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04-17-1995• I •'f?lf .1' E' .y..?,?,• .; o .`kLrl, ,fs .'a ..1,'y1 ? .f, ? '1I ?r ? ,?? ? ' -:r ''•• .. ? ? .. ?, . ji? ??4. 1+. E. P6 f ?• ''{ •?r`.!k'j>?: r, .£ _ •?r ,s •x ?,: r `r ?}.?_ ': i+'P:;:i='•,'>?lr?@ t ?. ?+ ;.vi 1 '1 hair. PIT P'. , t. r:c.. ;;.. r? A' ' l ??,. -? ?• , : t °';: ti? ••,?. y ?, .,1 •}? :• `?.'"'Sr rk.!Fri.:f H'krl''? ,"F i• F. `''S .k'; s6 y a rE .r :' • t: '.1;,' I . ai. r ,•?? 1 -; ?'?E?'K.nttlt t. .§'. '• r ' a•i. , ?• ;?' ?.,' ',? J P1•.; k F'?r g`,?' 4 F t l.r. i??. t .•rr 4:.Y t 'Yd's ':i .i; i- r?.,€` -f,. r`-' `tr'=aR.??. # r^'7'',!y1i?-.:"' `}?^ 'r ,jut f?? ?ir'F?f;'?4s ?irl .§].-'e?tz °?1? 5r:vtM /??;F?,7 r%:c, l?+;c?I;',V}?ar;`i.=;!:,. ?...E.?.i':}'t,jJ„'-..•?. .t, f` fr,t° Y;1'i[' s F `?? [ [ r' ??d? ?, !(?. •",?? ?ti s r,;ro lS?'? S §i ?q I?r., .>P ? r .E'!''f °? I: ?4•:. .s:.#iri J °'f.. is". .rl?.... ? "?i ?, , ?•' ' ?-'.`}?"i ?.t' '17.. °,^. 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L ? 1 i '.f ?. ?.; '.`('?t?lr ,.7f? j?7i ..{?, e:.,t•; ' ? :'1?? ? ? 3 ?Y' .. .i ( .. l} , f. ?. ?. ? `?f . •a?•? ? i + { .: f?.r.<ll!?.• .. i , , ( , .,>..a.}: '?.. :.1,'?.?{ !? •r., ,';1 ?. ,, `,/4 ",1: .cf sl,?., ,r•° 1?3 -,. ? . r r '.; . . r t , ?•?:.. :'f^'na.r, '(??fE ; ' r•'. .??= P.r Y?. .. ACTION AGENDA Board of Trusto a of the Employees` Pension Fund Monday, April 17, 1995 Call to order ' 1. 9:17 a.m ; } 2:., Approval of Minutes 2'. Approved as submitted. , of .413195 s '.:. '• .' 3, Request for acceptance' 3. Approved. ' into membership: a} Jared Bradham' : b) Michael Yoder' „ . ? . ; c? Karen Cunkle ' 4. Regular Pension to be granted: E 4'. Approved. - Albert Alston . , ' . 5. Jab=Connected Disability Pension 5. Approved. . to be granted: Kenneth Castelli 6. Other Business: 6. None. ' 7.. Adjournment: 7. 9:20 a.m. F TRUSTEES OF THE EMPLOYEES' PENSION FUND Item fl `- ' Agenda Cover Memorandum, Meeting. Date: 4/17/95 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. Q and that the appropriate officials be authorized to execute same, BACKGROUND, Name and Job, 0Au p?pt.lpi v. Jared' Bradham, Maintenance Worker I Parks & Rec. Michael Yoder, Maintenance Worker 11 Parks & Rec. Karen Cunkle, Senior Accountant Internal Audit. Seniority Pension Date Eff cflyc Date 10/17/94 2/20195 316195 316195 3/20/95 3/20/95 Reviewed by: Originating Dept: Costs: Commission Action: Human Resources Total Legal NA t?7 ? Approved Budget NA ? Approved wlconditions Purchasing NA User Dept.: Current FY ? Denied Risk Mgmt. NA' ? Continued to: Cis ACM Advertised: Funding Source: ? Capt. Imp. Other Date: raper: ? Operating ? Other Attachments: 0 Not required Submitted by: Affected parties Appropriation Code: Letter(s) ? Notified Not required ? None City Manager 4 ?' ?e'a'?.?1'•`i1-• ??iY?j?' {X,t'{r?@s?j '1; •rfe.•.,.'''."'''.1 ., c 4i . ,. .{r .y r:'ii,f'"'•z ??;:f}t'f.?•?°?"lr..,i;`S:•????•.:,?'::s`'•,}y. •1..f ?•fh,;••,?';E +l<5•,. ,. t,r% !?? . { ^. 4 i}anti: s'%{?•Sas•.: r}' ° ,.<t; ''d!'. '.E. ;5. y .F:t '}?'• 'i,'• i1 .x}?.4:,?).' n :F' {?7 ;?p: ?', . t:.:'q..? ,}„ .i.S',' i ).L. bl .41p• ''k' ... li'' ' .' ''L 1 ` 5} ' S,'p. ,1.? ..S sv.5•I''i fl `s'' F , •`i'.' '4 '. Y1.. `? `. i CITY 'OF CLEARWATER EMPLOYEES' PENSION PLAN PENSION ADVISORY, COMMITTEE ?TO:! Pension Trustees FROM: Pension Advisory Committee SUBJECT: Recommendation for Accepts c into Pension Plan }. DA'TMarch 16, 1995 As Trustees of the City of Clearwater Employees'. Pension Fund, you are hereby notified that the employee(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. NaMe,Job. Class, & DepjLDiy Birth Date Hire Date D-= Jared Biadham, SS#261-69-7937 Maintenance Wkr, I,' Parks & Rec.. Dept. 11/17/70 10/ 17/94 2/20/95* 'Employee hired 'from , permanent part-time to full-time permanent 'status. Hire' date reflects date' • hired as permanent part-time, Michael Yoder,. SS#270-760-1416 3/15165 3/6195 3/6/95 Maintenance Wkr. '11, Parks &.Rec. Dept. Karen Cunkle,. SS#261=19-8722. 8/27/55 3/20/95 ' 3120/95 Senior Accountant, Internal Audit Dept. !.'off its • t },r ' .... r TRUSTEES OF THE EMPLOYEES' PENSION FUND Item tf Agenda Cover Memorandum Meeting Date: 7/95 Subject: Pension to be Granted. Recommendation/Motion, Albert Alston, Solid Waste Department, be granted a regular pension under Section(s) 2.396 of t h e Employees' Pension Plan as recommended by the Pension Advisory Committee. ? and that the appropriate officials be authorized to execute same. BACKGROUND: Albert Alston, Solid Waste Equipment Operator, Solid Waste Department, was employed by the City on February 10, '1964, and began participating in the Pension Plan on that date. His retirement will be effective on March 16, 1995, at the beginning of the day, Mr. Alston's pension was approved by the Pension Advisory Committee at its meeting of March 16, 1995: Based on an. average salary of approximately $30,037 over the past five years and t 11 e formula for computing regular pensions, this pension will approximate $23,279 annually. Charts from Finance which take into consideration mortality rates and age reflect the "present value cost of financing" this pension will be approximately $266,505. The estimated pension cost (cash payout over the life of the pensioner and his/her spouse) is $512,134. Reviewed by: Originating Dept: Human Resourc Legal NA Budget NA Purchasing NA User Dept.: Risk Mgmt. NA CIS ACM J 'L-9-- Advertised: Other NA .. Dale: Paper: [A Not required Submitted by: Affected parties ? Notified Not required City Manager Costs: ?? 6.5 0 5 Commission Action: Total ? Approved ? Approved w/conditions Current FY ? Denied ? Continued to: Funding Source: ? Capt. Imp. ? Operating ® Other i?enslon_- Attachments: Appropriation Code: Letter(s) 6M-07410-514100-585- ? None Q4.? WW .. '?. r`7 'in ., t"!