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Approved as submitted. of 6112/95 ' .' 3. ..'Request for acceptance 3., Approved. 1 'into, membership: ` a) Howard McChesney b) Mladen Zdjelar c) Mark Beery d) Edward Kutta e) Janie Williams Regular Pension to be granted: .4. Granted. Judith Adriance 5. Job-Connected Disability Pension 5. Granted. to be granted: Stephen Revello 6. Jots-Connected Disability Pension 6. Granted. to be granted:* Gerald Klinske 7. Other Business: 7. The Deputy City Manager reported she has responded to the Unions request for further negotiations, indicating negotiations are complete. 8. Adjournment: 8.' 10:55 a.m. PFA 7117/95 .r TRUSTEES OF THE EMPLOYEES' PENSION FUND Item # Meeting Date:. 711 Z I U 5 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 Jab Class Howard. McChesney, PC Support Tech, II Mladen Zdjelar, Communications Tech. Mark Beery, Container Maint. Worker Edward Kutta, Maintenance Worker I Janie Williams, Librarian III Dept./Div. Information Mgmt. General Services Solid Waste Parks & Rec, Library Seniority Pension D-= Effective Date 6/ 12/95 6/12/95 6112/95 6/12/95 6/ 12/95 6112/95 7/1 1/94 5/30/95 6112/95 6/ 12/95 Reviewed by: Originating , Dept: Human Resources Legal NA I L Budget- NA- - Purchasing , NA- User Dept.: Risk Mgmt. _?NA- cis .,.,„ NA ACM Advertised: Other NA- Data: Paper: ® Not required Submitted by: Affected parties ? Notified ? Not required r posts: ? Commission Action: Total ? Approved ? Approved w/conditions Current FY ? Denied ? Continued to: Funding Source: ? Capt. Imp. ? Operating ? Other Attachments: Appropriation Code: Letter(s) ? None L =ill. .r j?• .,r• I., .. 1. ! ., .. j,. S ,,• : {t, • bias :h• .?;'. •r.^. -s)'J .r .+. aE. • ",! .. .. . . , , }." ` .a• •!7.'fT:. .?i -';?. .c.latn?:r..,..u?........ .. ....... ......-..t: it•h ii . ,. ?.' CITY' OF CLEARWATER ' EMPLOYEES' PENSION PLAN. PENSION 'ADVISORY COMMITTEE TO: Pension Trustees FROM: Pension Advisory Committee' SUBJECT:., Recommendation for Acceptance into Pension Plan DATE: June 8,'1995 As Trustees of the City of Clcarwaier 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. I , Pension Elig. Name, Job. Class, &'Dcot,jDiv. Birth Dale Hire Date Dote Howard McChesney', SS#482-72-7145 PC Support Tech. II; Info. Mngmt. 1 112 915 4 6/12/95 6/12/95 Mladen Zdjelar, SSU593-17-2669 111153 6112195 6112195 Communications Tech.; Gen. Svcs. Dept. [ ' I • I ' + ' • ' 11 ,.' ; 1 + '' t ' ' ,. } 1 ' 1 `• "i ' ' :} ' 'i 1" •> ,?r ' ).' tr .,j3?i11M.F ,i??rr{?. N51'd•ti ?j r'1}, 511.{''.:r.;t''n'I'}?,? 7?? IVeE ?' °M1`f'1??'1 ,t??rt 1, i,t ?1 ?' •,'E': E t.. •t? i• r?7;:; LLK'<<, ?;'t??'?T'S. .sj?i•,. .t r.f ?.- )? ''S: t'.1 '., f. a''?'? 1?? '.(„. .ts M S+• ' ? o` .. y: Jl::... ' CITY, OF CLEARWATER ' EMPLOYEES' `PENSION PLAN PENSION ADVISORY COMMITTEE ; TO.: Pcnsinn . Trustees r FROM Pension Advisory .'Committee SUBJECT; Recommendation for Acceptance into Pension Plan ` DATE: June 22, 1995 As Trustees' of the City of Clearwater Entployecs' Pension Fund, you are hereby notified that the . employee(s) -listed below have been duly examined by a local physician and each " has been designhted' as a,-"first class risk". ., Theie employees are eligible for pension membership as noted in the Pension Eligibility .Date . column: below, and it is the recommendation of the Pension Advisory ' Cormittee that they 'be accepted into membership. Pension Elig. ]!I;1mQ, Job, Class, &..QeaL iv.° Birth Date Hire Date p Mark Beery, SS# 589=22-3750 i Container Maintenance Worker, 316173 6112/95' 611 2195 Solid Waste Department ' Edward kutta, SS# 342-50-5667 11/13/53 7111194 •' *5130/95 Maintenance Worker,1 Parks & Recreation/Parks ; 'Employee hired from terporary to ..full-tinre permanent "status. Hire date reflects date hired as temporary. Janie Williams, SS# 266-94-8944 . 1219145 6112/95 6112195 Librarian III " Library Department •if R TRUSTEES OF THE EMPLOYEES' PENSION FUND Item # ` Agenda Cover Memorandum Meeting Date: 7117195 Subject: Pension to be Granted. Recommendatfon/Motion: Judith Adriance, Public Works Department, be granted a regular pension under Section(s) 2.396 of the' Employees' Pension Plan as recommended by the Pension Advisory Committee. and that the appropriate officials be authorized to execute same. BACKGROUND: Judith Adriance, Administrative Support Manager I, Public Works Department; was employed by the City on December 7, 1970, and began participating in the Pension Plan on October 30, 1972. Her. retirement will be effective on May 24, 1996, at the beginning of the day. Ms. Adriance's pension was approved by the Pension Advisory Committee at its meeting of June 8, 1995. Based on an average salary of approximately $32,453 over the past five years and the formula for computing regular 'pensions,, this pension will approximate $19,147 annually. Charts from Finance which take'-into consideration mortality rates and age reflect the "present value cost of financing" this pension will be approximately $215,837. The estimated pension cost (cash .payout over -the life of the pensioner and his/her spouse) is $478,685. Reviewed by: Legal , - NA Budget , NA_ Purchasing „ NA Risk Mgmt. NA