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` ;; ... ACTION AGENDA
Board of Trustees' of the Employees' Pension Fund
September 12,1994
.
1:. Cell to order 1. 1:55 p.m.,• ;
2.. ' Approval of Minutes 2. Approved as submitted. ,.
of 8!29194 ;
3. _ Request for acceptance 3. 'Approved.
into membership:
a) Walter Sarna =
b) :Jerry Butler'
c) Willie Porter
d) Derick Blunt
e) Thomas L. Wiggins
` f) Robert Ellington
'i
. 4. Job-Connected Disability Pension 4. Approved, "
' to-be granted:
Kenneth Hovance, Jr.
1... 5-r' ' Other. Business: 5. None.
6.. Adjournment: 6. 1:59 P.M.
!
tow
' TRUSTEES OF THE EMPLOYEES' PENSION FUND Item #,.
Car- Meeting Date: 91121I4
Agenda Cover Memorandum
Subject:
Membership in, Employees'. Pension Plan
Recommendation/Motion:
Employee(s) listed below be accepted into the Employees' Pension Plan as recommended by the
Pension Advisory Committee.
and that the appropriate officials be authorized to execute same.
' BACKGROUND:
Name and Job Class
Walter Sarna, ' Survey' Assistant I
Jerry Butler, Solid Waste Worker
Willie Porter, Equipment bpcrator I
Derick Blunt, PW Service Worker I
Thomas L. Wiggins, Equip, Operator I
Robert Ellington, Equip. Oper. I
Seniority Pension
Dept./Div. DAM Effe?tiye Date
Pub. Wks./Eng. 8/8/94 818/94
Pub. Wks./Solid Waste 8/8/94 8/8194
Parks & Recreation 8/8/94 818/94
Pub. Wks,/Pub. Sera 818194 8/8194
Parks & Recreation 818194 818/94
Parks & Recreation 8/8/94 818/94
Reviewed by: Originating Dept:," Costs: Commission Action:
Legal NA Human Resou s Total
? Approved
?
Budget NA
Purchasing NA?_ _
Risk Mgmt. _NA._ -
User Dept.:
Current FY Approved w/conditions
? Denied
? Continued to:,_,_
CI5 -_ NA
ACM
Advertised: Funding Source:
? Capt. Imp.
Other NA__ Date:
Paper: ? Operating
? Other
Attachments:
M Not required
Submitted by: Affaclod parties
? Notified Appropr)atlon Code: Letter(s)
Not required ? None
Citv Manacter
... :'}!t.,7.i? • d..a:. F'«'r•:r :v •c::1S'. .. , r. 1
'•N eH f':,Y'i9.L.: E.. r?'"f .:' .`i; •i '41' ,e: ??Ss, ti'IS: , ' ' 1 e il. i? iIY ,le ; I ';: f . J .
: '}. `S. i .. '
CITY OF CLEARWATER
EMPLOYEES' PENSION • PLAN
i` PENSION ADVISORY COMMITTEE
' TO. Pension Trustees '
FROM:: Pension Advisory Committee
SUBJECIC: Recommendation for Acceptance into Pension Plan
DATE: August 17, 1994
As Trustees of the 'City of Clearwater Employees' Pension Fund, you are hereby
notified that the
,
r . employec(s) listed below have ,been duly examined by a local physician and each has been
' . designated as a "first class risk".
. These employees are ' eligible for pension membership as noted in the Pension Eligibility Date
column below, and it is the recommendation of the Pension Advisory Committee that they be
accepted into membership.
Pension Elig.
Uamc. lob, ohm. -Dept./Div. irttt_Dgte Hire Dnte
' Walter Sarna; Survey Assistant 1,
P.W./Engineering 10/3/54 81094 8/8194
Jerry. Butler, Solid Waste Worker, 11/10/64 818/94 818194
P.W./Solid Waste
Willie. Porter,, Equipment Operator I,
Parks & Recreation Dept. 1 l/ 1315 6 8/8/94 8/8/94
Derick Blunt, Public, Works Service Worker I,
Public Works/Public Service 1 2/21 /67 818194 818194 '
Thomas L. Wiggins, Equipment Operator I,
Parks & Recreation Dept. 3/ 15160 818/94 8/8/94
Robert Ellington,' Equipment Operator 1, 216161 818/94 818/94
' Parks & Recreation' Dept.