+. s?,.l7:?l+:?pNK9.f i'??,:.., ..:S.a"ri,,'_'t'?P,?, 2iE,r+: ,,:JJ.., I".'?{" '1?i: 1'.l?:'h.'• '?r?• 'S.' ,E. '? ' ,?'.[er !fl, I?)V?" .i%?.1.,?''+,''S Ta ?"fs?''.'s?"+. f,$:.?+, r.,i!•?ti•Y3?,'E,.',.J-r e.;,.?rl, f..S , yi '(,'. rLi i;/. ,? .s„ ??:.y,'r?'°41'T?;,tr ,F?°., ..s '},: ;.i{' }`. r"+ '. ? ? `??'' ? '?tt'? ?i' •. , '+. ., :i` ''iYY!.°s'LV .. ?A : , ... .. t t. ..'IMI .. , r ?a •1'. 4• .. ?5 :. .c , r '1' ?' ? ? .. .''S.• ? ?'' r _ r,? i ;. . C I T Y '0 F C L E A R' W A.T E R POST OFFICE BOX 4748' CLEARWATER. FLORIDA 34618-4748 •.7 Human Resources Department • ? . 8131482.8870 'IC? Honorable Mayor and Members of the City Commission as Trustees of the Employees' Pension Plan FROM: Pension , Advisory Committee COPIES: Debbie Bailey, Payroll Services Manager Employee's File, SUBJECT: Regular. Pension-'Albert Alston DATE:: . March 16, 1995 r The Pension Advisory Committee received an application for regular ' pension' from Albert Alston on March 14, 1995. Mr. Alston was employed by the City on February 10, 1964, and has been a participant in the Pension Plan since that date.' The amount of Mr. Alston's pension will be computed by tile Finance Department at such, time as his last five years of service and salary can' be calculated. By motion made and duly carried at its meeting of March 16, 1995, the Pension Advisory Committee approved/recommended a regular pension based on years of service for Albert Alston in accordance with Section 2,396 of the City Code. This pension will be effective on March 16, 1995, at the beginning of the day. ' I hereby certify that the Pension Advisory Committee has approved the granting of a regular retirement pension for Albert Alston and the above dates are correct, Cha an, Pension Advisory Committee M, "Equal Employment and Allirmatlve Actlon Employer' grad `?r'??......... !!` ,,., 'y[ ,f :4 a:l'I't>,r• , ,.... ,. . ;It• , ..?. • . . ? ?• .. ',' .. •. PENSION REQUEST, FORNI '. Albert Alston do hereby apply for retirement from the City of Clearwater ' General Employe es' Pension Plan. My' benefits date is February 10, 1964 (Entry date ' into pension plan) M y, date of hire is February 10, 1964 My birthday is _ October 4, 1936 My job classification is solid waste Equipment Operator and I work in the Solid Waste Department, DivIs iotk. M y resignation date is March 15, 1995 The type . of pension for which I am applying is (check only one): ' x Regular Pension based • on years of service ,)lob-connected Disability Pe.nsion ` Non-job-connected Disability Pension, " My spouse's name is: Juanita 6/21/31 Dep endent children under the age of 13 . 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 correc : - ----- 2 .. Signature) March 14, 2995 (Date) STATE OF FLORIDA COUNTY OF PINELLAS T ? 11)rego•n5 ins umpntfftvas acknowledged b::fore nie this Lei I)by 0/12zt,r-- (Z"S Aa who is personally kng tv o me or who has produced as identification ?n who did/did not take an oath. bli 1' n My t Mss i stove as c u 1,1_1t!N,?_ _ Notary Gin 6. tq% ?,;.• : r ?,..rti• e?n?urm??w,?nwxa?.uc (Signature) Commission No. / nted) P N(t/ ?? L f N a otary i I rt. Name o OPTION 41:' Employees can receive a lump sum payment for vacation and holiday pay. and 112 of accrued sick leave at the time of separation from the City. There will. be no 6% deduction for pension from this lump sum payment nor will this amount count as earnings in the calculation of the pension. The last day of work will be the termination date and pension benefits will begin the following day. OPTION ;#Z: Employee can extend termination date by the time due for vacation, holiday pay, and If2 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 ' Albert Alston I, . . - ?. •..•„ an employee of the City of Clearwater, hereby apply for pension benefits under the City's Employees' Pension Plan. I hereby certify that I fully understand the two options offered to me. I choose to retire using Option n 1 and wish my benefits to be calculated under this option, I • understand that once this form is signed, my decision is irrevocable. EMPLOYEE'S SIGZNATURE ' Z /. SOCIAL SECURITY : 249-46-2914 WITNESSES: ,ADDRESS: 1206 Beachwood Avenue < ? z Cleangat_er, FL 34619--2611 ?• 1 ? ? -, -- DATE: March 14, 1995 T - -- TRUSTEES OF THE EMPLOYEES' PENSION FIEND Item # Q°` $ 4/ Agenda. Cover Memorandum Meeting Date: .17( ??i r u wM..rrr?r Subject: .Pension to be Granted. Recommendation/Motion: Kenneth Castelli, Tree Trimmer, Parks & Recreation 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. ? and that the appropriate officials be authorized to execute same. wrr•???wrr•?r?r^??rrwwn?i rrrr???r.rrr+rwr??ir,rrrw?rr BACKGROUND: Kenneth Castelli, Tree Trimmer, Parks & Recreation Department, was employed by the City on October 21, 1991, and began participating in the Pension Plan on that date. On March 10, 1994, he suffered an injury to his neck while on duty which is the basis for his request for this job-connected disability pension. Mr. Castelli has submitted letters from Dr. Michael D. Slomka, dated March 10, 1995; Dr. William W. Dodson, dated February 20, 1995, and January 25, 1995; Dr. Jeffrey S. Walker, dated February 17, 1995, and January 31, 1995; and Dr. Gary G. Moskovitz, dated January 27, 1995. The letter from Dr. Slomka states, "I believe that there is a permanent physieal impairment of 9% of the body as a whole ...I think that his return to tree work which involves climbing and placing himself in trees or on ladders would be hazardous and I do not expect that tie would return to this type of employment." Dr. Dodson states, "His official work description includes: climbing trees, using a bucket truck and chain saw. trimming and