,�,sL : o ��r�v � o r. �c� � � tr�' --- �� , _.—_ ' �s:�:c:_cNS: �9�li o r � /�- � 0/2�� ?'/.� `t/ � �,�1.. ~�...G �-s �.._.�-.',��/p i _.S"T�r�i ]_ - �2>_?- ��G.� �=� . G a!�/ �� TZ T��iU /5' .�/�/ rJ 7'� f rj7 ?' 7f�E 7`l �?�' .`iE.'{ ;. �3 n OI `i i"`: L:1 T E 5: W � �,i1 �%`/�li'�� , d� l��o �� r HC/li7---� _- �f� 7`/�= /�/ 7� S E�GU �� iZ S'�F�o. dv..� . a �� S I GYED : � ' ..., � _ I`� r ` �*�`Z--�'�� _.... •`:. D . �r =r,Sc �.E:'11c��I C�:!nL— �� =04:' :'p ?s,� _,�._ . . �wt� � . . , . �, ' . ' � � ' • � . , , . �r a V �.. 0 � u ' ' �Y �� 1 �� l� ��ontur�, c�'t�ivarz; ��onz�Za �' �i, c/i1�.1�.; � v�. �fa�+c�r a. a•�cnyr�n�, M.a. C?QNALD C. S1ILLNAH� M.C?. MICHAFI t]. $LCfMKA. M.C}. HqG+aN G._yr, M.1]. Sr�vEHi e`wapaEN, M.D. � 1�cnx n,��ainE r�uu�tty �Oi►sF c,�t�nccm�nt rsuv�cty ��,p� ��y . cS�os�t c1��r�inc ORTHOPEDIC EVALUATION. n,p�,o��a�s nF '±HE AMEptCAlJ BOAFiC] OF aRtFtQpEQIC SURGERY Please �eply to: � ' ' Re: C�leb Winston • - 4ur Fi.Ie No.: 03525 . A�A: 03J�2/90 ' Caleb W,�nston was seen �and eva?ua�.ed an my off�.ce on Auqust 31, 1992. �'he patient is a 4b-yeas--old k��ack ma�.e who i� 6'1" tall, we�gns 225 �b. and �.� r�.ght�handed. � He states that he was warking as a groundskeeper for �he City o� C}.earwater and that he was in�used on March �2, 1990. At that time, he was trying to 3i.ft a garbage can that was f�.Z�ed with wa�er �ta�fway �nd he states that he s�i�aped on the concrete, �.ost contro�., and f�ll to the ground wa.th the garbage can behind him. He had immediate �ain at that tim� and wa� seen on M�rch 15, ].990, by Dr. Pat�rick Lague. He was start�d on physical the�3py and was qiven pain medication. 1�e had severax Cortison� injecti�ns into the neck area. He was gzv�n Nap�osyn and was 3.a�t seen on March �9, �99�, aft�r a}aout a year of treatmen�, He was next seen by Dx. Sena who ref�rred him �or a MRT scan o� tUe cervical spine. The ' MRx showed bu].ges at the C4-CS and C5�C6 iev,��s. These are bulg�s or very smal� herniat�,ons and as a resuit of this �inding the ,paticnt wa5 p�a�ed on a cervica�. co�.lar and a TN5 unit was �r�scr�ed. He wa� �a'�er seen by Dr. DeSousa and had nerve cond}act�.an stud5.es done which w�re som�what equivocal. He was axso seen by Dr. Musel3.a who felt that no surgical int�rven��on w�s indicated. ' •• Tbe pat;��nt states that he now hurts in �he neck, upper ba�k� lower � back, right shou�.der and the l.e�t sh�ou�der. He states that his pain is increas�d w3th standa.ng, walk�.ng, b�nda.ng� �ncreas�ng activity, lying down and sa.tting but r�ot with coughing� sneeaing or bawe� movem�nts. He i.s most camfortabxe lwa�king ,and is uncom�ortable bending. He deni.es prev�,ous accid�nts or �.nj�ries, although �t is c3ear from h�s recnrds� avai�ab�.e to me, �hat he was se�n by Dr.'Logve fln August 2, 1989, for an injury which appears to have b�en the injury descxibed above, �xcept zhat this occurred on. ,7uly 22, 3.989. It woul,d appear upon fur�her exarnina�5.on that accidents occurr�d on Ju1.y 2Z, 3.589, March i2, 3.990, and February �.1, �99I. a0p0 pARK STREEi NOFiH S7. P�TERSSUFiG. FLOR�flA 3370Q • PHprd�. {613i 347•1?86 26a5 Fi�7i�i AVENUE �tORT?i • 5i. PETE�+S6URG, FLORIC3A 337t3 • PHDAt�•18t31�23•28RH • � r i y �: �• �• � • ! . Re: Ca3eb Winston , - �2 '-� . � � ' , Aug�s� 3]., .1992� . . . . . _ • ; � . . .. .. Eva3.'1aat�on revea�s a larg� bl.ack ma�.e who is 6' 1" taal and w�ighs �� 2�5 �3.b. H� wea=� a TNS unit •in the cervical'area. He walks vex�y. • verx slowly and moves about �very, .very slowly.' He is vex-�r � d�manstrat�,ve about expzes�ing da.scomfor� and,appears to exhibit �. a markedly e�agg�rat�d pain response. • He haa dif�icu�.ty witu . walking on th� heeZs and ta�s but can do so, T�ie Trendelenburg � t�st is accomp�ished with di�f icu�ty and��is negative.- Forward . �lexion is barely begvn before � he complains �f pain. Likew,zse, �.�ft and r�.ght lateraZ bending cause d�scomfort at only 2D°, each. • There is na spasn, ?here is pain to pa�pation from the neck dowA ' to the sacrw�n. This pain is present even w3�en x pa�pated tb� soft tissue of his back as lightlx as I could wi�h my own small fingez. and, in fact, he comp3aa.ned of pain when I pa3.pated the area with a Q-tip; Stra3.ght leg raising wa� to 90° in a sitting � position and t�e patient complained o� severe di.scomfort �nd grimaced at 20° o� straight �eg ra�sing in the supine posa.tion, both Ieft and right. There is total weaknes� of the great toe dorsiflexion bi�at�rally. There were nQ dastinct sensory de�icits The weakn�ss appeared to b� vo3.untary, - � Examination o� the cezvical area again revealPd a markedly exaggerated paa,n respons�, even �p zight touch. He fl�xed and extended to 20° each and camp�ain�d of �ain. He did not rotate hi� neck at a13,. Lateral bendang was to 20.• on th� r�.ght and �,0° on the 1eit. A1.]. o� the tests, such as Adson's and vertex campres�ion were invalid at these moticans. The d�ep tendon reflexes were sym�metrica]., Grip 5trength was adequate. No atrophy was noted. Examinata.on of sensat�.an in both upper and Zower extremities revealed a non-dermatomal decrease on. th� left side� both ugper aud 3.ower. The I�2i was reva.ewed and z agr.ee with the findings of the bulging at C�--CS and CS�C6. X-rays weice tak�n an aur of�ice today, •New x-rays of the cervical spine r�veal adequate alignment on the �1P proj�ction. The neuroforamina are w�1.1-mai.ntained. There is ,. som� straightening of the cervica�. spine wa.th a forward curve at C2-C3. The vertebral body hea.ghts anc� intervertebral disc spac�s do no� appear tn be markedly invo].ved. Ther� is sli.ght narsowing of C4-05 and s�.i,ght anterior spurs at that 1eve1. , _ Exama.nation of the 3.umbar spa.ne revea�s som� sclerosis in the �a�et �oints, The �.umbar vertebrae are well-maintained, as are the intsrvertebra� disc spac�s �nd the thoracic spine a3so appears to be w�thin no�mal limits. i! . This pati�nt gives a history oi an accident which occurred in July af 1989, three years ago, As far as I can se� by th�; objec�ive evidence, h� has mild degeneratav� changes, not out of keeping with ha.s age and occupata.on. However, his ��rrtrptnms ar� far greater than one wo��d expec� given his histQry and genexal bady condition. The a.n�ury would appear ta be a� strain and spraa.n injury involving the cervica�. and �.umbar areas wi�h a d�genera�ive �roblem in the � � ��. � �` • ' � � '. � ., ',. �� . � . ,. . . , • „ , . . , . , � �; , , . , � • , . - ,.. , . , , , . , • � ' � ' � ' � , � `,r ., . � . �� . : , � . ,,. � . � ' �, • ` � : , . ' , 1 , . . ; , � � ,. , " � ' � � . " , ' � � . � , , , ., . � ,< < . . . , . ' . , �� ' ,��'' � ',! , , � , ' ' ' . . , � . �.� .. " t � • r' ..I.F��. `5'..S ie• ,' i . 't ' .11•�, �,� � � , . , ' . � ' . � ..� .. .. � ��•. :i��. . , . . � � ' � ' . ' . . ' �. J v . . . . .. . � +� ' • 1 ♦ +• • ��~ I � j �+ . .. , . � ' ' ' � • • . � , Re: Ca].eb Winsto�a . � . . -- . 