CIS _ ACM ?. Other NA Submitted by: City Manager Originating Dept: Human Resources User Dept.: Advertised: Date: Paper: Lk1 Not required Affected parties ? Notified ® Not required Costs: $215.837 Commission Action: Total ? Approved ? Approved w/conditions Current FY ? Denied ? Continued to: Funding Source: ? Capt. Imp. ? Operating Er Other Pension Attachments: Appropriation Code: Letter(s) 846-07410.514100-505• ? None 09, a 1 C I T 'X OF C L E' A .R W A T E R POST OFFICE BOX 4748 S CLEARWATER, FLORIDA 34818.4748 Human Aesouices Department etar4ex•sa7o ' TO. Honorable Mayor and Members of the City Commission as Trustees of the Employees' Pension Plan :FROM: ' Pension. Advisory Committee COPIE& Debbie Bailey, Payroll Services Manager Employee's File SUBJECT: Regular Pension-Judith D. Adriance DATE: June 8, 1995 The Pension Advisory Committee received' an application for regular ' pension from Judith D. Adriance on May 18, 1995. Ms. Adriance was employed by the City on December 7, 1970, and has been a participant i n the Pension Plan since October 30, 1972. The amount of Ms. Adriance's pension will be computed by the Finance Department at such time as her last five years of service and salary can be calculated. By motion made and duly carried at its meeting of June 8, 1995, the Pension Advisory Committee approved/recommended a regular pension based on years of service for Judith D. Adriance in accordance with Section 2.396 of the City Code. This pension will be effective on May 25, 1996, at, the beginning of the day. Y hereby certify that the Pension Advisory Committee has approved the granting of a regular retirement pension for Judith D. Adriance and the above dates are correct. Ch it an, Pension Advisory Committee "Equal Employment and Al firm ative Action Employer" ;.. • 3 3 A. 'w ?. fir.. ?.....rw?.wS.:.iwy.,y... • . 3 ! ? I w . .. .. ti . PENSION REQUEST FORM - i'. Jildith D. ' Adriance do hereby apply for retirement from the City of Clearwater General Eriiployees' Pension Plan. My benefits- date is October 30, 1972 (Entry date into pension-, plan) M y date of hire is December 7,. 1970. ` My birthday is July 30, 1936 'My job classification is Administrative support Manager, T and I work in the Public Works Department.' Division. My resignation date.' is May .24, 199G The type of -pension for which X am applying is (check only 'one): Regular Pension based on years of service r' _ Job connected Disability Pension .Non-lob- connected Disability Pension My' spouse's name is: John G.' Adriance 5/4132 Dependent children tinder the age of 13 and '-residing i n my --household are: (Print Child's Full Name) (Child's Date of Huth) I hereby certify all of the above to be true and co ct: (St;nature) May 18 , 1995 i' (Date) !t o ledged before me this STATE OF FLORIDA he nrcgoing i strume w ik.? COUNTY OF PINELLAS by ha As pe nally r now to me or who has produced ??. as identification and w o did/did not ake an oat L otary Public { ignature) , ,• Commission Na. C'YNr1iIA M ANDMMON NOTARY PUBLIC STATE OF FLORIDA COMMMON NO. CC397649 - MY CAMMi56ION F7CP SEYt Z4L? 'r4? ;' 'i! .7rtt .. t '?:.d? , i':, k. t» _ ?•^ i, ,,_.,. 1.,.t .-•, dir.. , { . .. .L:• r!: ?' ,.1:'.4:4x..- i». . ` .. °t•' ? •. . ' :' • •• ' ` " • ' - ' , . r E r v?R..? '?V Zu .? rt :' _ Y; „' .. i1 .ir.,yr,r ` I ?Si r1'...? xf',.?r gut i . fit . ?1 T 1.: . ' •,?».. ? . .? _?.. .?. a. .. . ..1ir1: i ' ? ? ? ' '1.r i Mi ? ' ? ? r• . 1, ?.. .. ` . .I t ? ? . ? ?.Jr w•W? l1r..e .. V'. •• .wt.wr. ?..-.:rv.?..-.,;.ita,..},1?•t•n:aaw. e.. ..'r'n••r...r.....?,,,,. ? ..» r.,.. - 1 , .. ' 'i r em '„ •S• ? .? ? , ' ? .. .. .. . ... f? , . w?.w f t .• ? .? CITY OF CLEARWATER • ? ..: ..f'." . ' , ,. . err.». ??4.':.:.3..:.."..?-• •L ' '' "• ? ?'• ' ? ` ?? i' , ' . . ,? .. a ,. .. ?. . ?. . F- r . . , .•. .... i, .. .r .??.. ,. ....' i.. GENERAL •EMPLOYEES' PENSION-" PLAN-""-` ,_. ..... OPTIONS - GENERAL EMPLOYEES . -OPTION #X: 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 c o u n t " . as earnings ' in thin calculation f tha, '' Th L d f o o pension. a "a% ay 0 work will be . the.. termination date and pension benefits will begin ,. ' the following'-day' OPTIQ,N, #2: Employee can extend termination date by the time due fot vacation; holiday pay; and ,112 of accrued sick leave. Termination date will be ttie final day of extended time. Pension benefits will begin the following day. (Only available to employees hired prior to 1011190.) * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * I, Judith D. Adriance - 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 # ' 2 and wish my benefits to be calculated under this option. I understand that once this form is signed, my decision is irrevocable. 