U,W . .
i
r
I •
I
TRUSTEES OF THE EMPLOYEES' PENSION FUND
* Agenda Cover Memorandum
Item # 14
Meeting, Date: 9 / 1 9.L9_4Subject:
Pension to be Granted
Recommendation/Motion:
Kenneth Hovance. Jr., Firefighter, Fire Department, be granted a job-connected disability pension
under Section(s) 2.397 and/or 2.399 of the Employees' Pension Plan as recommended by the
Pension Advisory Committee.
ED and that the appropriate officials be authorized to execute same.
BACKGROUND:
Kenneth Hovance, Jr., Firefighter, Fire Department, was employed by the City on
October 10, 1977, and began participating in the Pension Plan on that date. On April 18, 1994, lie
injured his back while on duty which is the basis for his request for this job-connected disability
pension.
Mr. Hovance has submitted letters from Dr, Jodi A. Shields, dated May 25, 1994, and
Dr. William J. Near, dated July 18, 1994. The letter from Dr. Shields states, "...he fell off of a truck
sustaining both a knee injury and a back injury when lie jammed his left knee ...In any event, this
patient's job description conics under the heading of heavy physical labor. He will not be able to
return to regular duty as a fireman for the rest of his life .,,This is a permanent disability as it
relates to his specific job classification." The letter from Dr. Near states, "The above named patient
was seen by me for a second opinion regarding his lower back injury sustained on April 18,
1994...I do not feel that he will be able to carry out the activities associated with (flat of a Fire
Fighter which requires a significant physical activity on certain occasions...1 feel that this is a
permanent injury and I see no evidence of any improvement on this." Mr. Hovance was sent to
Dr, Richard Lyster for an independent medical evaluation. His report, dated August 10, 1994, states,
"The patient states that he was injured on 4/18/94 while working as a Fire Fighter...The
impression after reading the last definition of duties and tasks of a firefighter would lead me to
believe that the patient would not be able to do the jobs that were assigned as routine firefighting,
particularly in view of the fact that the patient has marked difficulty going to a squat position and
is unable to forward flex easily...,"
Reviewed lay:
Legal. NA
Budget NA__
Purchasing NA
Risk Mgmt. NA
CIS - NA -
ACM • _f 2?:tI
Other NA
Submitted lay:
Originating Dept: Costs: $2.55.9_'7 Commission Action:
Human Resources Total
? Approved
____? ? Approved w/condltlons
User Dept.: Current FY ? Denled
? Continued to:
Advertised:
Date:
Paper:
0 Not required
Affected parties
? Notified
Not required
f=unding Source:
? Capt. imp.
? Operating
JK1 Other Remain , _
Appropriation Code:
646.07410-530100.585
Attachments:
Letter(s)
? None
Manaaer
,.??)5 ij:':??F)'!, :-4''`>>{?Rt;l,?.'f. ,1:lZi ..4.9 ?Q ^(,•.?A'.`.i: 1 rSG? ,s?t• ., y.?..`k, A '_, q.' e'i +,s'
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Agenda, .Item!.- Kenneth Hovance,.Jr;
Page :,2 .. .
September 12'' 199
Mr. Hovance's 'request for `a job-connected disability pension was
FGi approved by the Pension
Advisory .Committee at its meeting.'of 'August 17,.' 1994. This pension .will . be effective at t h e
• expiration ' of, his vacation and sick leave 'as, prorated with Workers' Compensation.. .
Based `on and overage
salary of approximately $33,329 over. the past 'five, years and the
,
'. formula . for computing job-connected disability pensions, • Mr. ' Hovance's - pension , will
approximate. '$2 ,929 annually. Charts- from Finance which take into consideration
"., . mortality rafes and. age' reflect the '"present' value' cast' of financi ng" ,this pensionwill be
approximately' $285,917.