3 .. � August 31, 1992 `� - • � , , . � . . . � .� _ cer.v,kcal spine which bas resulted ia d�.sc, bulging ,at two levels .� I�3fl , not believe . that he is 'a . surgical candidate and � I believ� that . '. part of �.he ob3ective findings would. be relat,sd to his accidents, starting in �9F39, but t$at part of�these are also due to bis age ' and history of heavy labor. . . I believ� that .he does have a permanent physical, impai7nnen�, rated . at.5-6� of the body a� a whole and i feel that his paa,n behavior and respdnse to %is current symptoms is grossly exaggerated, He � - may not b� a candi.date for doing heavy manual labor but, certainly, ' he is iaot tcrtally disabled from doiny any type vf work, especial].y �, when lifiting or bending restrictions can be placed upon hiin.. It ". was evident to this examiner that this patient's reactions were � gro�sly� exaggerated and I was .somewhat surprised.to eee well- � deveZoped musculature in a pataent who states that.he has.not been 'ab1.e to exercise normally for the last three years. Zf we can be . of further assistance, please dv nat h�sita�e to contact us. , �II3S : iaav . ' Micbael D. S�omka, M.D. O' CONNOR, .SULLIVAN•, SLOMKA &�Yx , M. D., P. A. � 1 �. ' � 0 � 0 . , . `' , � . ,• � • . � . . , . , , . ' � , , �. . �. ,. � � � st. , . • _ . � •� . . � , • , -� . � . , � . ,,,...... '� . . �t��f.�1�.�tr.��/, � r �� ,,,f►,� � : C I ` '� '�. 4 F ; �' ��„ ..�L ; ,�.�, a�, iY9„¢ �-�`" �,�}� . =�� I'�A �;,�� -�.,,,.•�- � � �o: �_.�� - ��_ _ . 0 � C L E A R�Y A T E R P05T oF�ic� ¢ax--xT�e CL�AFIWAT�'Fl, FLOR1pA 3469 t}.A746 DATE: Aus 3 i �9� , SzTB,7'£CT: Request tor Medical ServicES - Florida W+orkers +Cnmpensation (FS 4ao.�3) Ei�'LOYEE NAME : �-�-` �, �,�,-Y�a-�'��-7c�! ..,,_. p / A -- / S y ... EI�'LOYEE S�CIAL SECflRITY NCl . You are hereby reques�ed and a.utharized t4 pravic�e services wh�,ch are medical.ly necessary ta diagnose and/ar txe�t t.he above-�named individual as �ollaws: � �..�..�._...�_.ef �.��- We are enGlosing all medical notes izt vur tiles re�.ated ta the inju,zy� at the above date. The empl4yee has been. iristtucted to brixag all X-Rz�ys to the appaintment foz your revieu. IZ m�dicines are required and psesczibEd as a result o� yau= �reaffient ar diagnosis, the prescr�ption m�diciries may only be o�tained from �7oeZ N'_ Jerrv' s. Z� medical supplie�, durable medical equipment, arthcses, pros�ChQSis and othes medically necessary apparatus are required and prescribed zs a xesult of your treatment andjar diagnosis, they may be obtained anly with prior ap�ov_a1 of City of Cl.ea=water/Tndustrial Nurse, Phone: �� 462--6756 . T�pon comp„�t�,,,ct�,o�„vCUr _se:.-v�ces ; in5t�uct ,the,_pat�ent to � etu� t�_C3ty of ��earWate�j�dus�' a�,, Nur�se. Pz�pare an approved Health Insurarsce Claim �orm ax�d submit it �o the address shoc�m a}aave, cjo 2ndust�ial Nurse, no Zater than ten (Z�) days trom the date of this letter �s required by Flor�.da S�atu�e 440.13'(2). Failure tv cpmply with the abov� may result in non-payment o� � claim. Sincerely, �- ��-...�.,. .��r r Nancy Deg�zz.er, R . N . Industria� Nurse cc; Johns Eastern company, Inc. SH�IILD TREA'.�l�iENT BE FOR A CONDxTION NOT JOH RELATED, IT IS THE E�IP%�YEE'' S RESPONSIBILITY TO PAY THE BIL3�. � �� "Equal Emplayment and All�rmali�e Action Empioyer" . � i - ' . � . • • • � , t 1 ' • • � t .. � . . ' � � , • � • , ' , . " - . ' . . : . � - : . -'�. � , . . . • , , t �............ .. . . � , . .. , � .'�'� . :s�...,. , _ ' , �- . . � � � � . � . , ', � � � � �. . � i � 1 , � . t . . . , � � � � . . . , . . , , . , , � . '. . ;. , . . � . ' .�, �: � , � �, , � � � , � . , � ��_ . .,igC «.. . , . , , :0 �i CO:t�L� i.:] 3 Y�l: �,:i:DI;lC c��IYSiC�.;.Y: ' ' ^r r� � . � T.r1 CJ d S., S� s ��t, c•-t..,.tf " l''�`-C�� ;S�l ;,�Lc-�-,+ " � ,, f . J . . �a"``"�`Y� ;�/�1^ `�� •�t-'��„ .. .� r..� , , ��... . i �' , . �r � y�i �i� l. ! //C1� `��lL'�� ' . T� i�.....il i I �� u �.'!�uCS: I �J�l:�� rf C:._ ��'S ..S �7��';� �i s ��;,�r%1•��l�' (�~�N�,.�. �i.� L� ♦tG.•Vi�A� �C} ZL�J�r�L� �Uii,: .t �//,1 r "/!/' �� G��5."'�( � �,� �, l� l. ! � � L'�' ;1Q't � '�tEN? � �.c.,r� �. -- . // A � � . �,� . .. � i.� � Q � iURt� : Q F. :G�I � D UTi ? - �_ (/fivti i t� �= �C"t.c.... ^� a.ESa:�iCI�HS: ��'�- - . YE;{± �?°O�V'i liV7 i5 s � ' � � "� . ��/ // 1 ,• �f '�� , r ♦ w ��' ` L•��/ �+• � � JraCi.iGTi2 / / G C. M � PLL �5� �E':'LfAN C0:!PL- ?D ?� 4:! ''� ? s — _.; : . r � .: � � , ... . , , . . .• •' . . . . . . ... .. . . �fl�$I�.��U� Rehabtlr"tatron Nasprtal ' Prne!!at Caurrl�r's Qnfy F�es 5randing RehabiJilation Hospital" PR�GRAMS A�mputee , � Nar+d Therapy H�+ad lrrjury A�lultrple Selerosis Neurologic Oisaders Orthopaedre Jolnt ReplaGement � Pain Manas�emsnr Pediafrics Spirsaf Cord lnjury Slrake Recovery venrilatDr Care Yocartorsal cour�seling Work lrtjvry S�RVJC�S Case Managemenf Medical Socia! Wak Neurobgy Neurapsychnlogy NLfrrfio�a! Courueli»g OCCUpafiona! Therapy Physiarry Ahy5ical Therapy PSyGhao�y RehAbrlrfation Nursia�g S�eech d tanguage Pat�otagy. 77rerapeur;c Recreat�arr ' Facursy acc��dlred ay i ra� : � r �� •f �i Jorn! Ccmmisslpn ...a�.�...r�...V.,oti...,.« 901 Geama�erLargaAoad ta�go, F� 3�6s� (S13J 586-7999 Fax [8 f 3J 58S•�636 � E. �� / . � �# � � . .j°� � v / � � . ca /°� � '►t �w �/ � � � � � ��' �� `1 S �� t �,� � �� i � AC�TY ASSESSMENT �� PAT�ENT:•WINSTON, CALEH PHYS�CII�N: �asepl� Sena, M. D. � ZNS[3R.ANCE CD. : Ga�la�•her-Hassett .AD�USTOR. John Marcin DAT� OF �NJURY: 3/IZ/90 DATE Ok" REPORT = �4 /�. 0/ 9 2 Than3t you �or your rezerral, of Mr. Wins�on who was �ef�rred fo the Hea�thsouth Rehabilitation Hospitai industriai Medicine Program for assessment af the cur�er�� physica�/�unc�ional. capabalities and for d�term�.nation o� saf� wazki.ng capacities. zt�p�ESSZarr: 5ased on the objectiv� tes� data and team discussion, �h� client may be appropriate to return to work a� a sedent�rY_,LliQht du��► ].ev�3, reflec�ing a maxirnum �i�t c�pacity of 37 lbs. and a trequent �3.�t capacity of i0 lbs. with restri.ct�.ons i.n squattinc crouch�ng� and overhead reachi.ng. However, the client`s QxceSSive pa�.n behaviors, sel� limiting iaehavior, incansistenciE obs�rv�d during testing, and decreased work �o3.erance i.nda.cate that �he client would li.ke3.y b� unsuccessiul with any vocationai ��tivitie�. CONCLUS�ON• Mr. Winston presen�s to the H�althsouth Aehabi.