01 EMPLOYEE'S SIGNATURE: SOCIAL SECURITY; 111-28-7540 CRESS: "058 Villa Terrace Clearwater, FL 34623 ?. May 18, 1995 i " TRUSTEES OF THE EMPLOYEES' PENSION FUND item # tit Agenda Cover Memorandum Meeting Dale: 7/171,96 Subject: Pension to be Granted Recommendation/Motion: Stephen Revello, 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. BACKGROUND: Stephen - Revello, Maintenance ?Vorker II, Parks & Recreation Department, was employed by the City on April 18,' 1983, and began participating in the Pension Plan on that date. On January 9, 1990, he injured his back picking up a high wheel mower while on duty which is the basis for his request for this job-connected disability pension. He suffered further injuries to his back on April 2, 1992, and July 2, 1993. Mr. Revello submitted letters from Dr. Ralph E. Rydell, dated February 13, 1995; Dr. Joseph M. Sena, dated September 23, 1991; and Dr. Kenneth P. Botwin, dated May 3, 1995. The letter from Dr. Rydell states, "...his symptoms are related to a mild disc bulging at L-4 with nerve root entrapment... He is then at maximum medical improvement and has a permanent partial disability of 3% of the body as it whole ...I don't feel that he could return to his previous employment which would require heavy lifting with frequent bending and stooping and twisting." The letter from Dr. Sena states that Mr. Revello "sustained injuries at work on 712193 when lifting a lawn mower ...I do not feel that Nir. Revello is capable of returning to his regular work duty job... He should avoid lifting greater than 50 pounds.-This patient's restrictions include avoiding lifting greater than 50 pounds and avoiding excessive repetitive bending at the low back This represents a permanent partial. disability." The letter from Dr. Botwin states, "I do feel that he has a component of mechanical back pain which is probably related to his disc degeneration at the L4-5 level...With regards to work restrictions, the patient would be able to work at the light/medium work capacity, which would mean lifting 35 pounds on an occasional basis, lifting 15 pounds on a frequent basis and lifting 7 pounds on a constant basis. These physical demands should not be exceeded." Reviewed by: Originating Dept: Human Resources Legal NA Budget NA Purchasing NA _ User Dept.: Risk Mgmt. ?t g.- Ci5 NA ACM =4 ,L 19 Advertised: Other Oats: J`?) Paper: 2 Not required Submitted by: Affected parties ? Notified ® Not required City Manager Costs: $2g3,31 0 Commission Action: Total ? Approved ? Approved w/conditlons Current FY ? Denied ? Continued to: _ Funding Source: ? Capt. Imp. ? Operating ® Other P__ension__ Attachments: Appropriation Code: Letter(s) 64b-074 10-5 1 4300-eiM ? None •'ll. ' 'l;I it i I t° ( .1 3 •. .. t , .!r 1• s•,l 1 11. '1 ? _. . F.. •1'•- 1 . ,f. i.", '• I .. , 4 '1 ': 7Y^ .y. v,,t5i v;j ..'?"«?? si '!' ,.. I 4,• r, eF .. .; , .' JE IFt ? i,l. , y,y.... ,,??yy''rw '??; -? E1`?'?i'• t.. z.'rie;. .f,. t. e?«..: '3..?r. foie ...y.sxlF! •!+: .,,..,?yiR.# :t*„ ' 'a•"??-. .'4? ..3 •F+':di ."}?j yiLt'sF=1r;'.C?:'. p 1:. • r •° ..-M,(L?r.` 1, 1.!L::f 4 a.'•If '. °L !7 .i?l .r 1?'?' ... 'lJl'. }?l`?•r. It j+r'ji? 1 I'.s"?" "1`!. ,..,. r.l/ ',tea "! •?Cy3. ,.4.....1.". .4 PI ,r?/'.1 , Agenda Ttem=Stephe'n Revello. ! Page 2 ; ; . July 17, 1995' Efforts have' been made . on the part of 'the ( City and Mr. Revello to locate . an alternative position ' far him; however, no position' is available that would allow Mr, . Revello - to 'w o rk within his physical ..limitations Mr. Revello's , pension was approved' by the' Pension 1 Advisory Committee at its rneeting?. of. June 8, 1995.. This pension, will be effective` on a date' to be 'determined.` Based on an' average. salary of approximately $18;624. over' ,the past five years and the . formula ' for computing , job-connected disability pensions, Mr. Re'vello's pension will approximate $13,968 annually. Charts from ,Finance which take into consideration. mortality 'Tate; and age reflect' the "present value cost. of financing" this pension will be approximately, $223,310. The estimated pension cost' (cash, payout over the life of. t h e .,..pensioner and hislher spouse) is' $632,417. ' .I I I . ,,...z .I . . o . • , .t.• •1l..*'Y4'N''r . . l . .. , . . .. . t . . - . . .. s.i' f ..t ., .i ..I I I#. C I' T Y O F C L E A "R W A T E R POST OFFICE BOX 47411 CLEARWATER., FLORIDA 34618.4746 Hunan Resources rlevanment ' 8131462-6870 TO. Honorable t'vlayor and Nlembers of the City Commission as Trustees of the Employees" -Pension Plan FROM:,. Pension Advisory Committee COPES: Debbie ' Bailey, Payroll 'Services Nlanager; Risk Management SUBJECT: Pension for . Stephen Revello--Job-Connected Disability Pension % DATE: June S. 1995 The Pension Advisory Committee (PAC) received an application ' for disability pension from Stephen Revello on ylarch 27, 1995. Mr.. Revello has been determined by the Pension Advisory Committee to meet the requirements of the Pension Plan for a job-connected disability pension. He was employed by the City act .?pril 18, 1983, 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 dilly carried at its meeting of June 8, 1995• the Pension Advisory Committee approved/recommended the granting of a job-connected disability pension to NIr. Revello 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. Revello's pension will be calculated by the Finance Department according to the formula in the Pension Plan for job-connected disability pension at such time as his last five years of service and salary can be computed. I hereby certify that the Pension Advisory Committee has approved the