Human Resources Depanment
8131402.13870
C I T Y Q F C L E A R. W A T E R
POST OFFICE BOX 4740
CLEARWATER. FLORIDA 341318.4748
"Ill Honorable, Mayor and Members of the City Commission as Trustees of the
Employees' Pension Plan
FROM: Pension Advisory Committee
COPIES: Kenneth Hovance, Jr.; Debbie Bailey, Payroll Services Manager; Risk
Management
SUBJECT: Pension I'or Kenneth Hovance, Jr.-Jab-Connected Disability Pension
DATE: August 16, 1994
The Pension Advisory Committee (PAC) received an application for disability pension from
Kenneth Hovance, Jr., oil July 22, 1994.
Mr. Hovance has been determined by the Pension Advisory Committee to meet t h e
requirements of the Pension Plan for a job-connected disability pension, He was employed
by the City on October 10, 1977, and began participating in the Pension Plan on that date.
Further, lie has submitted medical documentation, copies of which are attached, relative to
his disability which has been reviewed and approved by the PAC.
By motion made and duly carried at its meeting of August 17, 1994, the Pension Advisory
Committee approved/recommended the granting of a job-connected disability pension to
Mr. Horton in accordance with provisions of Section 2.397 of the City Code. This pension is
to be effective on a date to be determined.
The amount of Mr. Hovance's pension will be calculated by the Finance Department
according to the formula in the Pension Plan for jab-connnected disability pension at such
time as his last five years of service and salary can be computed.
1 hereby certify that the Pension Advisory Committee has approved the granting of a job-
connected disability pension for Kenneth Hovance, Jr„ and the above dates are correct,
I1?
_ _ -_ 1?.dz --
Chairman, Pension Advisory Committee
''Equal Employment and Affirmative Action Employer''
sur astI: .> ... s t .. ?`Lc r1 .:in .?• .. .. ... ....... .( ... - •. - .. ,1, .r ... ,
PENSION REQUEST FORM
I} .Kenneth Hovance, Jr. do hereby apply for retirement from the City of Clearwater
General Employees' Pension Plan.
My benefits date is October 10, 1977 (Entry date into pension plan)
My 'date of hire is October 10, 3.977
My birthday is December 31, 1949
My. Job classification is Firefighter and I work 'in the
Fire Department, Division.
My resignation . date is to be determined
The type of pension for which I ' am applying is (check only one):
Regular Pension based on. years of service
x Job-connected Disability Pension
Non-job-connected Disability Pension
my spouse's name is• LaVerna M. Hovance
Dependent children under the age of i.$ and residing in my household are:
(Print Child's Full Name) (Child's Date of Birth) '
I hereby certify all of the above to be true and correct:
'
July 22, 1994 (Signature) ?J
(Date)
STATE OF FLORIDA. Th foregoing instru ent w% a?knowledpd before me this
COUNTY OF PINELLAS b A,,c rho is er o all
known o me or who has produce' .
identification and ho did/did not take an oath.
k3A I STAtT7 F FLORIDIA.
ignature) COOK
44OptMhHIIttS??SLION EXPIRES; SEPT. 24, 19944
n IillSbel7rTMPuuuC uNnEnwiuviazi
`? \ ; 1 Notary Printed)
OPTION #I: Employees can . receiveI a lump sum payment for vacation ' and
- holiday pay . and 112 of accrued sick leave at the time of
separation from the City. Where will be no 6% . deduction for
pension from this . lump sum payment nor will this amount c o u n t
as earnings in the' calculation of the pension. The last. day of
work will be the termination date and pension benefits will' begin
"
the
following day,
OPTION #2: Employee' can extend termination date •. by the time due for
vacation, holiday pay, and 112 of accrued sick' leave. Termination.
date will be the final, day of extended time. Pension benefits will
begin the. following day. ,
,(Only available to , employees hired prior to 1011188.)
Kenneth Hovance, Jr.
an employee of the City of Clearwater, hereby apply foe
pension benefits under, the City's Employees" Pension Plan.
f hereby certify that I fully . understand the two options - offered to me. I choose to retire using
Option # '2 and wish `niy benefits to be. calculated under this option.
I understand that once this form is signed, my decision is irrevocable.
EMPLOYEE'S SIGNATURE;.