�itati,on Haspital 4Jnrk Start Prvgram appzoxxmateiv 25 man�hs since sus�aining a jc reiated injury. � Ft�nctional Capac�.ties -- The c�ient demonstrat��d a physical demand capacity at fihe 1 iQht auty �eve1 ref�ecting the abi ]. i. �y i safely li�'� and replac� up to I7 lbs. occasxona� {lx/hr. max lif�) and up to 10 �bs. frequent (lx/Smin. ) whi�.e c�emonstratinc fair body rne�hanics. I� was necessary to d�monstrate p:roper technique and provid� verba� cues �o insure consistently saf� laf�ing per�vrmance. Ti�e c�ient achiev�d general limits in th� followinq non--material handling ac��vxta.es; Si�ting, standing, wa�king, stair clxmbing, trunk bend, sq�at�zng*, and s�ooping. � It w�s nat possible �or the cli�nt te� da a full squa� durina the �epeti.t�ve squa�ting tes�; however, he was capable of a partial squa�. The Di.c�ionax�y o� Occupa�iona]. T�.t1es �ists �roundskeeper (DOT� 406.684-�i4) as a medi.um in physical d�mand. Ti�e 3ob d�scription as provi.dec3 by the ciient places the demand leve�. appraxima�ely a� h�avv reflec�ing a rnaximu� �.i�Cfi req�i remen � o�' � DO �. bs . � . ." S` • .. ' tl ' . 1 . 1 ' I � . � . ` I � y . , , .' ,i ' , ' . , • • � , , ' -'t . + .... . ...... : 1:.�['T � . . . i . . , ', .. . � . ' r Work Capacity Assessmen� Re: ,WINST�N, Caleb Da�ei 4/10/92 .. � Fage: 2 � � . .. } � .1 ` . . � , . � . . � . � �. ' ' Aerobic Capacit3.es - The client'S test results plac� him tn �the � faix category foz his age and sex and app�ar �o be 3dequ�t�.;�s compaxed wf�h the physi.ca3. demands of his job. • , � Musculoske3.eta1 Screen -- During tiie muscu�.osk�letal scre�n the cl�ent demonstrated m�.nimal to moderate bi].ateral upper extremity and cervxcal sp3.ne range of motion de�i.cits.� t��nua1. muscle testa,ng revealed significant test scare deficits for strength in the� 2-3 j5 r�nge. Many tes�s were i�npassib7,e' to pexform secondary ta �h� c].�ent's extreme pain belzayTiors and guarding. Upon � pa�.pati,on it•was fvund that the client was sensitive to ev�a superfieial touch_ " Pain Hehaviors - The c�ient presen�ed �o the assessmen� wearing a sof� cervica3. collar and a TENS unit_ He also reported hav�ng taken a Flexeril� tablet prior to the test. He was.very pain focused and moved in slow guarded range li.mit�d patterns. He was very 'pain focused as evidenced by ve�cbali.xation and faci.al. g�imaCes during activity. C?n a ar�0 pain sca�e wx�h p b��.ng pain f�ee and 30 being e�ergency paxn, th� client reported that he was currentl.y a� a Ievel 1Q (emergency} with 8 ts�vere} being the lowes� and i0 (emergency} the highest. The c1�.ent also demonstra�ed sign�.fican� selt limiting/magnifi�d ilZness behav�or as evi,denC�d hy the hr.gh �eveZs o� inconsis�ency (co--ef�icxence � of varian�e} i�x sta�.ic s�rEngth t�sting and exaggerated pain behav�.ors duri.ng �rip t�sting. �n one occasion duri.ng lift str�ngth testi.ng, the client was unabie �o.zegis�er a value on hi.s �3.rs� attempt. A�tex encou�agiYig th��.,,cli�n�, �� was able to �est 4ut a� a 2� f�./Ib. grig s�rength ievel. ' RECQMMENDAT?ONS: The cli�nt demonstrat�d functi.onal, c�pacities in �n� sedentary to light dutx �range as out3.ined by th� Departm�nt of Labor. �ssues �hat ma� inte�fere with the c�ient's success in re�vxn �o work '�.nclude self lim�ti.ng behavior, dec�easea wark toierance, increas�d paxn behaviors, inconsist�nfi effor�, and overall demonstrated lack o� function. These issues must be addressed to maximixe �he �l,ient`s success with ea.ther return �o work or �urth�r therapy, There:Eore, based on �he objec�iv� �est data and ��am discussion, w� rec4mmend the clien� participate i.n the �o� �.owinv • 1. C].inica� 'scozes �n �he cl�.ent's psycholog.�cai screen and his observed pain beha�iors indaicate that he may iaenefi.� from a �sychoiogica� cansu].�a�ion. � � , � � . ' '.... ,• : ♦ pf i � � � � � 1 F Work Cagacity� Assessment, Re: , WI23STON, Cal,eb Da�e: �, 4/1�/92 Page: 3 0 . i f � . . �� 1 PSYCHOLOGiC}�L SCREEN: �� , � ' :-�; : The responden�'s, SCL-90R symp�om prof�l.e reveals a pattex�n ��n magn��ude• to be considered in the ciini.ca]. range an'd qualifies i�fm as a p�sa.�ive ciinica� case. H�s �syrr�p�orr�atic distress leve3s �.::� cl.ear�y d�fined as being a.n the c�inical range which suggests that a moxe intensa.ve and detai��d evaI.uation of r�ental status is called �or. Overaii, in�ensa.t� of di.stress is cX�.nxca]. in nature, and he has endorsed a marked number of symptams. An extreme3y high levei of so�natiza�ion is �videnced i.n this inda.vidua3.'s pxo�ii.e. Scores at this Yevel place.the individual. in the 99th percentile of the normati.ve distr�.bution on �his • measure. The responden� reveals evi,dence o� se],f deprecation, feelxnas of inferiori�y, and a sense o� inadequacy and s�if doubt that is clinical. in nature and should be eva3.ua�ed in g�ceate� de�ai�. The respond�nt's �evel of depression is manifest3.y e3.evated and c�.ini.cal in nature. Tl�er� is evid�nc� sugg�sting a �rue depressive disordex� may be presen�. The respondeni's �eve�. of an.�rie�y is signi�i,cantly elevated and clinicai i.n na�ure. Evidence sugg�sts that•�he reapondenf may be su�fering ��orn a cli.nical anxiety s�ate or may b� experiencing anxiety secondary �o ano�her psychol.ogi.cal dzsorder. Th� r�sponden� mani�ests c�inical l�vels o� paranoid ideation with evi.dence of suspicious, mistrust, hostility, and px�o�ection, Such a posture may xef].e�t' a�ong-standing persona].ity coniiguration, the emergence of an acute disorder, ox a conccmitant of another relative3.y I.ong-sandi.ng psychoZogical disorder. T}�e responden�'s psychoticism sCOre is in the' c].�n�.ca� range, howevQr, it is r�ore likely that thi.s �eflec�s an �ntense experie�ce in sacial al�enation.rather than a though� disorder. • SUB,7ECT I VE : � , Mr. Winston is a�6 year old male with a pr�.mary diagnosis of •• cervi�al he�niatEC� discs at the C3, C4--05, and C5-05 Zeve3s. The client reiates that h� was injured on �he job with the Ci.ty of Cl�arwater when he was shove].ing and ��t neck pain and+heard some aopping svunds frnm th� neck reg�.on. The cli�nt's diagnvst�c t�sts to date as repor�ed by �he c].ient have consis�ed of x-ray, MRI scan, and EMG wxtt� �he resu��s of the MRI scan and Ei�G being posi�ive �ox injury. He a].so �cepox•ts that his , tr�atment to da�e has consisted vf physica3 therap� on and of.i for apprvxima�ely 12 mon�hs coinmencing in March o� �.990 with his mast recent tr�eatment in March of 1992. The ciient re�orts th� outcom� of thi.s physzcal therapy as pxovidina short--term � symptomatxc re�.�ef. � He reports havang tak�n medici.ne f.or his injury, however, he.is not st�r� what it was. Currently he � � � � .-� , . . . . .. . . .. ... .. ,., . . . • . . . .. .. i� ' C� . . ' � r � � • � . F , . i� � � , , , . , �. � , , /�. , � � Work Capaci�y Assessment ' ' � � Re: WINSTON, Caleb , , . Date: 4/30/92 � � ' � � Pagei 4 . reFo��s taking Fleas��il and N�pzosyn for pain management. He is a�so a recent insuiin di�betiC. He presen�ed ta the tes�•wearing a TENS unit; He reports long'sitting and standing as ac�ivitx�s wh��h bother h�m the �os� yrith layi.ng down prov�ding the most� xe3zef. VQCATIONAL: � The clien�'s job descra.ption was abtained frvr� the cl�en� who describes h�s job as a groundskeeper with the Czty o� Cleanaater a� cons�.s�ing of activities which�require a maxxmum Iift capacity �a� 100 lbs. in tihe �'loor to knuck3e range on an occasionai basis consistiiZg of garden�ng supp].