granting of a job- connected disability pension for Stephen Revello and the above dates are c rrect. rrxi, 4'? Chailr an, ?Pension' 'Advisory Committee "E,q.ual Employment and Atll'rmative Action Employer' PENSION REQUEST FOR,?t I, . Stephen Revello do hereby apply for retirement from the City of Clearwater General Employees' Pension Plan My benefits date is April 18, 1983 (Entry date into pension plan) M y date of hire is April 18, 1983 My birthday is October 2; 1954 My job classification is Maintynance worker 11 and 'I worst in Parks & Recreation Department, Parks Division. M y resignation bate is to be d6termined The type of pension for which I am applying is (check only one): Regular Pension based on years of service Job-connected Disability Pension Von-job -connected Disability Pension Pamela 6/10/54 SLY spouse's name is; Dependent children under the age of 13 and residing in my household are: Kristen Pamela _ April 10, 1984 - (P t child's Full Name) (Child's Date of Birth) Brittany a r1cla December 12, 1986 I hereby certify all of the above to be true and correct: 6 (Signature) March 27, 1995 -- .(Date) STATE OF K ORIDA The foregoing i?trument w? acknat %Xled-ed ? :;qre raze this COUNTY OF PINELLAS yO1 S by 'L---?-r -'r-?.': who is person-ally Known to me or who h s produced - ? ?``? : `?'? as identifacatign and ,into did/did no take an oath: Notary Public ?- (Signature) Commission No.. IN A-111- --(Yams., .ar'.. the 19 ,. ••{ , •. CITY OF CLEARWATER '. GENERAL EMPLOYEES' PENSION PLAN OPTIONS - GENERAL EyIPLOYEES OPTION #1: • Employees can receive a lump sum payment,. for vacation and holiday pay and 112 of accrued sick leave at the 'time of separation from the City. There will be no, 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. a OPTION 702:. Employee can extend termination date by the time due for vacation, holiday pay, and 112 of accrued sick. leave. Termination •1= date will be the final day of extended time. Pension benefits will begin the following day. {Only available to employees hired prior to 1011190.) ,Stephen 'F. Revello 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 # 1 and wish my benefits to be calculated under this option. I understand that once this form is signed, my decision is irrevocable. ENIPLOYEE'S SIGNATURE: SOCIAL SECURITY 051-52-6208 ADDRESS: 133B Sabal Court Oldsmar, FL 34677 March 27, 1995 .o, }w•?n,?.. ?• ? ? -?. is ? wM? .'1'•r.l •,.,re. 4L -. .,,fa ? ??'., • ?.? FOR CARRIER'S DATE STAMP ENT OF LABOR 'AND EMPLOYMENT SECURITY"` RECD BY CARRIER SENT TO OMSION pNiSION OF WORKERS' COMPENSATION -' ler I-aoo,342-1741. (or) contact your local office for assistance 4748 NOTICE OF INJURY FL 346' geport all deaths within 24 hours (904) 488-3044 Luc `,?} _ vtupi nvr= iticnatuertnu zesty Social Security Number Date and Time of Aeadent s=ephea Ft+rveLlo 051-52-6208 7/0/93 11:00 a.m. tincruda Zlp) EMPLOYEE'S DESCRIPTION OF ACCIDENT Wb Ile lifting lawnboy -133 B. Sabal Court, Oldsmar, FL 3461 ,,., cx+a 3 rsa.. 85?-$019 pr off truck, employee felt a inch in back.. DESCRIBE IMUAY..OR-OWW- ASE AND INDICATE FART OF BUOY AFFECTED n ht hdw fin er at second joint tracwred ribs le d i i t (o P ar xis Wor e r 910 ?p 3C,g g , p , a po son ng, o r-).. . Owe r -: -r- LU 1 02 ! 54 ". x 9; M ? F DID *(%M REQUEST MEDICALCARE? .AYES ? NO . . IF YES, DID EMPLOYER PROVIDE MEDICAL? X3YES ? NO EMPLOYER INFORMATION i r j ?. CARRIER INFORMATION Cartier Audit #r Locadon #t Service Co. Carrier File mi O 1. Controverting Case-OWC-12. NOTICE OF DENIAL ATTACHED ? 2. Lost Time Case-Date of First Payment f AWW Comp Rate First day of disability I -Date of First Contact with Claimant 1 ? In Person ? Telephone ? Mail -Notice Fled Due to Multiple Periods of Disability. Dates Covered by First !Payment ? TT,D. ? T.P.D. Date Form Ree'd. ? ? ? Catastrophic ? ?TD. ? Death _• ? 3. Medical Only which became a Lost Time Case. (Complete all information in item 2 above) . . REMARKS: ADJUSTER NAME: CARRIER NAME, ADDRESS & TELEPHONE: DATE: ? ADJUSTER SIGNATURE. ?*s nt _AHpal DOOAE der FEDERAL I.D. NUMBER DATE AND TIME FIRST REPORTED r Box 4748 59--5000289 7/06/93 6:50 A?i learvater, FL 34618 . W.C. COVERAGE BY POLfC1TMEMBER NUMBER ' ? INSURANCE CO. t3SEt.F•tNSURED NAME. ADORESS, TELEPHONE OF WILL YW CONTINUE TO PAY LEPHONE IN-C m 813..10. 462-6139 INSURANCE Ca. OR SERVICE COMPANY Johns Easte Co a c I SALARY? E YES ONO F' I lCfr OF AC . rn mp ny, n ta C DENT (StteeL City, CourKy, Stare) Post Office Box 3318 LAST DAY PAID THROUGH . City Hall Aurtetx. Sarasota, FL 34230 '.4is,zouri Ava=e N 5 1 - 800 - 749-304x4 RA1?¢F Y$/m HR ? WK , ;, aat: Pi ll FL 34618 NAME ADDRESS AND TELEPHONE tSL9?L er, ne as, . 7/07193 ER p DAY S ? MO OID THE EMPLOYEE KNOWINGLY REFUSE TO USE A SAFETY* F PHYS IAN OR HOSPITAL Dr. a all-ln Cliaic Number of twurs ti I P+r - 40 r b N APPLIANCE PROVIDED BY YW, THE EMPLOYER? ? YES QNO 2600 US 19 Norch g e k?ouM - DATE EMPLOYED LAST OATS EMPLQYEE WORKED Clearwater, PL 34621 Number of days ? per week 4 1 18 r 63 7 r 02 .? 93 DATE OF INJURY F71 0 R RETURNED TO WORK ? Yt S NO 6 • AUTHORIZED BY EMPLOYER 5%S ? NO S Y NO ? 