removing true branches, none of which can be done by this patient since that level of upper extremity use is not possible due to his neck pain which increases with exertion and radiates to the left more than his right shoulder. Within a reasonable degree of medical probability, the inability to do the above activities is permanent." Dr. Walker states, "He is having neck and shoulder pain radiating into his upper left arm. These symptoms are consistent with post operative C-5 and C-5 diseectomy which I feel he is permanently and totally disabled to return to his profession." Dr. Moskovitz states, "I do not think this man is able to perform the duties of his regular occupation, which was mainly tree cutting. This is very heavy work. I would recommend that he be retrained for a lighter duty type of occupation." Reviewed by: Legal NA Budgot NA Purchasing NA Risk Mgmt. , .NA CIS .---NA_....._ ACM _ ru' ,rw Other - b1A Submitted by: Clty Manager Originating Dept: Human Resource; User Dept.: Advertised: Date: Paper: 91 Not required Affected parties ? Notified ® Not required Costs: $243,93.6 Total Current FY Funding Source: ? Capt. Imp. ? Operating ® Other Pension Appropriation Code: -514' 00-585_ 64fiL0741Q-514'.)00-585- 4.itSZ Commission Action: Commission ? Approved ? Approved wlconditlons ? Denied ? Continued to: Attachments: Letter(s) ? None X41 .y: l r. «' .1 I r ,•? - '! . t `•'f ' 1 11. • 1 ' r, , , S : 1 , . ? ..'. .. I' .?'l,:, 3 „4;, ?; 1. +1 'l: ?•1;-:r !e f „1 .3 ?.4 a'.. '.:{)+ '1`E 'e ,},eCy, ,ii'?f:Fj+ •l.. ,:+.;±„r.'., i:M?.-4 ? ,i•. r i •s....'t?'.f.• ,IL... `?t',s' .t'.:.?`;... . .. ?.?i:i:tir ,c. .• :PS..et Sh , tt.'>;??;.,".. -•- .. .. ,t .: ;i?: ?' .?.: .?! v-rciVSs''';C{i. s:cls I , ASenda, Hein'. K nneth Castelli Page. 2, ` April '17, 1995 Mr, Castellili request for' a'. job-connected disability pension ' was approved by the Pension Advisory. Committee at its meeting of March 16, 1945. This pension 'will be effective at the expiration of - his vacation and sick leave accrual... . Based on an average salary; of approximately' $18,874 over 'the past five years and 'the formula for computing job-connected , disability, pensions, 'Mr. Castelli's pension- will approximate $19,02 arinually . (including 15% additional for each' of 'two'.minor ' children). Charts 'from . Finance which take . into consideration mortality, rates and age . reflect 't h e -"present. value cost of financing" this 'pension will be approximately $243,936.. T h e estimated pension 'cost' (cash payout over the' life of the pensioner and his/her spouse) ' is $758,740. . f s 0.4 .?l.rS •?Pf r.ft ,.?..5rr, ,i ' i .r,'1 [ .1 ; eel IL "ON '. C l T Y 0 E C L E'A R W A T E R POST OFFICE Box 4748 CLEARWATER. FLORIDA 34 818.4748 Human Resources Department 8131462-870 TC? Honorable Mayor and Members, of the City Commission as Trustees of the Employees' Pension Plan FROM: Pension Advisory Committee COPIES: Kenneth Castelli; Debbie Bailey, Payroll Services Manager, Risk Management SUBJECT: Pension for Kenneth Castelli ----•Job-Connected Disability Pension DATE: March 16, 1995 The Pension Advisory Committee (PAC) received an application for disability pension from Kenneth Castelli on February 1, 1995. Mr. Castelli 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 21, 1991, and began participating in the Pension Plan on that date. Further, he has submitted medical documentation, copies of which are attached, relative to his disability which has been reviewed and approved by the PAC. By motion made and duly carried at its meeting of March 16, 1995, the Pension Advisory Committee approved/recommended the granting of a job-connected disability pension to Mr. Castelli 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. CasteIli's pension will be calculated by the Finance Department according to the formula in the Pension Plan for job-connnected disability pension at such time as his last five years of service and salary can be computed. 1 hereby certify that the Pension Advisory Committee has approved the granting of a job- connected disability pension for Kenneth Castelli and the above dates arg correct. Ch it an. Pensior Advisory Committee -T•M - +Et-iL "Equal Employment and At IIrmative Action Employer' Nom` 1 PENSION REQUEST FORM I? Kenneth F. Castelli do . hereby apply for retirement from -the City of Clearwater General, Employees' Pension Plan, MY benefits , date is October 21, 1991 (Entry date into pension, plan) My date of hire'is October 21, 1991 My birthday is July 31? 1956 My job ,classification is Tree Trimmer and I work in the Parks & Recreation Department, Parks Division. My resignation date is to be determined The type of pension for which T am applying is (check only one): Regular Pension based on years of service Job-connected Disability Pension _Non-lob-connected Disability Pension My spouse's name is: Vicki, Castalli Dependent children under the age of 13 and residing in my household acre: Andrea 6/20/93 Melina (Print Child's Fall Nacre) 11/29/94 (Child's Date of Birth) - I hereby certify all of the above to be true and correct: ?.,?r.,?.... , 11(5bgnatare) STATE OF FLORIDA COUNTY OF PINELLAS (Date) T ic fore-Ding i trurnen w s r?ckn WI dged before me this by w o is ersQ all nUwn to me or who has produced as i ntificati anti w a d; id rtake an oath. Notary Public (Signature) .,i Commission No. 10 9z;N 12 'nted) A Iii A.MDERSON NOTARY PUBLIC STAIR CF FLORID, COMMISSION NO. C: °,,17;;49 MY COMMI ION FRCP. SLF'T 2.;,1(M, CITY OF CLEARWATER GENERAL, EMPLOYEES' PENSION PLAN OPTIONS GENERAL EMPLOYEES . OPTION #1: Employees can receive a lump sum payment for 'vacation and holiday pay and 1/2 of accrued sick leave at the time of separation from the City. There will be no b% deduction for pension from this lump sum payment nor will this amount count as earnings in the calculation of the 'pension. The last day of work.. will' be the termination date and pension benefits will begin the following day. OP'T'ION #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 1011196.) I, Kenneth R. Castelli an employee of the City of Clearwater, hereby apply for pension benefits under the - City's Employees' Pension Plan. I- hereby certify that I fully understand the, two options offered to me. 1-choose to retire using Option #. 