SOCIAL SECURITY #: 157-40-5828
TTNESSES:
ADDRESS: 11990 Orange Blossum Drive
Seminole, FL 34642
DATE: July 22, 1994
{ RICHARD ?F. LYSTER, M.0, P.A:
DIPLOMATE OF THE AMERICAN LARD OF ORTHOPAEDIC SURGERY
FELLOW AMERICAN ACADEMY OF ORTHOPAEDIC SURGERY
1201 FlFrH AVENUE NORTH, SUITE 300 TELEPHONE
Sr, PETERSBURG, FEDPJDA 337W (80) 822.311Q
10 August 94
Debbie Ford
City of Clearwater
Human Resources .
112 S. Osceola
Clearwater, FL 34615
RE: KENNETH HOVANCE
SS:' 157 40 5828
DA: 4/18/94
INS: CLEARWATER FIRE DEPT
Dear Ms. Ford:
I examined Mr. Kenneth Hovance for an IME per your request. The
patient was not accompanied by anyone, however my xray technician was
present during the examination.
The patient states that he was injured on 4/18/94 while working as
a Fire Fighter, He states that he slipped off a snorkle and fell injuring
his back and left knee. He consulted Dr. Rubin and had a cortisone injection
Into the left knee, and was then referred to Dr. Shields for his back pain.
He had xrays and an MRI showing degenerative disc and joint disease.
The left knee responded to Cortisone. The patient at the present has complaints
of back pain in the low back and into both hips. Coughing and sneezing
are negative, but bending, turning and twisting are positive.
The patient states that he has had 4 surgeries to the left knee, and
all menisci has been removed from the knee. He, states that he had 5-
6 surgeries to the right knee and recently had a cartilage replacement by
the Florida Knee Clinic.
The patient denies any other medical problems. He Is presently 44
years of age. He has a high school diploma and has no military service
experience.
In his younger day, the patient played pro baseball for the Astros
farm team for 2 years He As allergic to Penicillin.
On physical examination the patient walks with an easy walking gait.
He can heal and toe walk without difficulty and go to a partial squat, flexing
his knees only to 90° bilaterally. • In the standing position he has a lordotic
curve of 30° and can only extend another 2° complaining of back pain with
extension. He has forward flexion to 70° with no trochanteric or kidney
tenderness to palpation and percussion. He side bends to the right 15°
and to 'the left 14° complaining of pain on the right side. He rotates 90
to the right and left. He has +2 achilles reflexes bilaterally. He has
a right patellar of +1 and left patellar is +2. In the sitting position straight
leg raising is negative at 90°. McMurrays test is positive for mild crepitus
continued.. .
f .
City of Clw' Debbie Ford
• RE t Kenneth Hovance - 157 40 582E
10 August 94
Page Two
ORTHOPE-DIO GUrillIL: r,Y
1201 - 5th AVENUE id. -'SUITt= X00
ST. PUEP BURG, FL 33705
In both the right and leftr knees, Patricks test is negative. The patient
has good extensor tendon great toe strength. He has scars over both knees
on both the medial and lateral . sides. He can. only lift his- legs from the
table 15° complaining of back pain, , He had some mild abdominal tenderness
and tinkling sensation to abdominal exam.
The patient had multiple xrays which were reviewed. The MRI at
Suncoast. Hospital In Largo on 5/16/94 'was read as mild bulging of the L-
2,3 disc with some low grade protrusion of this disc toward the right with
incomplete disruption of the fat plane at the existing nerve root of undetermined
clinical significance. He also has bulging of the L-4,5 disc with incomplete
disruption of the. fat plane without confirmed frank herniation, L-5,S-1 disc
bulging with partial disruption of the fat plane centrally and toward the
left. L'-3,4. disc bulging without confirmation of herniation, mild _ disc space
.narrowing and discogenic changes at L-2,3 , L-4,5 and L-5, S-1 with arthrosis
at these 'levels. The patient also had a lumbar myelogram done on 6/13/94
which indicated mild to moderately bulging discs at .L-2,3 L-3,4 and mild
disc. bulge at' L-4,5 and L-5, S-1. They did not identify any -true herniation.
There was an abnormality of an conjoined nerve root' at L--5, S-1 on the
left side, and moderate degenerative , changes throughout the luinbar spine.
Post myelogram CT scan was performed on 6/13/94 and at that time there
was some slight facet hypertrophy at L-2,3, mild central disc bulging at
L-3,4 without frank herniation and mild degenerative changes. At L-4',5
there was no. appreciable abnormalities except for degenerative changes
around the intorvartebral disc and . some small to marginal osteophytes .