�es. He reports an average Iifted v�e�ght of 30-54 lbs. in the floo:r �o knuckle range on a frequent basis wi�h a maximum gush/pu11 0� 2SQ lbs_ and a maximum carry of �OQ �.bs_ Non-material hand3ing activities as�repor�ed by the ,client consisi of kneeJ.ing, crawling, and sitting on an occasa.onaZ basis with crou�hzng, stoopzng, sq�aa�ting, overhead rea�hing, s�stained bending, waiki.ng, and slcanding on a�requent basis. ilsing �he information provided by the c�ient, the 3ob description fa13s into the heavy demand ievei category. Th� C�assi.fica�xon o� 3obs 1is�s groundskeeper {DOT� 9D6,68�4�-p�4] as a medi�m in physica3. demand leve3,. The c3ient sta�tes tha� he is unsure as �o what�he can do in regards to re�urn to work. CARDIQVASCULAR ASSESSMENT ' :.".,. The Amerx�an Heart Association (cardiovascuiar profile} rates the client in the medium risic ca�egury for the development o� cardiovascular disease. The ciient's bodyfat composa.t�.on xeveals that anproximately Z5.�3� o� his bodyweigh� �.s s�condary tv fat, which places hir� approximatel,y 28 lbs. over his ideal • bodyweight. Th� aerobic capaci�y assessm�nt was pezfoxmed using the bxcycle protocol revEa�ing an es�imated maximu.m aerobic capacity of �.6 METS and an astimated func�iona]. ae�obic capacity o� 2.6 METS, He xs classified as having tai.r aerobic capacity for his age and sex. h1USCUGOSKELETAL SCREEN: Pt�STURE: The cli:ent presented with essentia3.ly nozma� nostu�� with �he excep�ion o� increa��d Iumbar Iordosi.s. . , . r �. ' � . . , � ;. ,.,.. , ,. 4 ' ' , ; � ,;f.'' ,j • ; . � , , , , • . . {, � ' ' - . . . � . � , ' '. ' ' • . • , . . � � . . � . . �at i. . .�i' .. � .. .,I�" . � t' `\�N� �> � I , ; ' • �.. . . i . , a , . ' . �Sy `. ^(^. � . . , .. . . .. `' � t� -�. . .. 1 � i . �. , � � � � • � w ' .�1.. • � , . , Work Capacity Assessment , � Re: WxNSTdN, Ca�,eb . ` , Da�e: 9/1(}/9Z �.' � . Page: 5 � . FLER�B�L�TY: ' . �tiaht � Act�ve/Passa.ve � , �. ' Left ' ;-, Active/Passive • • Shoulder ' . F3exion . t30° 3�0° • ].�,0° �.ZO° , Abducta.on ` �25" 115° 6Q° �z0° � � Ext�rnal Ro�ation 45° 90" 10° 4A° Intenraai Rotation 15 ° 55 ° 4p•° '1� ° Glen4h�xmera�,�Motion . . F].exion 16fl° � 140° 80° •�' � �20° Abduc�ion ' 100° I3.5° 40° 12q" ,� 'Externai Rotation 45° 9Q° 10° 40° Znterna]. Ro�a�inn � I.�° S5° �0° 75° • E� bow � - • � Flexion . 145' 145° J.45" 1�5° Extensxon --5° 0° _10° 0° STRENGTH; The client scored genera3ly in the 2--3/5 rang� in a�J. cituscie t�sting areas a� bi].a�era3. uppe� ex�rema.�ies and in the cerviCal regian. PALPATIC}N :� The ci i�nt was sens i t ive to even supe�cf i ci. a�. � touch throughou� the cervical and upper �horacic region. :; , NEUROL�GICAF.: lntac� . ' �'r'�, . RECD�F.NDATZONS' • ' The patient demonst�ates many pain hehavi.ors in passive vs. actave xang� of r�ation i.s inconsisten�. No furth�r recommendations. • FLINCT�ONAi� CAPACITY EVALUATION - WORK TOLERANCE SCREEN: A thoraugh functional cap�c�.t� ass�ssmen�,was comple��d. The resul�s of �he ma��rial and non--matera.a3, hand].ing are indicated on th� las� �wo gage� oi �his report. CONSISTENCY OF EFFORT T�ST_ING:_ Th� foi3.owing items are eva�.ua��d t4 assess standard d��iatiQn and Coei�icient of variance (cons�istent effort �or bo�h sexes is Q--].��} . DYNAMOMETER STR.AIN GAUGE; (Ft,/�bs,) Av�rage: 34. CV: 32� � , . (incon�is�en�}. � , , n_ ej. . . , � � '� . , 1 � i � � � I . . . , . .. . . . ' ' , ' , . . , . . . . , � , , � . ' � . . ' . ' ' . . � � � � • . i, • . . � . • ', : ' • ' , , ' : : . 1 ' � .. � •, ' ' - .- • . 1 . . .. � � � ' ' , . � ' � . � , . ' • ' - � � � . , � . � � . .."S . • � �`1 � � . � . � . , '. ; • . • .. .�. ,. • . ` . . . . , . . . f ' . . . . S ' ' � . . , . . . ,.. � , ;1 r : . • ' , � ' , . ' 'i' ' , ' . �, � '� I. , I . ' • ' ' 'I � � 1 . , i:r .7 ' . . . � � I , � ' . .� , � . . .. . . . . . . w��l./,,sx ... . .. .. ._ .... , � rr;l'f"'!��:.� .. . . . H ' � � � .l� 1 � , . � f.. . i . . ( � ' 1 . .. , � .�� . . . . ��F� . � . . ... �� . . . . . .. , i . . . . i� ' � � • � . �, . ' � ♦ , . � , . . , , .�3 , . ' i, . ' . •. • , � • , work Capacity Assessment � . � ' � • � � , Re: � WxNST�N, : Caleb � . � .' � , � � "`. ' � � Datp: , � 9/�D/92 . .� � � � Page: 5 . �� •' � �SOME�'R�C PUSH: (Ft./Ibs.) �Average: 3Q. C�I: w4� (inconsistent). � ' ISOMETRIC PQLL: (FL./Zbs.j Averages Z�} CV: 31� {i.nconsa.s�en�j. .' � DYNAMOMET�R GR�P STRENGTH: (Left Hand} Average: ].2.5 CV: 51$ � � {�.nconsistent). � � � . . , . . l7YNAMOMETER GRIP STRENGTH: (Right Hand} Average: 1�_ CV: 27� � . {inconsis�ent}. - �, � � . � MATERIAL HANDLFNG/_LIFTiNG: " . , � F3.00z to Knuckle Li.ft Knuckle to Shoulder Li�t Shoulder �o Overhead 100 �t. Ca�ry wi�h Pivot NON--MATERIAL HANDLING: ACTIViTY: Sitt�ng Standing . wa].king , Sta�r Clxmbing Trunk Bend Squatting S�ooping Overhead Reach � Crouching . Occasional ( l.xy3�=• ) 17 Ibs. • ].3 �bs _ 8 lbs. �3 3bs. �`requ�nt . (lx/�min.) l.Q l.b�. 8 Zbs. 5 ibs. 8 �bs, CAPAC�TY: Achieved General �im3.ts �� r� . ,► .;, tT � � �" r� � � n Restricted t4 2 min. due �o ancreased c�rvica� pain Unable tio perform - • . secondary to inabili�v to squat a�.l the wav �o the �Ioor. � COMMENTS: The client observed fair body mechanics on a consis��nt ba5is. �t was necessary to demons�rate proper lifting techniques to the c� ient �n insure � saie movement �attarns _ The cl i.ent t�s�cl excessive guaxding during li�ting which did no� promote vexy c�aod bady mechanics. Durinc the .��nctional �agacity �esting th� clien� demonst�a�ted v�ry siow and guarded movement patterns in �� conjunct.ion with exaggera�ed pain behavi.ors inc�uding �acial � � .. ,,r � .• . .. � ' . '' r• . ' ,. , � „ ,. .. ' , . . . .� I .... • . , � • ' � � • , '. . , . ' . ` ' . , ' . . ' , ,�,� �... .. . '�. , . , ' , , � , , . ' � � � ' � . , .� � . �. .1 , . � .'. , .. ; �; , " • . , . . . , . , � . ; . . � " . . : . , . • � ' ' , e , � ' t.l' ,.1,1, . •{ , '/. .� ' . . . ; , ' . .i . . . � ' � ' . � . . 'f � . � . ,i ', '? . ` 1 .. . ,�� 1! . .-6 , �r� • ' .li r <. I 1 1 ' ' ' I. , r t ' � vl4N'.^rriwA..a� � .i ., . ve. ...I` '�?:�t's:i�fi:...ila,trtrx '� - , . � �. , ' �'I' • "'. ... ,�Q:Y�.i......... _ .. , . , .i . .� . . . . , j 1. i� 3F' , ..-.i . . .. . � . . , � , /A� � . �1 � . � .� � • � • � . • � � . i ' . . � '�, • • Wark• Capa��.ty� Assessm�nt Re; � W�NSTi�N, Caieb . . IIa�e� 9/�0/92 �� • � Page : 7 . ' � a � , g=ima�es and verba3.�.xatior� of pain. i�e reported �ha aeck and .', upper ax�ms wexe particu�ar�.y painful wi.th n�mbness mos�ly- in..;.