1 and wish my benefits to be calculated under this option. I understand that once this form is signed, my decision is irrevocable. EMPLOYEE'S SIGNATURE 47?6// SOCIAL SECURITY :: 055-46--0366 SES: ADDRESS: 2920 Bayview Drive Safety Harbor, FL 34635 r D February 1, 1995 httls"• ... , .. . AUTHORIZATION TO . RELEASE MEDICAL AND RELATED RECORDS I'. Kenneth R. tastelli an applicant -for disability pension under provisions of the Employees' ' Pension , Plan of the City of Clearwater, hereby authorize any physician' or other medical . care provider who examines or treats ' me or. who has examined or treated m e or who, in the future examines or treats me to release' any and all medical and related records pertaining to the to the City of Clearwater's Pension Advisory Committee, Pension Trustees, Personnel Director', or authorized employees or agents of the City of Clearwater, Florida. Signature February 1, 1995 -Date STATE OF FLORIDA -;h foreaoring instru nt was c!c wle' ?ed, befor Mme this COUNTY ' OF PINELLAS b y ?y'i1 '? (\w o i •,N Pe tonally ??Nn mR. r has produced as identification o di and whi/did of tak an oath. i\?1 11 otarv Public (Signature) Commissi in o}Err.,i •Tr ." : ?iEAL r (Nam or???C. ',Ft d F? ^?FDt, MY Call-[ M152 I 7 M S Dermot'l, O'Connor, M.D. " General Orthopaedics Board Cendied Donald C. Sullivan, M.D. GenemlOrrhopordics ORTHOPEDIC EVALUATION Board Ceruied Michael D. Slomka, M.D. CenetolOrrhopaedks Bwnd Ce ;hed RE: Kenneth Robert castelli Fellow AADEP (Amer-kan Academy Our File No.: 3 5 5 8 5 or Visability Fvotualing Physicians) D I A: 03/10/94 Steven B. Warren, M•D. • SSN: 055-46-0366 Totoljoint Replecement Appointment gate: March 2, 1995 Adult Reconstnxrive Surgery Odhopoedic Surgery BoardCerrised Kenneth Castelli was seen and evaluated at my office on Philip A. Davidson, MA March 2, 1995. This subject is a 38-year-old white male Shoulder &Sports lnjuries who, is 61011 and who weighs 190 pounds. He is right arthoratdc Surgery handed. Board t gable -- - -- He was doing tree work for the City of Clearwater on Fellows of the AAOS March 10, 1994, about one year ago. At that time, he was AmencanAcademy 11 in a high lift 'truck in a bucket 30 feet above the OrthopoedreSurgeons ground. The handle in the truck got stuck, causing the ' truck to -tip and strike the ground. He states that he was thrown out from the bucket, but had a seat belt on and was flung back into the bucket. He had severe pain at that time in the neck, ribs, and the left shoulder, but was not unconscious. He was taken by his boss to Morton Plant Hospital, where x-rays were taken, medications were prescribed, and he was released. The following day, lie was seen at a walk- in clinic and was placed on light duty. About a month later, he was seen by Dr. Dodson and again received physical therapy. This did not help. Eventually, an MRI scan of the cervical spine was performed which showed a disc herniation at C5-6 with a bulge at C6-7. He was then referred to Dr. ,Teffrey Walker, who again prescribed medications and a cervical collar. When he did not improve, he was taken to surgery by Dr. Walker and on September 8, 1994, he underwent a C5-6 anterior microdiscectomy with fusion using iliac crest bone. Kenneth now states that his pain has not improved and, in fact, has been worse since the surgery. He has decreased range of motion. He describes numbness and tingling into the left hand which he did not have before the surgery. 4000 Park Street North 5t. Petersburg, Florida 33709.4026 813-347-1286 FAX: 813.345.3084 r ? 1. A ai. RE: Kenneth Robert Castelli 2 March 2, 1995 He was referred to Dr. Moskovitz, who suggested that the bone had "never fused" and that another surgery should.be'performed. He stated that he could not guarantee that this would improve his symptoms. Kenneth now complains of pain in the neck area, numbness into the left arm and hand, inability to sleep because of pain, and severe headaches. He has been taking Percocet, Darvocet-N 100, Soma and Robaxin. He states that he never had any neck problems prior to the accident. He has not been able to work since the accident and has had increased pain with any activities, although he states that his pain is there all of the time. He is.most comfortable in a reclining chair and is uncomfortable when sitting and lying down. Physical examination reveals a white male. There is a healed anterior cervical scar on the left side. He is tender to palpation over the left trapezius, over the mid cervical area, and over the left. paraspinous muscles. Range of motion is severely limited to 15 degrees of bending in both directions. He extends only to 10 degrees and flexes to 20 degrees, complaining of pain with even the slightest motion in these directions. Rotation is limited in both directions, as well. Deep tendon reflexes are intact in the biceps, triceps and brachioradialis. There is significant weakness of grip on the left side. I do not see any atrophy at this point and there are no specific sensory deficits. I reviewed x-rays which were performed in February of 1995. These show a fusion of C5-6. There is a little bit of posterior spurring. The lines surrounding the fusion are still discernible, however, there is no indication that the graft is being rejected or not incorporated and I think that given more time, it will indeed perhaps incorporate. I am somewhat discouraged by his lack of significant .response following the surgery in terms of pain relief and decreased range of motion. This young man seems well motivated, yet despite the rather discouraging results from the surgery, I do not feel that he should jump into another surgical procedure at this time. I would recommend new x-rays in about six months and perhaps another MRI at that time, especially in view of the post surgery MRI showing no disc herniations. I believe that there is a permanent physical impairment of 9% of the body as a whole based upon the 1993 Florida Impairment Rating Guide, page 13. i:5. .e 1 •' a '' , t `' 1 •' 1 ,` ... . 