At L-5, S-1 a conjoined nerve root was seen extending toward the left.
The Impression after reading the last definition of duties and tasks
of a fireflghtar would lead me to believe that the patient would not be
able to-do the jabs that were assigned as routine firefighting, }particularly
in view of the fact that the patient has marked difficulty going to a squat
position and is unable to foward flex easily, and when coming, back to the
erect position he got an acute pain and had to do a little back manuvering
to coma back to the erect position. His extension is virtually 0. I believe
that the dogonorative changes as seen on xray will only increase with time.
The knees appoar stable today, but both have crepitus present that will
also advance with age,
If there are further questions please feel free to contact my office.
Sincerely,
C k(Lk J L/Lpw-? Jf
Richard F. Lyster, M.D.
RFL: jch - DBNR signed in his absence to
avoid delay
hlad i taLh ' F..•. .. d I 3`c,?i! f ?V U5- •'?-',t;? ?$ ? ? i MI'1
E., I
16, 1994 SUN COAST HOSPITAL
LARGO FL 34649-2025
813-581--9474
JEXAK 08:11 PO BOX 2025
RADIOLOGY DEPARTMENT
ATIENT NAHE: HOVANCE'KENNETH J
TTENDING DR:.SCH, HOUSE PHY
EFERRING DR: SCH, HOUSE PHY
Y.AM DL.TE: , 5/16/94
UTPATIENT: XR RADIOLOGY'
DESCRIPTION: KnT--MT-LUHBAR SPINE
ZAGNOSIS:
L J.•S ? I. I
,. M/R NUMBER:
RADIOLOGY NUMBER:
TRANSCRIBE DATE:
ORDER NUMBER:'
ACCT. NUMBER:
PAGE 1
203394
7851.8
5/16/94
2355257
9424849
RX cf the lumbar spine uti112.ing 0.5 Tesla GE stationary Vectra unit
tilizing T1 intermediate and T2 WI sagittals and T1 WI axials from 012-L1
hrough L5-S1 reveals Schmorl's nodes along the superior inferior
ntervertebral end plate of Ll 2 3 and superior intervertebral pnd,plate of
4. There is some loss of signal intensity of the discs at L2--3 L3-4 L4-5
nd L.5-S1. There is subtle anterior impressions L2-3 and lass prominently
t L3-4 and on the.l.eft at L4-5 and more centally at L5-S1. There is right
ateral impression on the fat plane with inbomplete disruption of the
nferior margin of the right intervertebral foramina at L2-3 with disc
?ulgirig and probably low grade protrusion of undetermined significance.
'here is some central bulging at the L3-4 disc without confirmation of
kerniati,on in'two planes. At L4-5 there is evidence of some bulging of the
,4-5 disc centrally and slightly towards the left without disruption of the
at plane, Some central bulging of the L4-5 disc with only partial dis-
uption of the fat plane. There is facet arthrosi.s at all lumbar levels
Treater at L4--5 L5-S1 and L3-4. Disc space narrowing at L2-3 L4-5 and
,5-S1 and early at L3-4 is identified.
NPRESSIONS:
MILS? BULGING OF THE L2-3 DISC WITH SOME LOW GRADE PROTRUSION OF THIS
DISC TOWARDS THE RIGHT WITH INCOMPLETE DISRUPTION OF THE FAT PLANE AT
THE EXITING NERVE ROOT OF UNDETERMINED.CLINICAL SIGNIFICANCE.
BULGING OF THE L4-5 DISC WITH INCOMPLETE DISRUPTION OF THE FAT PLANE
WITHOUT CONFIRMED FRANK HERNIATION AT THIS LEVEL.
. L5-S1 DISC BULGING WITH PARTIAL DISRUPTION OF THE FAT PLANES CENTRALLY
AND TOWARDS THE LEFT.
1,3-4 DISC BULGING WITHOUT CONFIRMATION OF HERNIATION.
LD.D SPACE NARROWING AND DISCOGENIC CHANGES AT L2-3 L4-5 AND L5-S1
.AND EARLY T L3-4 WITH ARTHROSIS AT THESE LEVELS.