�iis '.3.e#� upp�� x�r�mity with some in the right. H�.completed�l5 F� c�rcu3ts o�•�he frequen� materxai handling and�requi.red two res� „ periods during this ti.m�. fn the non-materfal handling porti.on , o� the eval.uat�.on the cl.ient reported that i�e � wa� �speriencing headache and was very �atigued.' He eontanued to demonstra�e �ery ,., de3�berate and guarcied movement patterns and had difficulty with `. repeti.tive squa�ti.ng. He was unable to go complet�ly t'o the fxoor thereby using a"hal,f. squat" technique. The overhead reach •reportediy��ncreased hi�s neck pain. �Tha yo gain �4r the referra3 af �h�s c3i.ent, � ,. . ' - ' . . . f� �+ rb �� , . D id 'A1 sio, OTR%i, ' �, Date � ' ' . iCurt Gray, �T ,/�, �� Date • , �� , � � � . CQ.� - jb -�z .� b U1mer, CVE �►�►�v , . . Date DD/eb � . ' � D/T: �/10/92 � ' , . , . . cc: �oseph Sena, M,D. , . � � cc: GaYiagher-Hass�tt Insurance � cc: Bea K�ine, Quala.ty Caz� Syst�ms ` cc_ Casey Car�.son, Attorney , � , . � � , � , : ' . I - , � . ' � ; �_ . ' --------- _- '__. .__ � � � . � ., �� .--• FUriCTx�1�A.L CAPA.CI�'I�S EVI�LUATIDI� . W0�2� TOLERAI�YCE SCR�EI�I �,ALt-� � r�� . 14 QAr� .�.�- Q� � �.-� 0 S'C�TiC/COi�S�STEriCY TESTI�IG - i.� Star�dard "Ca�tficient af . Qyn�mometer Strain Gauge ❑ tVot 7'ested 3?� b��c)� �cl��Average:��_,..1... Devial�an�� Variation �2 1� �� / �� Sta�dard" '• «Caefficient of/ lsametric Push ................ 0 Not �'ested a)3J b)� c).,� d)�� Average:�� Deviation �_.,,� Variatton ��1� � ' � Standard "CoeF�cient ot' � . y C. . Isometric Pul[ ................. ❑ iVot Tested �?��5 b? �� c) %� d) � Av�rage:� {?eviatlon �� Variation �i�ti 4.' Oynamometer Grip Stren th , St.aRdard . «Coefficient o . , �� y �efL li�nd ...........:............ ❑ Hot Tested a)� b) c)� d3� � Ave�age: t� Deviatian ��l.. Varsatio� �,� . Oynamometcr Grip Strangth ° � / � � Star�d'ar� "Coefrc9ent� Rig�t Hancf ........................ C] Nat %sted a) l�.�. b) c?� d? � Averag�: � Deviati�n �' � Variaiian � • SEandard �Coefficient ot Other C3 Nat Tested a) b) c3 d) Average: Oevialion Var�iaticn " 0�15� considered co�sisten� in effo�-t Dynamortieter Sfrair� Gaug� � Q Maxim�m Abiiity Q�aiR in '�`'" isametric Push ❑ i-]axirnum Abi2it C} Pain in l,ametric Pull O Maxirnum Abilit ❑�ain in w [� Grip Slrength ❑ Maximum A�iliLy ❑ Pain in �ther j � Maximum Abilit,y ❑ Pain in � MATERIALS HA�DL�][�iG/LiP'TIi�iGI t�OT OCCASlONAl. ( i -33::) i. Fianr ko Knuekle (siart at 2S� o!' � � ; 5. Kn�ckle to Shouider T. Shaulder to Qverhead 3. 344' �arry wiPivot, 9. � 5od�/ !�- t^�r.� � C�._, �r.� `� '.''�..__ i;O�mant�: � �n (,�tf ; �..�.��_ c- d� .,��: �� ti1., �..� �-r. � ) Jt� i' i�:i.��.i� .. "Safe M ximum i.ift' Actual bs. . 0 Stop�ed �y Clie�t ❑ Evaluatar Attual bs. � Siopped hy Clfent � Evaluator Ac ua s. 0 5lopped by Q"Clisnt ❑ E��aluakar ACLU�3 �� ❑ Stopped b/ a�Ciient Q �vale,atar r.ua s. Cl/ Stopqed by �'�:lient � 0 E��alu�l�r. �� !Z f Evatuator C1'.�'��hin t�flrm�l'_im�i� _. !. rtr:Sr� Fi�QiJEt�T (�4�-bfs73 CO�ISTANI"(57-f04 :) Adequat� for A rox. i2x/Wour A rox. 6�x/Haur .lo�? 5tart wit� 7�Z of "Max. 40?. aF '�1a �' um' Yes No � A�tua! �bs. Projected .�" tbs. SLnpped by�f3�ient ❑ � Evaluator- ActuaL,.�..-�.� ibs. C� ActUa! bS. Pro jett�d - b5. / SLoppQQ by � Client � 0 �3' �-� Evaluator Ativai%�� `lbs. C ua s, rv�oc ed � _ � Stapped by Client � � 0 ` ! � /' 0 ��alua�ar Actusl� !bs• , � � Ac uat s. ro,�ecte • s. �/ Stopped by ��ferrt �_ 0 t1 0 ��aluator Act�a).--'� Ihs. 1 ! .�AC ual 5. f.•� r�O�eCt,ed �5. ' � ' �. �� r'+� SLopped by ❑ C1ren� �..- ' � � � �•. �.Eiaiu �r �cic�sl w5s. �` H.R. ' L.__ �.L H.R. ___. � ._._ .___ ._... �valuatar ..�� vaivator � _.�..____� ��,b�ormal �s Cofio�nrs• � � � �'�'u ' �`"�'�' ��`' ,..r�_. • — -- �� ; u ..�.. �1'k* �� t� ! J � c�� • , r r • ttin�v,l��: '� �� ,�.�- - . ��, i ,�•�. z.�,.: {�` � � iT'r�C �.�-�- i! ---• ' d �� . . , � ., .. ,. .. . . . r , � , , . P�IOhY-�M.A.'TERIAL �AMDLt..tG ACTI , . , . ,-�, � TXES � � "G�p�ra!" .�db Sp�clri� Nat LlR— ° �i�quat-� . . . , . . � �rcque�cy __,.. ❑ � Re�trlctad to� � Unable d�e io Yes No ittin 3D minuies �sntnutes ' Que t,o p p tanding �regttency d 0 Restricted to ❑ Una�te due to Yes t�o stationary+ 3a minutes .�.�.m�nutES Due ta - p p Distance ❑ ❑ Restricted to Q t�nabie due to Yes f�o laiking i/2 miie �ime Due t.a � � � Fr� uen ' � freq�t�ncy _/ � RestriGied to Ci Unabie•d�e ta Yes Ho Siasr 4 fltr�hts Fiight.� � C� D�c ta ❑ CJ limbi� (60 ske s} Ste � � ,. � �unk 8end 1�inute (fix �*►inutes i� g" L� R�S�i iG�E'� ZQ � l�nab�e d�re to Yes f�o 5�3%�C} Ff'� U�liC �i �D � ❑ ❑ erhead 4 mit�ute (5x) R+inutes ❑ ❑ , Restricted to �� ❑ UnabEe dus ta Yes No each Fra uenc � �7ue to "�- �'A � 0 rawiing t� feek (x6) ---- minutes 0� ❑ ❑ Restricted Ro 0�nabie due to Yss No Fre ue�c � aue ta ❑ 0 quaf.ting 5x/min. (x63 ��minutes ❑ � Restritted ta� ❑ Unable du� tfl Yes t�o� treve�itive Freave�cy Due ko ❑ ❑ Kneeling f minute (x6) __..__.�minutES ❑ ❑ Restricted to 0 Unable.due la Yes �fo Frequency Due to ❑ ❑ Stnaping 5x/min. (x5) Cl Cl Restricted � Q Unabie due to Yes Ho {rep. bend) Frequency .____.._ �ue to � Q Gra�s�hing 1 minute (x61 �...�m#nc�te5 � � ❑ Resiricted to__._.�___ Unable due ta Yes No fsus. s�uat) Frepuency D�e to �'�i�-'� ��- d 0 Ladder 3x� wtQ�a ��.minutes ❑ C) Re�tricted to � Unable due to Yes No Climb (xo) Freauencv Due to � ❑ wammenls: .,c.L✓�cvrc:.� �- t.c�. •.L� �irL::�' � ,�G —.� �. (J � � i.x, a..L? r. c.t� �•'t ..9 F' � r i%<: `! ; ' f • � ,/L„�� f/1/►'t.v,.t�' � '1 ' �! .-�:-.. � ' I 'J ��C��'� :';a��•4'2 ' I 1 i � �:.• �'l�i��{ e.:<i..��+-�-- vaiva -r.'I� '/ . r' � �� . � � U i ; =� '� f�Ll �' £ tu �`.s�r.� �.../ ' � � — — , 0 � � �'�-'_. .. .. � ' � � ' . ' � ' ' , . . , � '. . . , i .' ' , , : �,' , � . , � , � • ., , ' - � . . - �' . i' .. � S. , ' ' ' � ; . , { . ' , . � . ' , ' ` , . ` 'i .. . � ' ' . � . . . .' . ' , . �> . .� , .' . ', . . • f • ' . . " ' � � . *,r�� . .. ., . . .. .. . _ . :t..,� ,. . � . .��.,. _ .. . - . . , , , . j: . ' . � , , . �� . . �- , . . . . . • . � � • ' � �"' , � .'� . Qtxafity Care Systems, lrrc. . , , , , . RES�(JME ' , �' �., . Ja�v o. SCULLY � � . . , � � . a�r�onK�rrT xzsTO�Y : . . . 1991 - Present: QUALITY CARE SYSTEMS; INC. • � , Vocational Case Manager. , . . �Provide'vacational case management sexv�.ces , � , � For property-casual.ty customers and .. , coordinate j ob placement for in� ured wvrkers .. � Also provides Expert Testimany, vocational � : testa�ng, �ab analysis pr�paration, and o�her � . .' related.services. , . . 1.R89 - 1991: CDNSERVCO, xNC. ' . Na�iona�. Quality Assurance Manager. . Responsib3.e for planning, implementing, and , , � � overseeing a natzonal qua�ity�assurance , �. ,� � program �or case management service5. 1984 - �989: �C�NSERV�O, INC. � , Voca��onal Case Manag�r. . ' Provided vocational case management services � for property�-casu�alty customers and . coord�nat�d ]ob placement for a.njured • ' workers. Provided Expert Testa.mony, vocational testing,job ana.�ysis �reparatzan, � and other related services. 