'rt•iY:'-'J`.K,'l.'d ??<,?h°?i`nl:'.rr P'rf slr'.. ...,w?rn.uCai.. .t. ?', "?1 a'• ri t, .,s,,<'` •'S'''1'=i. :f:r. •.y. 'RE: Kenneth Robert Casteiii 3., March 2 f 1995 If we can be of further assistance, please. do` not. hesitate to contact us,' Michael D. Slomka,.M.b. TAMPA,BAY ORTHOPAEDIC SPECIALISTS MDS:ef' 3/13/95 - ADDENDMIt Ken Castelli called on 3/9/95. He wished me to specifically determine whether or not he could do tree work in the' future with his 9%- impairment and the type of problems he is having in, the cervical area I think. that his return' to tree work which involves•climbing and placing himself in trees or on ladders would be hazardous and I do not expect that he would return to this type'of employment. MDS/maf ,f ALL FLORIDA ORTHOPAEDIC ASSOCIATES Robert G. Hamilton, M.D. Lawrence M. Gnage, M.D.. Brett R. Bolhorncr, M.D. Dale G. Brarrilet, M.D'. ' . Clinton B. Davis, M.D. William W. Dodson. Mt .D. Jorge A. Rodriguez, Jr., M.D. February 20, 1995 Re: Kenneth Castelli Pt#: 43852WC To Whom It May Concern: This report is in support of the request of Kenneth Castelli for a Disability Pension. Kenneth Castelli continues to be seen as a patient in regards to injury sustained in an on-the--job accident on 03/10/94. At that tine, he was working in a high- lift truck which fell approximately 30 ft. Injuries at that time included neck trauma which caused pain. Initial x--rays were negative for fracture, but because symptoms persisted, an MRI was done which showed disc herniation at C5--C6. 'Despite treatment, the symptoms persisted and discectomy fusion surgery was done on 09/08/94 by Dr. Walker. Following the surgery, he continued to have significant neck pain which radiated towards his left. Symptoms continue despite treatment with collars, medication and therapy. A postop MRI was negative disc re-herniation. He was been TTD and not able to work since the surgery. His official work description includes: climbing trees, using a bucket truck and chain saw, trimming and removing tree branches, none of which can be done by this patient since that level of tmper extremity use is not possible due to his neck pain which increases with exertion and radiates to the left more than his right shoulder.. Within a reasonable degree or medical probability, the inability to do the above activities is permanent. The extent to which this injury disables the employee from job performance in relation to specific job classification of duties is total, although he might be able to perform safety checks of equipment prior to and during use, and might be able to drive certain vehicles although they would have to be an automatic transmission and be able to be safely driven with a limited cervical lateral rotation range of motion. It is anticipated that he will be able to stand and walk, although he may not be able to do repetitive lifting over 20 lbs. PHYSICAL, EXAM: Reflexes 2+ at bilateral biceps, triceps, brachioradialis. Strength 5/5 in all muscles tested in the upper extremities for short duration only secondary to discomfort generated. Sensation intact to touch in the upper extremities. C-spine range of motion limited to lateral rotation of 30 degrees bilaterally. There is no point tenderness, however, there is bilateral paraspinal muscle tightness in the C5 region radiating into the bilateral trapezius muscles. P.O. Box 76330 - St. Petersburg, Florida 33734 4600 4th Street :'forth - St. Petersburg, Florida 33703 - (813) 527-5372 - Fax (813) 522-7412 L. i' .+wr4'4!'•f'z§?v?c nl?;i:d?:!.11•'FPfmte.wa. .»r..«s:, to r, r:.?,,rf. .: 4v. r;a ,f 1•Y?7 rj. .j.. r .FC!4.'... r. .. Page Two ' . February 20 , 1.995 ' Re: Castelli, Kenneth t' Pt#: 43852WC ASSESSMM: Neck pain with muscle , spasm.. He,has' limited' range of motion- secondary to C5-6 discotomy with postop MRF negative for recurrent disc herniation. Disabling'factors -include the range of motion''loss of 50% of both neck flexion' and extension as well. as left and right, rotation loss of approximately 35%, This range of motion- loss, as well as the . neck and shoulder pain which radiate-into his upper left arm, are consistent with postoperative C5-6 discotomy. Within a reasonable degree of medical. probability.. he is permanently and,totally disabled to return to his profession. He will continue his TNS unit and medications. He will call for problem or change and follow up per his adjuster. Sincerely, • 1 William W. Dodson, M.D. WWD/rizr , f ?rww Tr3k#? ALL FLORIDA. ORTHOPAEDIC ASSOCIATES Robert G. Hamilton, M.D. Lawrence M. Gnagc, M.D. Brett R. Solhofrier, M.D. Dale G. Bramlct, M.D. ' Clinton B. Davis, M.D. William W. Dodson, M.D. Jorge A. Rodriguez, Jr., M.D. January 25, 1995 RE: CASTCLLT, Keni,eth PT# : 43852 MC O WH014 IT MAY CONCERN : This report is in support of the request of Kenneth Castellz for a Dizabi.lity Pension. 