COMMENT: Y VIEW OF THE SUBTLTY OF THE FINDINGS IN THIS STUDY
CONSIDERATI N OF LUMBAR MYELOGRAM WITH ATTENTION TO L2-3 L4-5 AND L5-51
SHOULD BE C NSIDERED WITH POST-MYELOGRAPHIC CT CORRELATION,
i2: 1229
X94 1207
SHIELDS
0 GULF TO HAY BLVD
MWAT ER FL. 34615
The Florida Knee .
and Orthopedic
Centers May 25, 1994
Oythopedic Surbely
John P. Barrett, M.D.
Ronald Hayter, M.D.,
David Rubins, M. D.
(lrthpedic Medichie
Ricky P. Lockett, D.O.
r Geoffrey Gibson, D.O.
• Jodi A Shields, M.D.
Spille Surgery
Prank: Gomes, M.D.
Clearwater
1664 Gull to Bay 131vd.
Clcanvatrt, FL 3•#615
(613)416.5633
Fax (813) 441.6312
St. Petersburg
3901 66th Street NOtLh
St. Petersburg, FL 33709
(813) 344-5633
Fax (813) 347.6492
Port Richey
9238 U.S.19
Port Richq, FL 34668
(813) 845.5633
Fax (813) 843.0694
Palm Harbor
32572 U.S. 19 North
Paltti Harbor, FL 34684
(813) 766.8800
Fax (813) 766.9388
outside the Tampa Bay Areal
. 1-800,981.8485
Port Rtchcy
Pi1m Hirbor • ,
?1CitMiltr? n ?
5t. Petcaburg ZI a1-
%p
I
City of Clearwater Fire Dept.
610 Franklin Street
Clearwater, FL 34615
RE: KENNETH HOVANCE
OUR CHART NO. 25917
SSA` 157-40-5828
Dear Sirs:
Mr. Hovance has been under my care for lower back
pain since April 26, 1994.
As you are aware, he fell off of a truck sustaining
both a knee injury and a back injury when he jammed
his left knee. He had pre-existing degenerative
joint disease in his right knee and his left knee
and pre-existing multi level degenerative joint
disease of his spine. When he fell out of the
truck, he exacerbated all of these problems.
He has been treated by Dr. Rubins for his knee
problems. The date of the injury was 4/18/94 and,
he was first seen by Dr. Rubins on 4/26/94. fie
first saw me on 5/3/94 for an epidural steroid
injection to help with his low back problems.
The epidural steroid injections did not help with
his back pain in any way and it was decided to do
an MR1 of his lumbar spine. This was done which
showed multiple levels of degenerating discs and
bulging discs from L1 through L5. In addition, it
was recommended based on these findings that a CT
myel.ogram be done for correlation of the subtle
findings on the MRI.
i
SEE,
11' 1 N E' K N 1'. E S 111 I's SHOULDERS
L.
In any event, this patient's job description comes
under the heading, of heavy physical labor. He will
not be able to return to regular duty as a'fireman
for the rest of his-life.
Mr. Hovance, as'you are well-aware, is required to
raise and climb ladders, effect forcible entry into
buildings and ventilate burning buildings and use'
heavy.equipment. Because of his multiple levels of
degeneration in his spine as well as his chronic
DJD in his knees and an acute •synovitis in his
knees, he will be unable to perform this job
function. Light duty would'be appropri to for him
but according to the Clearwater Fire Dept.
guidelines 'light duty is only to be granted when
the patient is expected to become able to perform
full duty at some point in the future. I do not
expect that he will be able to perform full duty at
some point in the future.
This is a permanent disability as it relates to his
specific .. job classification:. If you have any,
questions or need further clarification, please:
contact me at my.Clearwater office.
Sincerely,
Jodi A. Shields, M.D.
JAS/mjn'
ANESTHESIOLOGY'
Jemrar J. La+?. M O.
Robert A. Lewonson, M D.
An&vw Pawl, M.D.
Jonath.n S. R.5, M 0.
CARDIOVASCULAR
THORACIC SURGERY'
Ch"" Car
DERMArpb.l, M O
H.TOLOGY
Ftod S. Ou nw% MO.
Lk+da J. L*)m MD.
WAkmO. Wrd,M.0.
ENDOCRINOLOGY
woi.m P. Ctoorn, M.D.
FAMILY PRACTICE
Jon W. UrMdey, Mo.