7 E IF YES. GIVE DATE ? ? LOCATION ADDRESS WAS INJURY FATAL? O YES NO , . , IF YES, GIVE DATE OF DEATH ? ? (LOCATION 0 - , IF APPLICABLE) AGREE WITH DESCRIPTION OF ACCIDENT? NATURE OF BUSINESS *See Atta i6 hed (Muxticipalicy) ?YES 1 IF NO ATTACH EXPLANATION Any person wno, knowingly and wrth infant to iryura, de1=0 Of doCerve arty emp"t or oniployso, insurarxe company or sad-insured program, files any statement of ciaim contarntrlg arty tekse or mrsleac&V vulormadon is guilty of a to" of the third degrao. I heft prox t? B nvk a Uw copy M this mtno: pr M 0 i l n y ai 'dot available for 'siSna.ture 7/07193 ' EMPLOYEE SXU4ATURE (k n dnow to mw) OATS -EMPLCYER SIGNATURE. ." -- -- DATE LFS Form OWC t I1r411 EMPLOYER COPY ::. • tYYlaMINMIGA0" #.;6?. ? - Jw, 'S r?'???t`;i••"f?v??? ?yl!' ;,? w r .. w r .. '4+? -? r?:•• ti::?.i.+ -r3-;,v?.'.. ?R• BRjuI7ATE STUMP' FCORICJA'DERJ qq mE-.•L-AeoR.Ai4D-EMP_LOYMENT-SECURnY?-fi j NT.'?O DIVISION RISK jVIRP??lGE31 I?`DIVIS+ION OF WORKERS' COMPEN^A tdN _ ..,.., :,,..• .rt,--800-3'42-17A?..(Or) tanitact your kkW Oroe !or stance -F air.-.+va +.rr? r•r, rs? :F s ?e? r, ?? City of ' Clearwatvr%,,,, '?'?""' NOTICE OF NjURY"': ?.,, ...,. Yti=lln, c t'r; . ?:::?._ ?: _.,.4.. : ?•,.,:.,. ,,.: nr..c ?.,r :, n.• r •'.' .'. _. "+» .. r ??^. y.. ? •.,K ri . •; X11 _,, .a.. F:•0:•Box 4748--,Report 0dealhs wilhin,24hours (904) 488.3044. ...?:._ .. _.. ,.t . " ,:u... c•; .?,.•,? ?':.:.... Clearwater, FL. 3488 APR 9 ?_.._.._.•??? ??_?.??,:?`.-••?....'n??.'?..r..?"?:••...._ , : , ,.,.:?Wcr,• ,.,,n,'r.r.;~ ?,??: `r,..,. ; . ?,._.•. EMPLOYEE INFORMATION NAME (Fk%1 . Last1 ».... _. _ _ _ .. - _ _ SC".SeWnty.Nirri,ber _ Date arxt Time of AccKl6ni M?ph+n F: xra+t?13 a 051--5236205.- .4102192 11 a k5 AN I,oMt_ ADD E55 ;fncn,w Zip) 133 D irbwl Caaart EMPLOYE 's DESCRIPTION OF ACCIDENT, 7-1s easia? 1f'1yt1w? ?-? ; ^ ?rrrr?asiw Lake= 0 ¦ ?L 3#514' 2691.85 +Qd' ="4:*2' in -lmmr• back. - TELEPHONE 513,?,ro.r 85S-?BA19 , LESCRI INJURY OR 015 E AND 1NDfCATE PART OF BODY A E D IPHO N (s.g.Amputation ot.rWa inda finger at eecoW cant hactmad nba. bad po,sorvN; efc+)_v.. ` Valckar 9102 T.owar back st- raia ` I +fw::ter to +vs+ •,••• : ':sEX - • ,. :.,. .. ?AfD YOU REQUEST I+ tEDICALCARE7-._--X YES 1) NO ': .. '.. _ n••',i'?.D J '? `~r0 ! • Y1.1 Q F ?"` _a'It= YES, DIO EMPLOYER PROVIDE MEDICAL? _••M YE5 ONO •x: .H._ EMPLOYER INFORMA770N -..:.. . . FIRM'S NAME-AND ADDRESS _ FEDERAL I.D. NUMBER" DATE AND TIME FIRST REPORTED City of C14aximtar 1691 39-60000289 4/02 . 02. 92. 1145 n.A. P.O. lax 4743' i K`'r ??c' 'VIr C: COVERAGE BY-- POLICYTMEMBER NUMBER ??r! 3"18 ? INSURANCE CQ jVSELF•IN$URE4 •r. L'5 .. E ?• ??. - • yt=?», •. s -' - ti.. ca. 0"p-b-W rah- 0731 .ACE QE.ArMOENT IStrost. CItY, Countyr StaZA) - i Cleammor Eat aL L1brary1.y_, :.,• 411 • • 2251 • brf>rer • g txsalt • - . ?ttlZ. Z?ir,ea7 T rte. YL es r. DID THE EMPLOYEE KNOWINGLY REFUSP-TO USE A SAFM. , APPLIANCE PROVIDED BY YOU, THE EMPLOYER?" =YES" " DATE EMPLOYED LAST DATE EMPLOYEE WORKI 41 t 18 133 _1-4 1 02 RETURNED TO WORK '-" vE O - "- r 9 , r IF YES, GlyE DATE 4 kist' off 4n __ - -- -' 11LL YOU CONTINUE TO FAY ALAAY7- AYES" ONO JOHNS EASTERN COMPANY, INC. ISTUAYP o-mROUGH POST OFFICE BOX 3318 SARASOTA, FL 34234 1-800-749-3044 ?MOFPAY jkHR•.QWK R C DAY C rMO ni" _ "' ?::? •_•:. ..... , _, . _.e.., s-- ? .• .r- _ ?' _ Numbe of flotrs ., 0/ D!. s -valk ?•l?intic 6/92) Num a ? `-` ""- •„,.,ice. , par week " -3?? PAID FOR LATE OF INJURY ^ ^ 11JTF 0P ZEV &Y IF&fPCOYER- -?YES ? NO YES x NO C ATICN. ADDRESS WAS INJURY FATAL? , "YES ENO ? .- • - : z - - > . _ .,l IF YES. GIVE GATE OF DEATH! "ROCAnON-d = IF APPLICABLE) - - AGREE WrrH DESCRIPTION OF ACCIDENT? -NATURE OF BUSWES$ : - - ?. .-- ' + YES CI NOO A717ACH EXPLANATION Any parson who, knovnngty and with iment to injure. aetrauo or Cocenre any employer or em"ea, insurance camp" or serMnsured program, files any statement dl da+m asntairt•r+q ¦rry talsa or misleading +ntormatgn guilty of a felony of She third Degree. .- JLI provided the empioyea their spy of this nalK t: °'. _'•'S>G ??' ' hr.?• :CY C.. -' _.t in Q By Mall r;l _0 >'-v0?: ,' .•,i* •4rir61 . ?t• ? ' .IS9^•: ..•? : ii ?? r••r •^•.. f .r .. J , I ? ?. 'l' ?el 'tY EMPLOYEE SIGNATURE to av%AaLN ro ygnl GA EMPLOYER SIGNATUAlt- % ,,pa. ._ ,; r, r: •..r.., •A4. CARRIER INFORMATION '. .. _. , • _. Carrier Audit # ' Location + Service Co. --- 0$ '? Carrier File .t - - s? 1, Conuvvening Case-DWC-12, NOTICE OF DENIAL AT:rkNEO L 3 - -s _ - '? 2, host Time Case -0ateOf First Payment r r AWW- .Camp Rate Frr,t day of 'disability t•y•'+7r ' 3, S•s,-r°c.' -'4?3e o('!First Contact with'L`faiment II-In Aerscm ' C'Teieptroni_.2-Vair -Natice.Fileo-Due,to Mulupte Periods of Likability. Oates Covered by. First Payment ? T.TO.. ? T,P.D. Date Form Reed. L. 11 O Catastrophic ? ?TD. ? heath 3: Av edical Only which became a Lost Trine Case. (Complete all Information in hem 2 above) - '_"? ' REMARKS? _ - -- i - .r- ADJUSTER NAME: ADJUSTER SIGNATURE: ? LG? imn awci I1r4iT DATE: r 1 EMPLOYER COPY a JOHNS EASTERN COMPANY, INC. POST OFFICw BOX 331D SARASOTA, ;L 34230 r 1-800-749--3044 3TAT11 OF FLORIDA R[loRTew' ACC 7Y![ ACC. aAY11C[ Notice o Injury ?-+?? 0CPAf1TMCNLAf]OR AND EMPLOYMENT SECURITY 064 lon of Workers' Compensation IND. an?usttrsNO. 