7 Kenneth Castelli continues to be seen as a patient in regards to injury sustained in an on-the-job accident 3/10/94. At that time he was working in a high-lift truck which fell approximately 30 feet.'' injuries included at ghat time was neck trauma which caused pain. Initial x-rays were negative for, fracture but because symptoms persisted an MR1 was done which showed disc herniation at C-5-C-6. Despite treatment the symptoms persisted and diskectomy fusion surgery was done on 9/00/94 by Dr. Walker. Followina the surrrery he continued to have si.yn:z icant neck pain which radiated towards his left. Symptoms continue desr_i ze treatment with col lar:i . medication and therapy. A post:-op MR_! was nesatitre =or di se re- herniation. lie his been TTF1 -nd not a;:l .. to ,q-rk since tile l is, of fici l work description includes: climbing trees, using a bucket truck and chain saw and tvitruring and removinn +:rtic? branches, none of which can be :lore by this patient since that level cf upper extremity use is not possible due to his neck Pain which increases with exertion and radiates to hiz Mt more than his right shoulder. Within-a reasonable degree of medical probability the inability to do the above activities is permanent. The extent to which this injury disables the employee from job performance in relation to specific job classification of duties is total, although he might be able to perform safety checks of equipment prior to and during use and might be able to drive certain vehicles, al though their would haves to have an automatic transmission and be able to be safely driven 'with a limited 6ervical, lateral rotation range of motion. P.O. Box 76330 - St. Petersburg, Florida 33734 4600 4th Street North - St. Petersburg, Florida 33703 - (813) 527-5272 • Fax (813) 522-7412 Page 2 RE: CASTELU, Kenneth.' PT# : 43852 DATE: 01/25/1915 It is anticipated that he will be able to stand and walk. although he may not be, able to do repe i t.i lre 1 ; 44 tin:: Cv<- twenty caunds . PRYMBICAL EXAM: Refclexes 2} at. bilateral biceps, . trice'us, brachi:oradialis. Strength is 5;5 in all muscles tested in the. upper extremities for short'duration only secondary to discomfort. _ generated. Sensation As intact to touch in. the upper extremities C spine range of motion limited to lateral rotation. of 30 degre-, bilaterally There, is no point tenderness, however, there ss balateral paraspinal muscle tightness in the C-5 regior radiatinc into the bilateral trapezius muscles. ASSESSMENT: Neck pain with muscle spasm. status post surgery wi l MRI negative for-.-recurrent 'disd herniation. He will continua.- to ?ase his TErY5 Unit' and meditations. lie will continue on TTD Lor Dr.. Walker. He will call for problem or change and follow-up Per the adjuster. Sincerely, William W. Dodson, M.D. WWD: c= T: 01/?5/'95 g)E 9b, 1201 FIF'T'H AVENUE NORTH. SUITE 511 PHONE: (813) 894-5511 ST. PETERSBURG. FLORIDA 33705 - FAX: (813) 822=0135 February 17, 1995 TO WHOM IT MAY CONCERN: Kenneth Castelli is a patient of mine who had a Worker's Comp accident on March 10, 1994. He was working in a high-lift truck which fell approximately 30 feet. He sustained a neck injury. An MRI was performed and showed disc herniation at C-5 and C-6. He failed all types of conservative measures and was incapacitated by severe neck pain. Surgery was performed on September 9, 1991. Following the surgery Kenneth continued to have significant neck pain. ' His official job description includes: climbing trees, using a bucket truck and chain saw and trimming and removing tree branches,'none of which can be done by this patient since that level of upper extremity, use is riot possible due to his neck pain which increases with exertion. lit regards to Kenneth's disabling factor to his injury, the limited range of motion which is a loss of 50% of forward flexion and loss of approximately 50% of extension. Rotation decreased left and right by 30- 40%. Accompanying his limited range of motion in his neck. He is having neck and shoulder pain radiating into his upper left arm. These symptoms are consistent with post operative C-5 and C-G ' discectomy which I feel he is permanently and totally disabled to return to his profession. ss `. If you need additional inronnation, please contact my office. Sincerely, Ir Jcffrcy S. Walker, M.D., F.A.C. Neurological 5urgcon i Y JSW:rab DIPLOMATE AMERICAN BOARD OF NEUROLOGICAL SURGERY 1201 FIFT1-i AVENUE NORTH, SUITE 511 ST: PETERSBURG, FLORIDA 33705 January 31, 1995 s? •1 %J t: .F TO WHOM IT MAY CONCERN: PHONE: {813) 894-5511 FXX: (813) 822-0135 Kenneth Castelli is a patient of mane who had a Worker's Comp accident an March 10, 1994, He was working in a high-lift truck which fell approximately 30 feet. He sustained a neck injury. An MRI was performed and showed disc herniation at C--5 and C--6. He failed all types of conservative measures and was incapacitated by severe neck pain. Surgery was performed on September 8, 1994. Kenneth was only given a 50 percent chance of helping his neck pain, and no promises of neck relief were given, that the operation was not a really good operation for neck pain, and that it was only done since all corsearvarive measures failed. Following the surgery he continued to`have significant neck pain, despite treatment with collars, medication an therapy. His official job description includes: climbing trees, using a bucket truck' and chain saw and rimming and removing tree branches, none of which can be done by this patient since that level of upper extremity us is not possible due to his neck pain which increases with exertion. Based on his injuries, I feel he is permanenantly unable return to his profession. There will be no improvement to his medical condition in the future. If you need additional information, please contact my office. rel Jeffrey S. Walker,?M.D. Neurological Surgeon JSW:rab Stamped in his absence to avoid delay DIPLOMATE AIMER1CAN BOARD OF NEUROLOGICAL SURGERY ?