1979 -- 198a: CRAWFORD REHAHxLTTATIL�N SERV�CES, xNC. � Super.visor/case Manage'r. � Supervised medica]. and vocata,onal..case � managers who provid�d case management serv�ces for property-casua�.�y custamers. Pravided vocationa� case management services � pzioz to promota.on to sUpervisor po5ita.on. - EDUCATTONAL HISTORY: Seton Hall. Un.ivers�.ty. New Jersey. Master o� Arts. Rehabilitation Counseiing. ' Stocktan State Col�ege. New Jersey. .� � . Bach�loz o� Arts, Psychol.ogy. � . �ERTIFICA,7'�ON: C�2C, CIRS. , . PROVID�R LICENSE I�UM�ER: XA Q04744. d � � . ., � � � .� .. ' � '1�. ' . ;' '' r' , ' , , . � ' � � . . � • ? . . � ' � .' � . ' E ' . . � . . � � � r , e . , . �' [ . , • j '� ' , ' . . � , . . ` . ' : ',a� . � � � �. '. •• . �.� ,. . . ' . , ' . � ` ., . � . . i, . ' . . . - . " , , , . ' ' , , ' ' � ,' " , ' ' ' . ' . ;,,:, �� , ', ' , '" '� � . • � . , , - t', , ' . ,r , . .+; � = • ' ' . , � . .. ' . . . �•� - ' ' • ' . ' f. � r� ,� ,� , � . .. , ' . . . . . , , . j�'- . r.�...�_,..,.,. _.�....,.�.. .'I'4•f'..A.��.�� .'i�'iii"h. ... . . ...., ' . �. . '�' �'�, � ' ' . � .. ..,.. , , .�. � . ' , . ' , . „ '1. �a , 1 • ' " ' . ..5�"'� ' • , • � . . r�� :� � � �� ,� �.�e��, l��=� ' . � � . � . � , 2(102 Narih Lafs A�nue, Suit� 65Q. %mpa, Flarrda 33&Qr �"elephone: {� 13j 87.6•6900, (800) 669-980i, Fax.• (8 �3J 877 5333 ' ; , ' . • � . • ' . � C�NFIDENTIAL REPORT � .� ,. . �,' FOR PRQFESSIONAL IISE ONLY June 3, 1592� 0 Jon. Marcin GaZlagh�r Hassett Pr Or AdX Y�4L7 C�earwater, F�, �4618 . � RE: . Client. Ca1eb Winston . � S-S- f�: 263-96-534�. � � � D.�.i.. 3-1.2-90 , . Emplayer: Ci.ty of Clearwater, Claim �: OOti1�49-005�37-WC01. INITIAL REPORT REASON �'OFt RE�FERRAL : ' � � Vocata.onal eval,uation. Z m�t with the cl.ient rar vocational • ,, evaluation on 5-29-�92 in the o�fzce of hzs,a�torney, Casey Carlson� �squir�. Throughou� �he evaluation, botli��Mr. Winston and Attor.ne�y • Carlson w�re found to be '�U�.l.y cooperativ�. ' R�COMMENDATION5; 1. As per our consuJ.ta.ti.on on 6-1-92, � wi13. now cl.cse th,is , . case out and prov�.de na further vocatianaI. rehabili.tation , ' services. , -- i I . MEDxCAL FACTt)RS : . � ! Zt i� my understanding that �Mx�. Winston has be�n diagnased as havinq hypertensi�n and dzabetes myel�.ta.s, wh�.ch a,s contralJ.ed by dai.�.y insulin and �zet. Mr. Wa.nston is �urther diagnosed as hava.ng � multi.pl.e l�ve�. hernxations at C3-C�, C4--C�, and c5-C�. �t is my understanding that Mr. Winston has nat opted to, have ' surgery pQrformed on the muYtipJ.e �.�vel. disc herniations due �o the : complicating Eactors o� hypertension and d�,abEt�s myelitis. At the , present ta.me, Mr. WS.nston rec�ives one prescra.ption pai.n tnedi.cata.on, however, he cou�.d not name thi.s drug. Mr. Winston Cvr�orafe Neadauarters� 770 Lexi�gton Avenu� New York, N.Y. 1002J Telephone: (212j 223•1�,20, (800) 669-9660 Far: {p12) 980•3380 " � � � , . . . � .. � ,� . . � • �� " • . � � . '. � . . „ �, � , 1 � ' . . � . • ' - , _i r ' � r . ' . .• . . ' . � , � � . 1 • i � .. � ...... .-..� � . .:r,. . . S',+' . . `y��.,sr�. �. . : . .. . � ' , , . � . . 1 . Cluality Care Systems, Inc. " . . • Page 2 . � • .R�: Caleb Winston � "` reports that whenever he takes,tha�s pain medi.cation, it makes him sle�py and drowsy. Mr. Winston ha� finished all physi.ca]. therapy, and no �urther m�di.ca]. treatment other than follow-up monitor�.ng tzeatment is. r.�commend�d by his treating physica.an, Jaseph Sena, M.O, � � It is.my understandi,ng that Mr. Winston is judged to be at MMI and a sPdentary/ 3.ight work restra.cti,an is imposed upon ha.m wa.th a maximum lif� capacity of 17 paunds, and a frequent lzft aapaci,ty af x0 �ounds, Mr. Winston has restrzctzons in squatting� crouching, and. ovexh�:ad reach�.ng. , . Ei]IICA'Y'IONAL FACTORS; Mr. - Winston �:eparts h� did finish high school, graduati.nc� �'ra� the 12th grade in x967. Mr. winston i.s cons�.der�d to be fu:nctionally zlliterate. ThereFore, I did not perform any vocational testing du.r�r�g this evaluation. Mr. Wihston reports that he learned the construc#�ion trade while �.n ha.gh schoo�., and �he on�.y � oth�r train�.ng reported by this indiv�.duax can be termed on-the-jab train�,ng during his invo3.vement wzth varao�s em,p�.oyers during his work life. Mr. Winston has never be�en a member o� the Uni,ted States Armed Forces, VOCATrONAL FACTaRS: 1.' x983. to Date o� Zn�u�y E�p�.oyer: City of Clearwater �;. oc�upation : Gzoundskeeper : ��'. �' � Salary: $9.36 �er hour with bene�i.ts �"ob Description: Duri.ng thi5 ter�u oF employment, Mr. � Wins�on work�d as a graundskeeper on ath].etzc �'ze�,ds and parks owned by the Ca.ty of Clearwater. As a groundskeeper, Mr. Winston fertilized and cut grass; � c�ayed �ields, cut trees, p�r�arzned gardening chor�s wi.th � decorative �lawers, operat�d a tract�r, a pi.ckup truck and a fiv� ton truck. Throughout the couzs�: of h3s narmai duties of �mpJ.nyment, Mr. �Iinston used hdnd tools and prawe'r toals. Mr. Winston was al,so assigned as a he].per tv a carpenter �mp�oy�d by th� city o� c].earwater, � and empioyed carpEntry l.abor job �unctions, z. 1968 to I.98x Emp�.oyerr vaxious cons�ruction companzes Occ�.pa�ion: cr�nstruction Labozez Job Descra.ption: During this peziod of emp�.oyment, Mr. Winston reparts he per�ornted the narmal. d�Yt�.es of a constructi.on labor�r, and per�orm�d �in a ut�.�itt� capacity am+ang the various construct�zan �rades, such as . 0 � 0 � , „ , . .. .. . . , , . - . � , . • , �. • . , ,.� . ' �, � . , �, � , , f. `. � 4 . � .. ' • �� • e . • � � . . � � .. ' , � � ' , 1 � . ' . . • � • . � . . � . . � . ' ' � . . � i �;...rjly',.. � ' � ' -0.5�' :y. t� . . � , • . . .. .... . .. ... . . v� � .f^. . ,�tr .. , _ ., i ,. ' .e. - " .. . . . . � ' ... � , , , . . ' • � � � ^. „ , . . . . . .. � Quafity Care Systems, tnc. � � , Page 3 - .. , . RE:. Cal�b Winstan � � "' , •. �. carpenter.s, plumbers, masons, etc. Mr. W�,nstvn was most � o£ten utxli�xed in supplying supplies ta skill,ed craft � � workers, and a�so�performing �asic 3.abor chores s�ch as . � da.gging ditches, •hvles, etc, ' Throughout this long peri.od � ' of successfui emp�oyment, Mr. -W�.nston �uti].ized vazious hand too].s a�sociat�d"with construct�.on. Mr. Wiriston l,�ft this occupati.an to accept empl,oym�nt with the City . • of Cl.earwat�r, which h� Eound at�ractive due to th� � empl.oyee benefit package. . The preceding cons�.itutes this individual`s total vocational h�.story as..reported ta me. Mr. W�,nston reports no long per�.ods vf � ' unemp].ayment thzoughout his work l.a.fe, exc�pt since the date of his i.n3ury. Mz. Wi.nston i.ndicated that he enjoyed his 7ob wa.th the Ci.ty o�E Clearwate� wox-ka:ng as a grAUndskeQper and carperitry hel�er. Thouqh he is c�.eared �or a retuzn to.work i.n a sedentary to mod�.