1691 1321 Executive Center Otive, East taps}. CNART W[ l,utroFtoos AWW J site. rratue[ TaHehAssee, Flolicds 32301 REHAB. s[[ Exp. ATTENTION, W.C. CLAIMS orFlci: j Report all deaths by telephone or telegram within 24 Tours. PLEASE TYPE f'Ttone: 1.000,342.1741 EMPLOYER INFORMATION EMPLOYEE INFORMATION FiRM•S NAME NAME [First. Middle, Lasil SOCIALSECUnITY NUMBER City of Cleazaater Stephen F. Revello 051-52-6208 MAILING ADDRESS tlnclude Zip Codex HOME ADDRESS ilnclude Zip code OCCUPATION - 910Z P.O. Box 4748 2275 Curlew Road Parks Worker/Parks Clearwater, FL 34618 1SK ?JIAZ?A??A4E??? Palm Harbor, FL 33546 SiUPEnVISOR'S NAME Robert Maut:e A ARWAlE DEPARTMENT NAME -{ 1;LE ?rl 1? ?? U L A748 Parka 6 Rea. /Parka TELEPHONE {{?? t I r?r? f 95 T LEPHONE ` DATE OF BIRTH SEX Area Code: fi13 Num Ja Area Code: 713 Number 797-1463 10/02/64 M ? F LOCATION me Is Mailing How long Number of hours (2?per Week Number of days RATE OF PAY City Hall Annex empty716/83 worked 40 F 1 Pe D worked per weak 5 734•36 1] P H t - r [Y our ar + 10 South Hiseourt Avenue JAN It piece work or commission, enter If board, lodging or other B/W W ? Pef Day ' Clearwater FL 34616 furnlshed, enter weekly average weakly amount [] P i Week , amount e WORKER'S COMPENSATION COVERAGE BY ?Insurance Company Sell insured GIVE NAME, ADDRESS AND POLICY NUMBER OF INSUIIANCB COMPANY MP N NATURE OF BUSINESS A OR SEL.F•INSURED SERVICE CO Y. 59-60000289 Munici alit GALLAGHER BASSETT SERVICES, INC. ; FEDERAL EMPLOYER I.D. NUMBER 2953 U.S. 19 North, SUIIQ 301 59--60000289 Clearwater, Florlda 34621 I ACCIDENT INFORMATION DATE AND TIME OF ACCIDENT DATE ANO TIME FIRST nEPORTFD NAME. ADDRESS AND PHONE NUMISER OF PHYSICIAN, 1/09/90 1/09/90 12:34 PH Dr.9 Walk-In-Clinic PLACE OF ACCIDENT !Street. City, County, State? LAST DATE EMPLOYEE WORKED 2600 US 19 North 1/09/90 12:30 Cle.n-water, FL City, Garage/Fleet M1iTlt@ItnnGB RETURNED TO WORK Yet No PHYSICIAN AUTHORIZED BY EMPLOyEn OYes ?No 1900 Grand Avenue IF YES, DATE NAME, ADDRESS AND PHONE Or- HOSPITAL Clearwater FL 34618 041661 l ` •`°'°• MYes ?Na In Wr EMPLOYEE MISSED ONE SHIFT.ONE DAY OR MORE? C] Yes (3Na N/A WAS INJURY FATAL? C]Yes X]Na It Yes, Dste at Death EMPLOYEE'S DESCRIPTION OF ACCIDENT (Give details such as, fell, was struck, ate.) DESCRIBE INJURY OR DISEASE AND INDICATE Mr. Revello picked up a high wheel mover and strained his PART OF BOGY AFFECTED ie.q. Amputation of rlghl index finger at recona joint. Fr,ctwed r,tn, Lead back. Poisoning, etc.! Law back strain EMPLOYER: I agree with this description? ® Yes C] No It no, explain in comments. COMMENTS: Sent: co wair? -tn-koixaic Dy ULLY nurse. Any person who, knowingly and with intent to injure, defraud or deceive any employer or employee, insurance company, or itfif -insured program, files 3 statement of claim containing any false or misleading information is guilty of a felony of the third det}ree, PLEASE FILL IN ALL SPACES ABOVE Z--7? EMP LOYER (Read and Sign) ?"f?'' a? SIGNATURE Art: Not Available EMPLOYEE (Read and Sign) 4M for signature 1/09/9{1 SIGNATURE DATE LES Form 8CL•t (Rev. 6.791 ?? --d J xzr Cttf71 nv[n r nr]Y . , R.E.` RYDELL, M.D., P.X AND WM. O. DEWEESE. M.D., P.A. PROFESSIONAL ASSOCIATIONS NEUROLOGICAL SURGERY AOORLSS ALL CORRESPONOENCC TO ARMEMA OFFICE (3!5106 NORTH ARME141A AVENUE " WM, d, DEWEESE M.D. P.A.C.S. SUITE :11. OIPLOMATE AMERICAN SOARO TAMPA, FLORIDA 33603 OF NEUROLOGICAL. SURGERY (6131879-8060 013801 BRUCE B. DOWNS BLVD. R.E.'RYDELL„ M.S. M.D., F.A,C.S, SUITE U 403 CIPLOMATE AMERICAN BOARD TAMPA, FLORIDA 33$13 OF ?YCLJROLOGLCAL SUPOERY 18111971.8101 FEBRUARY 13th, '1995 PATIENT: STEPHEN REVELLO CHIEF COMPLAINT: low'back and right lower extremity pain. HISTORY: This 40 year old righthanded man had an. ,original back injury in 1990 while at work. He states that at that -time scans were, performed and protrusion or bulging of the disc at L--5 was revealed. He recovered from that and did well until April 2nd, 1992 when he had a second injury while at work. This time he was mowing on a hill. The patient was off work for approximately three months. Scans at that time showed bulging of the disc at L-4. He then had a third exacerbation of back pain on'June 14th, 1993 and again while at work. He returned to work, but the back pains increased and he has been off work for the last ten months. The pain that he describes is in the low back area at the lumbosacral junction and radiates into the right buttock and posterior thigh and at times it extends into the middle toes. He has numbness and parasthesias in the same distribution. There has been no cough- sneeze effect., He has not identified a specific muscle paresis but a feeling of generalized weakness in the right lower extremity. The patient has had an MRI Scan, a myelogram and CAT Myelogram. These are reported to show some bulging of the disc at L-5. Patient' saw Dr. Sinoff and conservative treatment 'was carried out. He had some epidural steroid injections with variable results. He was discharged as being at maximum medical improvement with a 3% permanent partial disability and diagnosis of unresolved lumbar sprain. He saw Dr. Ibrhin in St. Petersburg. He felt,that the patient had degenerative disc disease at L-4-5 and lumbar sprain. 