='S , _J ff 1*/ V ?L• Eau=_...- Mia mdk SwmetyC met ORTHOPAEDIC SURGERY Diplomaler Of The AmcHcaa Board Of Orlbopwdic surey CASTELLI, Kenneth 'Johtt hl. McClure IIf, ht.D. ' Tltonus n gthwab, ,y ;'. 1 / 27 / 95 11arry 5te111matt, hl.D. Charlcs E. Abrahamson, M,D. hilchael L. ltothber,, M.D. Diagnosis: Gary G. hloskovitz,.M.1! NH]`SIC.a! MEDICI.-VE .Cr REHABILITiiVON DOB: 7/31 /56 ACE: 38 Probable.C5-C6 nonunion, six months post C5 - C6 discectomy and autograft effusion. • Cr lg A. Schwartz, 61.Proposed Treatment: Recommend further 6 - 8 weeks of observation to see if there is any increase in consolidation of bone graft. If not, consider reoperation with instrumentation. Mr. Castelli is a 36 year old male, who in March 1994 sustained an injury to his neck at work in his tree-cutting packer, Sustained a fall while he was in the hoe. He rolled in the ground following this. He had severe pain in his neck area with (L) sided dominance. As symptoms persisted a short while later he began experiencing radicular discomfort in the posterior aspect of his shoulder radiating down the posterior aspect of his arm, but not into the forearm, according to the patient. His symptoms are persistent. He had a trial of conservative therapy without improvement, which included anti- inflammatory medication, steroidal anti-inflammatory-s, and physiotherapy. He had an MRI scan done in September 1994. He has had the C5--C6 discectomy and fusion performed by Dr. Walker. Postoperatively, according to patient, he has not had improvement in symptoms. He continues to have persistence of this difficult: neck pain which is mainly on the (L) side. %pproximately a month to six weeks after surgery, he began experiencing radicular discomfort into the forearm and the dig.-.-:s of the forearm with numbness and tingling. In the last 2.5 to 3 months, he has been in physiotherapy without any improvement in symptoms. He feels that when he does active range of motion exercises this exacerbates his neck discomfort. He does not have any problems with passive .modalities. He feels pain in his (L) neck -nd trapezial area, and apparently on a fairly constant basis with frequent radicular symptoms in the (L) upper extremity. He has had no improvement within the last several months. He grades his symptoms as being approximately 7/?0 and on an ongoing basis. He has been a tree-cutter over the past 20 years. He has been working for the City of Clearwater for the past 3.5 to 4 years cutting trees. His job involves heavy 1'..1 to}it 1'tL'?' ??'Ylll t??l?itPd;ttCr 1'1ur11j,1 1)I?1(1 ii11,1} •+i?l.hfl?i. {:?,?? {51? .. .t11 ' w. ,E I ORTHOPAEDIC SURGERY CENTER OF CLE.ARWA TER, P.A. • 1528 Lakeview Road Clearwater, FL 34616 (813)461.6026. Fax (813) 461-1492 -2 CASTELLI, Kenneth 1/27/95 Continued: work: using power equipment; using saws; pushing, pulling, and moving on the heavy branches, either directly or through various pulleys: It also involves frequent work,at heights, and also the use of ladders SOCIAL Married with two children. He does not have any HISTORY: other skills other than tree cutting skills. EXAMINATION: Pleasant 38 year old male, with well healed (L) anterior paracervical scar. Well healed iliac crest scar. Neck range of motion is markedly limited. Loss of 50% of forward flexion and loss of approximately 50% of extension. Rotation to the (R) and (L) is decreased by 30-40%. Extension and rotation to the (L) causes marked exacerbation of (L) neck pain and trapezial discomfort. Shoulder examination is normal. MOTOR: Full. SENSORY: No deficits. Reflexes are bilaterally equal and appropriate. X-RAY: Review of the radiological investigations: MR! scan from 6/14/94, T1 and T2 weight images, post sagittal and axial reconstructions. Sagittal reconstruction reveals a finding consistent with degenerative disc disease at C5- C6 with posterior osteophyte formation with some impingement of the thecal sac. No visible impingement of the cord. Axial reconstructions reveal combination of bony osteophyte and a small central to the (L) sided disc herniation. IMPRESSION: Degenerative changes C5-C6 with a small central to (L) sideu disc herniation C5-C6. Small disc bulge C6-C7 central. MRI Examination 12/21/9 reveals post operative changes at C5-C6 with graft placement in the middle third of the vertebra. No visible signs of residual compression of the thecal sac or spinal cord visible. This is after review of the sagittal and axial images. Review of the plain x-ray films, and I only have a lateral C-spines, one is intraoperative placement of the C5-C6 space. The other ones were taken in September and October.. They reveal good position of the bone graft at C5-C6 j.3 14 ti- 1"4 a ORTHOPAEDIC SURGERY CENTER OF CLEAR41ATER, P.A, •. 