�i�d l�.ght duty status, Mr. W�.nston �eels h� cannot . successful.l.y per�orm i.n today's� �akaor market, due to his �di.sabilities. - VQCATIaNAL SRILLS_ . . Mr. Wi.nston was successful�.y involv�d in accupati.on� requa.ri.ng � ph7�sical demands of up to and inciuding heavy and very heavy duty �abor_ Due to tlt� phys�.cal restra.ctians xmposed an �4r. �73rtston, he � can na xonger perfax-tr� the normal duti.es of his former occupations that h� was successful in. Mr. Wins�on's jvb skil.�.s �.re found to be a� the unski.l�.ed work vaziety. Mr. Wznston, durxng the course � o£ ha.s joi� dut�,es, was requested to work''both inside and outside, . lo�ing expos�d to weather 'conditions, beinq ab�.e to cZi�nb, crouch, crawl, stoop, wa�k, bend, and s:�t occasionalZy. Mz. Winston was no�mal3.y expec�ed to carry up to 100 pounds in weight, on an o�casa.onal basi,s, and 50 paunds in we�.ght on a frequent basi.s. =M�R�ssroNS: ` As x�nda.cated to you dur�ng our consultation on 6-1-92, x�ind this individual,. Mr. Ga�leb Winston, �o hav� extremeJ.y limited patenta.�al �or any type o� �uturE gain�ul �mployment. Th�.s a.s the result v� a combinata.on o� factors, incl.uda.ng his various d�agnos�d conditions and their syner.gic e�fec�s, his r�ported funetionaJ. '�11.i.teracy, and tiis e�c],usi.ve 7.a.fe�ong znvo�,vement in unskii.l�d heavy to very heavy work. Due ta his pri.or work h�.stary . and tak�.ng into consa.deration the labor market �actors 'in the C7.earwater, �'Iorida, area as they exi.st taday, I fee�. that M�. W�.nston wauZd have 3.itt].e, if any, chance , , . ■ :�±r;:�w;q'f''y�ri.;= �,c �r�. t .; . p . r;' . !: �i:� f�.i.�+; °y4. �, �°� �r� a/' „ i='�.' . . . , � .. . . , . . . , ".i•- -r�: ` =[. , . :'if '� r . • � . �l,'. . �� . � t ' , , ' . . � , ' ` . , ;5�: ;�ii.:r,� " , ..,,. , '.i , .'V' '1 , ' ' , � . .. •i�, ; �. , ' ' . ' � .. .. ' ,, '' ' : � ' . ii�• ,. , ' � ��f 'i'° . . . ., . �. . • ` . � • '' � � . . ' , ' . �iit. .•.'�1 ' . ' �� ., ' , ' ' f , . ., . / . ' . ' ' . . . . + � � ' �I ji�r�� _:�� _.> ' , , � ,�1,� .,�i.` , � ' � ' ' . .. � ' • ' . . �, . t,. . � . . . � , ' . ��• `` i ' ��•. . . , 4 ��' . • �'. ' I. 1 .'��'.1' ' 4 ' . � ` , • ' . . � . � . • � . ' � ,'F' f '�1J' � ',S�t�'..�� . . '�• . . . .. . ° . .. ' . ' �. . . " ' . � . , ' . ` �� .��.. �� . � . • . ` . • . r�t. a r' o ��. , ;. �' '�<s'�,:`;. ,1 , .E. ,r ., ' � ' . , ' . . .:. , , _ "i •! • ,'�; •s' {: 'S't� . � � - , . , :r�i�, .. .�� .1t ,.�� '� � ''.!' . ' .� �t ' ' . . . . ' � . . . . . , , . , . � , }. > 1 }:�; � . . ? . .. . , .t � . ' ',} ' . . ' � ,� : . . . . , . . .. , ,r , , � `I': � , .' . ii >' . . ,r? i r • ' �� . . 1: •• , .. � . .. . . ; . , : . ° ;. f�'f" . , ;• .. . , ! • �it'i��.'!� .:a1''w.a.... � ` ..:,I: ! ' ry �y�� `i;is=`•, ;�,MF+ ' S �, ' " i, . e . � . . ' '. ' '` ' . , • . . . . ' . ' . . � � � . i . A, .,G.:!!-..bb.a.l�;'l.�`_i5.xt �.�ry.%� Ya.a:b» ... _� t.. ., ..•i ��....:" . .. "�TEn.� , '. � • . . .� . •• � 1} . . . , ri .r .jf„ i . . . � ' , ' , � � � j, . . •' . •T � • ~' 1 � . . '� . ' ..' � . . . rr � , , • . ' � 1Quality, CarQ Systems;.lnc. ' , ,' . � ,� � • . � . Paa�e 4 � . , � � . , , e , , , . . � � RE: � Ca3eb.. W�.nstan � . � � � � � � � � - �k , t=ansferring his unskiZled warker's ski�.ls� tv sedentary or mocii�,�ed � � . :�, lzght duty wcrrk accupations. . . . . . ' ; . � . , It'�was grati.fyi.ng to le�rn- duzing our r�cent consul.tation that �you , �' ., ��,, ' �eel my s'ervice has� beein 'of. b�ne�it.to both yau and the client, arid . � . I would Zi.ke ,,to personally thank you �cr_ the �pr�.vilege, o� this �. re:�erra3. and , evaluation. �f I can be of any he�,p ta either the , � ,�' , cl�ent or you. �.� the future, nlease feel. fzee to contact me at your . � . aonvenience, and this case can be re-opened at no cost.to.you. � � Respect�ul].y Submitted, � � � Q. � w,� . . • . . . . . . ��f . . �' , Ohri O. SC�.17.1.y, M.A. , C.R. C. , CIRS � . , � . � Case Manager . � � � . , ' . � � J�S:slw : ', � � � . � cc: Casey carlson, E�quire . . - � ' '�� . � 250 �Be?�cher Road North . � � . '• . .. Suite 102 ,� � , � � . � � � C�,�arwater, FL 34625 ' � . . . � � . � ,� , . 0 � �:- . .,. ,. ,. , . . . 7�5:'t :�' i '. �. ' . � :i°� , i � . ', . . .. . . .. , , . � ri ' '{, . . . , � � � ' � , • f . � i. � �, � ' '� .. . . �, , ' . � . ' . • , ' ' ' , . .r � .. � . ' . � . . . ' , ' . ' ' , � � . '� �, . � . . , , ' . • . � ' . . ' � � , , ' ' ' . .. . ' � . '!�. . . . . ' ' ' , '� � , . , . ' • ' , , '' .�l'. . I�' .� � . �� ,. ' . � , . � .. , � , . • ` . t."��,,: .s';r� , . , : ' ` . "� . i �,� ' " , ; � � : ' ' f . , i � , ' . � . � . 3 I �1 , +t, � i. � • .> , . ! . .. �'} . <� � , . . , . ' . .. . , . . ' ' , ' � ' , , . . . ' ' ' �.,� . � , t . �. , ' � , � � . , ♦ , . ' ' . . . � . } . ' : , . �f' � � . ' • 3 ` � . . . � ' . ' � . . �!tl^i.y'�..�, ,. '>... .w.:.��,�,trY��!f+:r`.".S�f'.��'s..�...., i� ' , , . � � � , i ', , }� . n ' ' ' : . . . ,. .��.. .. � . � , , . . . �.� , . • . r ' , .�.� � �� - ... . .r�:. �.�� .� . � . . � .,; , . .I, . . � .... ,,• ........• � , . , . ,.� . , , �.;;��:;:.:.. . , � � �. , , �', �•.+= L�': � , • . , . . ' . .i�; .. • ' � • � � . �...�.,� .: . . � � � � : �� 'T�e OrtHop�di� Ce�ter uf West F!o'ryida � � � • ��"' ' ' `� ' .ln: '1. �.�.:.� , • . . . " . . . � . �y.si ' < ' . � �ti�� :I� .'�l".`.��f1'+ ��1 T� �:� i:, , ' •'� • . , . ,.;�� , �� • )as�ph M. sena, M.D. ' � . ,'• a�i �n+s,�,uri�o�;+ . . �. 9S3s so..wu eiu� ', , . , . � Sbsrayl.� f�A�ta+► 51642 � � � '' .St. i�rsoeni:C. P��nA 33iD4 • . . , • � . R�ars 4iU1 � � i � . - � Ptton�: (81 aj 3ii8-d870 , � . • . . . , , . A.. � � � : t�t�u .. . A� • � • . � r ' ' � r ` ' AmRax '... ':•;.�� . :_. �, .: . '. .. D�n !� '« . . � , � , �. � . �^��=� � ' . . . . � . �r . �'` . '• . .. . . � .- � , � . TORA�QL� ORAL 10 Ms . . , , . , . . . • r. ; . �' � .� � , ` � , DISP: # • , ,., �. ' . , . - � � . � � � � . � � SiG: i TAE A. �'6 HRS `- � ' � ' , . ' . . . . . . . ' �. � PRtd PA - . � � � . . ; �, . � � , . ., . , . , 3 � �\ ! ' � R�}'ILJ. �Mt�! ` � ��/i / �: �� ' . ' • . I ' . . . .. �_.� . , � Q , . , .� ..� -.r.+w.wu+.. ' ' ` ?"he O�'t'hopedic Ccrster o f Wiest Florrdd . s� i�r�s+u' aa�n 'lvstph M. 5ersa, M.D. � � �� . SwwuR,� F�� 3�{2 �3l ' R+a►�s Al�'A3-273� // / ' 1'/ _/l i i �r Ph°n�t iai�? 79 N,�,. ,�.�. . Acs � � Aoot�or � � . • U,�rr I . . � � � �� . , � �� .� , � � l/ r . ;f- � �� - � . . �, . � � . , �� . . � � p R� r.� � � /1 a� � r —�LZ � i � � � � � � � �. . . • . . . .. . , , S !M . � `� rF Ti2[35TEES OF mHE ETSPLOItE�S PENSYqN PLAN � Agenda Co�er Memorandum ltem ti Heeting �ate: 1Z/� ' �- � ._.. -.. SUHJECT: CONTINUAT�ON OF 8� EMPLOYEE CDNTRIBUTI4N PERCENTAGE FOR 1993 _� RECOMMENDATION/MOT�QN: AUTHOR�ZE A CONTINUATIDN OF THE 8� EMPLOYEE CONTRIBUTION TO THE PENS�ON PLAN FOR CALENDAR YEAR 1993, AND DESZGNATE A CrTY CONTRIBUTI�N FOR F�SrAL 1.994 WH�CH IS EQUAL TO THE ACTUAL EMPLOYEE CONTR�BUTIONS FOR 1993 � end thnt the appropriate oifictels be uuthorrtzed to exeGUte some. IIACKGRDUPID : � �.