James E LoL N. MD.
DIAC-NOSTIC- _ CLINIC
July 18, 1994
E Dorot11 Plena, MD. TO WHOM IT MAY CONCERN :
Chdstophat J. Purodl. MD.
QUIERAUVASCULAR SU;MGW
Jam" T, Elowl, MEL
Mitt" E. Na MD•
INTERNAL M?ulcl RE : HOVANCE, KENNETH, JR. JAMM A. Awry, M.D. 1$ 61 30
R. (anger Down. MD.
Yew Y. Eis, MD.
Karkw I« Kul)k MD.
PalncitF•MuD. The above named patient was seen by me for a second
D ?eE•Prba. o. opinion regarding h45 lower back -injury. sustained on
E+ s MJD. April 1$, 1994.
Janet F. R3vsnbM4 41, MM.
RobeA N. Shobq M.D.
Mkfiael J. Tlturoacvt. M.D.
fikJaraF.Tlmrrwa.MD: Because of the degenerative disc disease found in his
Miptwl E. Trim, MD. ,
JrInS.Vresill.,MD. disc in the lumbar spine, I do not feel that he will be
INTERNAL, Ne=1NMARDIOLOQY
Atant3.GokWnKMD, able to carry out the activities associated with that of
?deW +l°'E MMD. a Fire Fighter which requires a significant physical
Daniel w. Meson iv. M.D.
J.xreys. MD. activity on certain occasions. Forcible entry into
• Sleytr.n 0.S'T "t.?i.r, LAD.
INTERNALMEDICWE buildings, raising and climbing ladders and the use of
GAS&V04EA..Sdm MD. heavy equipment are not compatible with his degenerative
Mrcf" smntel. M.D.
Jowr•AKwdomm%MD. disc disease in his' lumbar spine. I feel that this is a
INTEFVVAJGEMT= MEDICINE
cyn:raA.POOLnInLM.D. permanent injury and I see no evidence of any improvement
James H. Stag. MO.
INTERNAL MEDICINE on this.
HEMATOLOOYrONCOLOOY
Lute F. Fornw%Wr. M 0.
INTERNAL MEOIC1NEINEPMR4LOGY ,
CarrrioWFuul..RD Should you have any questions or comments regarding the
I"ERNAL'Wrqq'???`IN, OWGY above, please do not hesitate .to contact me.
INTERNAL MEDICINE
PULMONARY OISFJISE
Frsncia J. Ave* M.0.
Ronaid E. Bowers, M.D.
Wiff n J. RWwds. Jr.. AID.
INTERNAL MEDICtNE&HEUdATOLOGY
wiuq, M. wagon. Mn.
, EAR, M.D.
NEUROI.OCiY WILLIAM
MkAW S, Evans. MR
Cyntiu Huxrtun, M O. .
Stuart E. Sinox, MD.
06STE7i CS.19YNECOLOGY
James E. Doran. M0. WJN : ms
Robert J. How. MD.
Joseph O. Ku" Ill. Mn,
IVae.as Ruir, MD.
OPHTHALMOLOGYISURGERY 3
DISORDERS OF THE EYE
Edwaa M. Daarsd*r, AID.
Jar*a A. Robe ft 1.10.
ORTHOPEDIC SURGERY
Alan J. Graves. MO
William Now, MD.
Gorden 7yemdoder, M D. ,
OTCLARYNG41.OCiY
EAR. NOSE d THROAT
Jamey s. parna M O,
worn S. GokWem. MO.
PATHOLOGY
Fur morel P". MD
PEDIATRICS
A. Frank Games. MD.
A. Robed Mareik MD
R+ckay Vow. M D.
1uIW C. Vrvaso. M.D.
PEDIATRICS
PEDIATRIC RHEUMATOLCGY
Hobert W. Nckesom Jr.. MD.
PLASTIC SURGERY
Robed P. McCune, MO.
RADrOLOGY(DAGNOSTiC iMAGINa
M. Loton Hwbsd, MO.
T. Lee, MD.
Howard B. Rube. MO.
UFMOGYMBOtOGICAL SURGERY
Robed E. Harken. M D.
Bruce A Senay. M D.