1f..^ - J!E ° s. ?,r..r...n dL .e,.. •.......+n-a.r+i .r:«ry..» .... ... .,. ., .n. , s .. r.1' f l 1rr r?. l',: » f ....°'.. r " .. , FEBRUARY' 13th, 1995 STEPHEN REVELL0• OFFICE,EXAMINATION PAGE TWO ` He recommended conservative treatment. Dr. Balis saw the patient for an.I.M.E. and recommended light duty with no lifting of weights over 75 pounds. He did not recommend. any-surgery, He also saw Dr. 'Loque who recommended conservative treatment and anti-inflammatory ` medications and analgesics. PAST HISTORY: MEDICAL ILLNESS:None. SURGERY: None. MEDICATIONS: None currently. ALLERGIES: None. PERSONAL PHYSICIAN: None. FAMILY HISTORY: 'DIABETES: None. CANCER: None HYPERTENSION: Father. SOCIAL HISTORY: Patient is married and has'two children, ages six. and ten. He smokes approximately one pack of cigarettes a day. He drinks approximately three beers per day. He was a parks worker doing landscaping and general outdoor work for the City of Clearwater until ten months ago. NEUROLOGICAL EXAMINATION: MOTOR: The strength is normal in the major groups in the upper and lower extremities. REFLEXES: The biceps, triceps, and brachioradialis are normal.'`The quadriceps are normal. The right gastroc. is (-1.), the left is normal. The plantar response is flexor, bilaterally. SENSATION: The sensation to pain, touch, light touch, joint and vibratory sensation is normal and bilaterally symmetric. COORDINATION: He walks with a slightly slow and careful gait , FEBRUARY 13th, 1995 STEPHEN REVELLO OFFICE.EXAMINATION PAGE THREE but has a bit of valgus position to,his feet as he ambulates. '.The base is norma1,.however," and there is no ataxia. There is no list. He has normal heel and toe walking. No tremor. SENSORIUM: Patient is alert and oriented. SPINE AND EXTREMITIES: The lumbar paraspinal muscles are of normal tone. The lumbar lordosis is normal. There are no exquisite areas of tenderness. Lumbar spine range of motion is limited (-2) in flexion and extension.. There is (-l) ..right and left lateral bending. Straight leg raising is to 4& degrees on the right and to 60 degrees vn the left. Patrick sign is negative, bilaterally. 3 REVIEW OF IMAGES: MR1 Scan of the lumbar spine, 4-21-92, Morton Plant Hospital, there is some degeneration of the disc at L-4 and there is mild bulging centrally. MRI Scan of the lumbar spine, Morton Plant Imaging Center, ,10-29- 93, there is mild central. bulging. Lumbar Myelogram, 11-16-93, Northside Hospital, essentially, normal. CAT Scan post myelogram, 11-16-93, Northside Hospital, mild midline bulging of the disc at L-4. MRI'Scan of the lumbar spine, 9-10-94, UDI, there is mild bulging of the disc at L-4 and it extends slightly more to the night than to the left -although it is more to the midline. IMPRESSION: 1) Degenerative disc disease of the lumbar spine.' ss'yt' •°` ;?i'iF;` ' • .1?; c3:. Vii! " .. . .r t ? .1d.. }:3ay1T°sy.YEx.vJ:`;Fn. i,ar.!4.YI"•S, i' 1 , .' ,S' ,rr 7 ..F rl ,: :,Ekj. iT,.. .. r r:'r'.rrirjj ., FEBRUARY ',13th, 1995 ; OFFICE EVALUATION "• STEPHEN REVELLO .PAGE FOUR RECOMMENDATIONS:.' 1)•1 dont 'feel that:the'patient would have a high chance of being improved by lumbar.laminectomy though there is some possibility that his symptoms are related'to a mild'disc bulging at L-4 with, nerve root" entrapment . However, the likelihood'of improve- ment would be small:' 2) He is then at maximum medical improvement and has a permanent .,'partial disability of 3% percent of the body as a whole when. t.. reference is made'to the'FLORIDA IMPAIRMENT RATING GUIDE. I'dont feel that he could return to his previous employment which.would require'heavy lifting with frequent bending and stooping and twisting. I feel that he could do light,duty type of work with weights limited in the range of maximum of 50 pounds. •z also would recommend limiting bending and stooping and twisting. RALPH E. RYDELL, M. D. RER:gt CATHDPAEDIC SUAGERI 2334 SEMINOLE BOULEVARD. LARGO. FLORIDA 34548 - 1ELE1MC)sK IA 1 31 334.1 1 12 September. 23 , 1994' 13131 383.4379 Christopher J. Smith Attorney at Law .324 South Hyde Park Avenue Suite 21.0 Tampa,.PL 33600' RE:` Revello', Steven Dear Mr. Smith: 1 am writing in regard to Mr. Steven Revello who is a 39 year old male' who sustained injuries at work on'7/2/93 when lifting a lawn mower. Because of continued back and •radicular symptoms, this patient undeiwent -MRI scanning and CT, myelogram. This patienVs findingsAre consistent with'a lumbar strain which is unresolved, lumbar radi culopath?y, and bulging disks at the N--15 level (although herniated disk is not.completely ekcluded). He has had continued complaints of back pain since this- accident and has been unable to return to his regular duties. ? understand that the 'following Auties are incorporated in his job' description: 1'. Lift heavy par; benches. 2. Hoe weeds and scuffle hoe. 3. Mow with Lawn boy on steep heels. 4. Gift Lawn Boy or'edger on and off truck without hydraulic lift. 5. Empty trash cans that weigh over 50 pounds. 6. 'geed eater used around hilly ditches. 7. Pull weeds by 'hand. 3. Lift heavy tailgate on truck. 