`he Employees Pension Plan ordinance pro�ides for a minimum 6� contributi,on by the employe�s, and further grants the Trust�es the authori.ty to i.ncrease the contribution percentage up to an add�.tiona� 2�, prov�.di.ng the City contributes a 1ik� amount. Due to pheno:n�nal asset growth in 199]., a 9.2� total contr.ibution wauld have b�en suffici�nt to meet the state required minimum contra.bution for calendar year 1992. At our suggestion, however, on Ju].y 13, 1992 the Trustees authorized a continuatxon of th� 8� employee contribution �or cal�ndar 1992, and designated a].ik� do�lar amount to be contri.buted by the City during the first six months of fiscal. 1993 (see attached memo for expl.anation oi th� timing of City contra.butions} . At the same t�.me, the TZ'LISt@�5 authorized staff to begin investigating benefit adjustments which could be o��ered to employees without requi�cing a total contribution .i.n excess of 16� (8� employees, 8� City}. one such adjustment currently und�r discussian is an annual increase (ar decrease, but never below the guaranteed bene��t), not to exceed 3�, based on the ac;tuary�s determination tha� it can b� Funded w�.thin the 1G� g�ide�.ine. Pre�.zminary discussions with the actuary indicate that the relativ�l.y �tagnant performance of psnsion pZan assets thus �ar in 1992 may requzre a tota]. contributa.on for 1.993 in excess of 12�. As a result, and in I�.ght of the ongoing d�.scusszons reyarda.ng benefi� i.ncreases, we are recommend�ng a continuatian of th� current a� employee contribution leve�.s at least through 1993, with the City contribut�ng a like dallar amount in the first si.x m�nth� o� fiscal 199�4. Pending another Favorable actuarial report, either bene�it increases could be appraved or contributian rat�s could be reduced effecti,ve a�n 1994. Revicwed by: Qriqirwtirg qept: Costs: N/A Coaa�issivn Attion: l.r.gal S/Fi�a e Total 0 pFproved eudget �.�-- C1 App�oved sr/condltions Purchesing , �A Risk Mgmt. �A �lscr Dept: Cur�ent Fiscnl Yr. 0 a�nicd CIS �! A C] Cantinucd to: ACH � F�nding 5ou�ce: Other 0 Capitul Imp. � 11a++ertiucd: ❑ Ohertinq PcnsiohneFtunding Nemo Dnte; ,• �I f�aper: � � Not Reguired Affcctcd Pnrtic3 0 None ��x� �� ❑ Natified �►PP�QPriatian code: � Hot Rcquired City Hnnager . . , .. i . . . . + , .. �, , i ' , � � ' ' ' ' . ' � � ' . . . , � � � • . 1 � . . . . ' . i . ' . .� . � ' � � , . . i , � . ' �. � . � , . � . t , , . . . {. . , . . ; . ` . 1 , ' ' � � . " ' . . ' . 6�5~ �.�1,.. ' .i.� �...... .� ., �.�,��.,' ..� e � ....... .� �... -. , . ' . , �... . � - ,. . � . 'i . . '. � .. . ... � � � . �1 , . , , � ' ,. CrTY OF CL�ARWATER � ,•' � � � xNTERDEPARTMENT"CORRESPONDENCE . T0: � Kathy R�.ce, Deputy City Manag�r � � FROM:. Dan Deignan, F�.nance Director ' > � COPIES:• M�.chae�. Wright, City Manager . , � . .Setty Deptula, Assi�tant City Manag�r. , . ', ' Je�f Harper, Director o�' Administrative,s�rvices SUBJECT: Explanation of Pens�.on Funding and Discussion o� � . Contribut�.on Rates • DATE: Decembr�r. 3,. 1392 � You requested a clar�.fication of.thE tima.ng di�ferences between � the employee's and tk�e City's annual pension contributions. The . � key point to remember is that th� pensian pian op�rates on a , ca�.endar year, and the annual, actuaridl study is done as of the end of each calendar year. This report, wh�.ch is usually completed in May,:determines the required mi.ni.mum contributa,on for the subsequent calenda� year, which is already five manths ,� old when tl�e report is released. This report determines �he required City cantribution,�(assuming a constant emp�oyee ,contribut�ionj which is then budge�ed and paa.d during ths first six months�of the City's upcoming fiscal year, which begi.ns in October. The'chart below is an attempt to i1.lustrate this ' graphica].].y, usi,ng a circl,e to r,�present th� calendar year. You wi3.]. noti.ce thdt the City � s contra.bution do�s not begin until the ni.nth month of the calendar year, and continues through the third montti of the subsequent cal.endar y�ar. This "delay" is taken into account by the actua�y, and an appropriate interest , adjustment is included in their cantributi.on ca].cuJ.at�.on. EAip � O � �' , DEC JA N � �' ,. ' � ,,t� �. C� , ' � O �, � ty T R 2 � U,�, 1 � "� � ' � � . U F,� � ,y.i 'J3 p "� U' � H U ....�. l7! ' ' � � � � . � b W � � .. � � � o � ` . .a.� � �? � _` � * � ' . � � �� c 3 � � / , '__� . `� : � * ACTUARY REP�RT RECExVED .... , v � :r. .� , '. ic . . , � � . . � ' . . . � ' ' . ' . ' . , � ' .� , . . ' ' • ' '1 . ' � . • ' ' � ... � . � . E' � ,' ' . . . � � � . . . . . . , ' : ' , ' .. � . , ' _ � .. . ' . ' � , . ' ' I t . . I. ,i.��, ': , , '� �I` .� . . � ,• ., ' , • 1 • ,' . . ' . ' y . ., '' . . • � , ° . ' . ti� ' . , . ' ' ' , ' . . . ' . ' � ' • . � � t � 1 € . ` , � . � i � . i • , , � . � d . ' ' � � , , . . . .. � ' . ' , � . . I.. . � , � � � . . . , .., . . ' � ' ' ' � . . ' . , ' . 1.' ' . ��rY :. ... . . . .. . ...... . sl..,�! .. �nt'�'7 r[�.i�l�*',f} r1;��^,1: w'�'t^IYf'I °- . . . ,. . . . . .. . � . . • ' . , . � , ' 3. ... � . . ' • ' r . . . . �' � � . 1 . . � . . . . �, o � . i . ' ' ,Based an the actuarial rep�rt received last May, the required �. aontribution �or calendar�.year�1992 was $3,377,977 whi.ch the. . actuary est�.mated to be 9.2$ o]: total 1992 payro�.l. The ,��ordinance pravides for a minimum�5� contributa.an by th� employ�es, anc3 further provides that the C3ty shall contxibute a � �tlike« amount. �The orda�nance �urther a7.l.aws the Trust�es to �.� increase the contribution by.up to an additiana� 2�, ��should a.t be�found necessary in th� da.scret�on of th� �rustees.« Based on s�taif recommandation in Ju�.y of �.992, the Trustees authorized a . continuata.on af the 8� rate through 1992,�with the City � contributing a like amount in the first six months o� �iscal 9�, ', ,This pxoduced an ��excess" contribu�ion of $2,482,21.7, wh�ch when ,, aqgregated with excess contributions from prior year�, gives a "credit" balance in the pension pZan of $3;�08,107.. This credit , bal'ance is reserved for use in any iuture year when the C3.ty's , contr3.bution wauld otherwise exce�d the employees' contribution. Recent discuss�ans with the actuary have indicated that the stagnant p�rfarmance of.'p�.an as�ets thus �ar in 1J92 may well requa.re a tfltal cnntribution �or 1993 in excess o� 12�. As a� � result, T beliEVe'it would be premature ta reduce the , contributian rate for I993 back to 6� at this tim�. I am, ther��ore, recommending a cflntinua�aon of the 8� rat�, at 1�ast � � until th� 1992 actuarial study�is received in May. If it ,'appears, based on tY�at study, that a reduction is still warranted, one could still, be impl.emented �or the s�cond ha�.t of the �year. , .� � .