1528 Lakeview Road Clearwater, FL 34616 (813) 461-6026 Fax(313; 461-1492 ..3 CASTELLI, Kenneth • 1 /27/95 Continued: middle third. I do not have any x-rays that.are any more recent that.October of 1994. In regard to laterals o£,the C--spine, I do : have an AP from December of 1994. X--RAYS: Examinations were performed here. Flexion and extension films. Interpretation of current x-ray reveals that there appears to be a change in the position of C5-C6 vertebrae relative to each other. In flexion vs. extension films, he develops slight: anterior angulatory deformity. There is increase in the anterior space and decrease in the posterior space. With extension, there is also appearance of radiolucent lines both superior and inferior to the graft. i' This is indicative and it is highly suspicious of probable nonunion. IMPRESSION: 38 year old male who is having persistent symptoms in his neck and also is having some intermittent radicular symptoms in the {L} upper extremity. His neck range of motion is poor. He has exacerbation with active range of motion in physiotherapy.. Clinically, ;his is consistent with possible/probable nonunion, This is to further confirmed. radiologically. I recommended that we discontinue active range of motion exercises at physiotherapy and continue with passive modalities. It appea-s to be providing some symptomatic relief. Usually, there is a fairly solid consolidation of the graft in a male of his age by about 4 rnDnths of age. I do not see this occurring in his case. it has•been six months already. I am not sure if he is going to go on to a solid union. Nevertheless, I thank that we should wait a while longer to be completely sure. I would recommend repeating lexion/extension C-soi.ne vie..s in approximately a month and a half. T f by that which will be a total o= about 7.5 monti:s there as no evidence of consolidation, and the patient is still symptomatic, and I believe that is what is likely going to be the case, we will consider operative intervention. This would be in the form of removal of the old graft, taking down the nonunion site, and replacing it with another wider surface bone graft with likely plate fixation of the area. .Nit,•••[??it?????r'. ?r'?`,:j?,ai rp, , ..». ,.h, a.... .. .. ., ... n - .: f' .. .:'/ '' • .. i-„' "'E?:,., .'. ,. , '.' .' ORTHOPAEDIC SURGERY CENTER OF CLEARWATER, P.A. I528 Lakeview Road I - Clearwater, FL 34616 (813) 461=6026, 'Fax (813) 461-1492 CASTELLI, Kenneth., 1127195 ' Continued: I do not think that this man is able to perform the duties of his regular occupation, which was mainly tree cutting. This is very heavy work. I would recommend that he.be retrained for a lighter duty type of-occupation. He has an option to return to'see me in six weeks if he wishes. Dictated by: Gary G. Moskovitz_t_ M.D.[chm. UPON! xc Andrew LoScalzo Palm Harbor Physical Therapy 2323 Curlew Road, Suite 2-C -Palm Harbor,'FL 34683 Wm. W. Dodson, M.D. All Florida Orthopaedic Assoc. PO-Box-76330 St. Petersburg, FL 3.3703 1 , .?1 0 SION LOCROnLM FLORIDA DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY ' DIVISION OF WORKERS' COMPENSATION 1.900-342.1741 (or) contact your local office for assistance NOTICE OF INJURY Report all deaths within 24 hours (904) 488.3044, Cif AI AVCC 1?4CAr]fffTlAfl FOR CARRIER'S DATE STAMP RECD BY CARRIER SENT TO DIVISION NAME (First, Middle, Last) . Social Security Number Date and Tlma of Accident Kanne t h Robert C :astelli 055-4b-0366 -3/10/94 9:40 ?.r?. HOME ADDRESS (Include Zip) EMPLOYEE'S DESCRIPTION OF ACCIDENT 2920 ;3a-,ti,1W Jrivr, Sz.iuc! Harbor, 'L 34695 11.:411 Li=t t:-tuck tilted over. TELEPHONE .off coryf )1.) rte 1 V L-U.) I J DESCRIBE INJURY. OR-016EASt AND INDICATE PART OF BOGY AFFECTED i n er at sec nd Joint rracluro of r' ht Index f ribs land lsonln tc (e I OCCUPATION s r C e: X ' _]mt r ;• L t i , •g? g g o i d 9„e ) , e a Lit: 132c?._ UL :.LD:; /tilts L8wer llt. Vi :l•:C7C ,o wa C DATE O BIRTH SEX DID YOU REQUEST MEDICAL CARE? 6} YES ? NO V 1 1 31 1 56 Q M OF IF YES, DtD EMPLOYER PROVIDE MEDICAL? ELI YES D NO EMPLOYER INFORMATION FIRM'S NAME AND ADDRESS FEDERAL I,D. NUMBER DATE AND TIME FIRST REPORTED City Clezir :tce r 59--n(7002IIS9 3/10/94 9:00 a.m. P arlt0 iiid Nccl: a atikhn D- ept. 1691 W.C. COVERAGE BY POLICYIMEMBER NUMBER ?.J. L;o:, 474,, 0INSURANCE CO. -ISELF•INSURED Cl as r a c nt r , .'L, 34 613 NAME, ADDRESS. TELEPHONE OF OR SERVICE COMPANY INSURANCE CO WILL YOU CONTINUE TO PAY TELEPHONE r . ,) 1+U`??J . ALARY? YE ? ` Nei Johns Eastern Compan Inc S C71- NO S PLACE OF ACCIDENT (Str"t. City, County, Stale) y, . Post Office Sox 33 18 LAST DAY PAID THRCUGH 41=+ t 13;tL?? 1 a :i Ca Be t Sarasota, FL 34230 r 1 Ci1_-a rwa t o ` , piae ills , _, I - 800 - 749-3044 RATE OF PAY © HR CI WK NAME, ADDRESS AND TELEPHONE , OF PHYSICIAN OR HOSPITAL 3/ 1U! J•+ S-8 r) 7 • 1 PER O DAY Q MO NUm0er01 hours 13/tar DID THE EMPLOYEE KNOWINGLY REFUSE TO USE A SAFETY ., s .. , , darton ?haft: per on Number o t hours , .- rU APPLIANCE PROVIDED BYYOU,THE EMPLOYER? ?YES CNO per week M DATE EMPLOYED LAST DATE: EMPLOYEE WORKED f;L1? TKtltlCV (::tre o orr week ayu - 1J t :.'1 t `?1 1 323 Jr:Llgrd5 St. :]-w. 346 1'3 PAID FOR DATE OF INJURY RETURNED TO WORK YES ? NO F AUTHORIZED BY EMPLOYER r? YE5 ? NO YES © NO C) 1 1 94 IF YES, GIVE DATE U 31 LOCATION ADDRESS WAS INJURY FATAL? E3 YES G NO IF YES, GIVE DATE OF DEATH 1 1 (LOCATION N IF APPLICABLE) AGREE WITH DESCRIPTION OF ACCIDENT? NATURE OF BUSINESS (TYES ONO IF NO ATTACH EXPLANATION .Yu±aiCi.pa? ity Any person who, known" and with Intent to injure, dafraud or deceive any emptoyer or employee, insurance company or sell-insured program, files any statement of claim containing any tafse or misleading Intormauon is guilty of a felony of the third degree. I h o provided the employea their copy of this notice: Persan ? ay 11 _ EMPLOYEE SIGNATURE (tI A,.ulatAa to %In) • WE EMPLOYER SIGNATURE ? DATE . l.tis!. CARRIER INFORMATION Carrier Audit # Location # Service Co. # Carrier File # 0 1, Controverting Case--OWC•12, NOTICE OF DENIAL'ATTACHED ? 2. Last Time Case-Date of First Payment { I AWW Camp Rata First day of disability f -Date of First Contact with Claimant ! ? In Person ? Telephone ? Mail -Notice Filed Due to Multiple Periods of Disability. Oates Covered by First Payment ? T.T,D. ? T.P.D. Date Form Ree'd. 1 © Catastrophic Q P.7D, ? Death ? 3. Medical Only which became a Lost Time Case. (Complete all information in item 2 above) REMARKS: a ADJUSTER NAME: CARRIER NAME. ADDRESS S TE DATE: ! 1 BAR 1 1 ? ADJUSTER SIGNATURE: 1994 EMPLOYER COPY