AOAMMSTRATORCUO
Robed R Dipponq 1351 wosl Bay Dave, Largo, Florida 31610 Phone: 18131531-8767
3131 McMullen Booth Road, Cletuwalof, Flalda 31621 Phone: (813) 726-8871
1465 S. Ft. Harrison Avenue, 5wto 204, Cluarwatet, Ronda 34616 Phone: 1917) 443-4302
CENTER FOR OUTPATIENT SURGERY
1401 west Day Drtva, Largo, Flanda M640 Phone: (813) J15-9500
AEV .
FLORIDA DEPARTMENT OF LA60R AND EMPLOYMENT SECURITY
DIVISION OF WORKERS' COMPENSATION
f : ! 1.800.342-1741 (or) contact your local o..ice for assislance
NOTICE OF INJURY' :.?. ., .
hours (9t74)'488.3044..,,, .:.,?•r, .?,::. r., ... ;,:
Report all deaths idthin 24 hou
EMPLOYEE INFDRMATION
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NAME (First, MiCdie, Last} 5ouet Security Number-,,,
; : ti:
Date t o! Accident
157 -40- $2$ 2 '1615?irs. ?` _ ..
[tIXiEADDRESS Inctude7,
{ p) '. :?:,, ! ';i l .EMPLOYEE'S DESCRIPTION OF,AC (DENT.
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EMPLOYER INFORMATION
FIRM'S NAME AND ADDRESS.: FEDERAL I.D. NUMBER DATE AND TIME FIRST REPORTED -'
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learwater,
Dept. 1220
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( Post Office Box 3318 LAST DAY PAID THROUGH,
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FC 34230 ' '
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,_
Clearwater, FL (Pinellas) •'. .: , _ - . _ . : .. 1 - 800. X749-304.4 RATE OF PAY:. - 0 HR•? GWK-
.. NAME, ADDRESS AND TELEPHONE
_ = ?J? Z,,J7?R ? DAY: O MO':
OF PHYSICIAN. OR HOSPITAL.' Number of hour.? biweekly .
DID THE EMPLOYEE KNOWINGLY REFUSE TO USE A SAFETY DOCt6r' S WElk-In Clinic Number of hourn 56-
APPLIANCE PROVIDED BY YOU, THE EMPLOYER? G YES NO
2C 00
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DATE EMPLOYED 1
AST DATE EMPLOYEE WORKED- •
.
.
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per'rreek
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L
RETURNED-TO WORK 0 YES NO AUTHORIZED BY EMPLOYER 0 YES ONO YES 9 NO ?
IF YES, GIVE DATE I 1 _
LOCATION ADDRESS
WAS INJURY FATAL? ? YES
? NO
.
IF YES, GIVE DATE OF DEATH _____L / (LOCATION 4 IF APPLICABLEI
AGREE WITH DESCRIPTION OF ACCIDENT? NATURE OF BUSINESS
p'YES r) NO IF NO ATTACH EXPLANATION
Arry person who, knowingty, and with intent to injure, defraud or deceive any employer or employee, insurance ccmpany or sell-'insured program, fates any statement of
cta,m containin
false or misleadin
information is
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EMPLOYEE SIGNATURE GI aevMatse to son) DATE % EMPLOYER SIGNATURE DATE
FOR CARRIER'S DATE STAMP
REC'D OY CARRIER SENT TO DIVISION
.t'
UAHHICI1l IN?-UHMAI PUN
Carrier Audit # Location + Service Co. 0 Carrier File 4'
? 1. Controverting Case-OWC-12, NOTICE OF DENIAL'ATTACHED
? 2. Lost Time Casa-Date of First Payment ! I AWW Comp Rate First day of disability !
':-Date of First Contact with Claimant ! ! ? In Person ? Telephone ? Mail
---Notice Fled Due to Multiple Periods of Disability, Dates Covered by First Payment
? T.T.D, ? TP.D. Date Form Rac'd, 1 1 ? Catastrophic 7 RT.D, ? Death „
? 3. Medical Only which became a Lost Time Case. (Complete all information In item 2 above)
REMARKS:
ADJUSTER NAME:
DATE: ! /
CARRIER NAME, ADDRESS b TELEPHONE:
RE:
LES Farm DW`C t {trot)
EMPLOYEE COPY
i DIVISION MiCAOFn.M