9. Rake seaweed or pitch seaweed on truck. 10. Use post hole digger to put in signs. 11. Use shovel, to'edge overgrown grass on sidewalks'. I do not. feel that Mr. Revello is capable of.returning to his regular work duty job. He is capable of full time light duties, to avoid excessive bending, twisting, and heavy lifting. He should avoid lifting greater than 50 pounds: it is recommended that- he change rosition frequently. E. test, '? ;J, „§' ' f r 1 t1• 1, 11 .i Y ,? i, .1" ?1: {?,t f r, ? ,1. '.rl •1, i ,Ir 1, .. k'rF`Ft•1 ft 4. vT M'Y .. S.. •.l..w+rk Rtr-na .nj. e .- ... v r .wf:'w y. If, ., ?,.°?.lM• _ r3..>: ?. .,,;r{•:? ('e .. 5?•P t'?' ?`- F4 1 RR Revel lo,, !St.e,ven , . Pagq 2 , In, summe'ry'. this. patient's diagnosis is unresolved lumbar strain. • . Regarding his prognosis we expect ' him to have continued residual back.di.s'eomfort indefinitely :pith continued residual stiffness.' He has within reasonable medical'probability,, reached,the point of, maximal medical improvement with regard to'his injuries sustained at the time 'of accidents 1/9.0, .'.4/92, and 7'2/93 Maximal medical, improvement was 'reached' on 4%,8/94. His permanent partial impairment, according to the Minnesota guidelines for-an unresolved lumbar strain, would-be on the order of three point five percent to the ,body as a whole. This patient's restrictions' incluc3a avoa di;tg. l if ting greater than 50 pounds and avoiding . e' 1 essive repetitive bending at -the low back. This represent a, permanent partial"d?sability. 'It is recommended that. the 'patifnt sta;,r on a home low back exercise program.' 5incey, Josue h?-.1'. Sena, M. 0, (signed in my absence 4o, avoid delay} ; JMS/kc . ? Yw1'.r • ,. Jr .... ... 1.. • .,.. Ie 1 ._ a rl .. .. + r , ,. ., i . r •r ,. . , ..,. ,r. • ,. . ' ?;re Spine Cure E r erts i 1 Institute . . . p l tlnhopaed1cSpine Surgery Florida's Largest Center Devoted Entirely to Medical and Surgical Care of the Neck and Back Douglas 1, Weiland. NIA, PA. Fllxatt..lth C. Slrna.,,NIA, RA. : Paul J. Lk, llrl)r Troy D. Lowell-M.D. ' PATIENT : REVELLO, STEPHEN tiudrety C,1lascr. U.U. NUMBER: 18925-WC Physical Medlcine AGE : 40 DOB: 10/02/54 A Relrahtlitatlan REFERRAL : Robert U. Gruber. 0.0. DATE : 0 5 / 0 3 / 9 5 "')),amine G. iiouchlas, M.D. raneisco 11. Torres-Ramns, M.D. Kenneth Y. Botwin, b1,D, i INDEPENDENT MEDICAL EVALUATION tieurufu?y ? - ' biro D, Librerns-Cupido. M.D. ' Lids G. Figueroa M.D. ; \euraradiology f The following Independent Merli cal Evaluation is performed on patient, Stephen Revell.o, for evaluation of injuries , received status post occupational injury on 04/02/92. i sychodogy RichattiN.Frank.Ph.D. It is based upon review of medical records, examination of the patient, review of current x-rays as well as my training and experience as a Board Certified Specialist in'Physical medicine and Rehabilitation. ' ' r:irreCare SertFre.s CHIEF COMPLAINT: Pain in the lower back, right leg, Imaging stiffness in the lower back, cannot stand too long '.t'Ai without pain, pain in the toes in the right foot, pain in -?.'czn the right hip. 11}•1•lugrzaf 50ne;uraer.y ' HISTORY: Stephen is a 40-year-old, right-handed male who ?1:i1t71Reconsiruettsssls ! was working for the City of Clearwater in lawn • L.ISert):skertom}' maintenance when he injured his back on 04/02/92. He i'rrcutaneousF+?;slms ' ? said that he initially injured his back while working on :cnllslsis a hill and was bending forward pushing a mower when he Voinlact:11M,cs felt a pull in the lower back. He then subsequently had a re-exacerbation of pain in his lower back on 07/02/93 roulagnu;tlcaledlclrrc E I while he was lifting a lawn mower off of a truck. He was ,% G ;It' at . L! I,ow3urttun ?t11dy apparently working at that time at the light-duty level.. He developed pain in the lower rack; which radiated ::oiln into the right buttock region, right hip. He also had 'r4nrnluilcaiA*'er""nt some pain in the right posterior thigh, which has ' ,;WnalDisorders :-eraeiaeht•s.43clturhs remained persistent. He also noted that he had some , tingling and numbness along the base of the right great dcllabttitatiunse'l•sices toe, He was initially treated by Dr. Logue, who treated r'•,}sic,?i rher,p}' him conservatively with physical therapy for several "'hy? lcai Recondltianin;; -.rii,,ulc rhervy months. He then was referred to Dr. Sena who performed -.,ck?rll?lul a comprehensive work up which consisted of a lumbar spine AahntisRelief MRI done at Morton Plant Hospital, 10/29/93,' which was available for my review today. This revealed a disc '.:>rlt„lokicai5erslces duation&Treatment . v bulge and disc desiccation at the 4-5 level. No evidence . . i'Ylttll,?nagetnciu of' disc herniation was identified. No evidence of iiiulee,tback stenosis was apparent. This was the second MRI. The sort 'issue lnlury !tanlpulatinn CONTINUED : 111&icai Therapy pidural Steroid lnlections Trltrcr PoLm hllectlom 2250 Brew Street, Clearwater, Floricla 3.1625 • (813) ih-SI'INI: - 1813) +97-i-163 + Fax (51:3) 726-1a?i} .oto INDEPENDENT MEDICAL EVALUATION, CONTD. PATIENT: REVELLO, STEPHEN CHART #: 18925-WC DATE: 05/03/95 PAGE : ','2 first MRl:was obtained on 04/21/92, which revealed degeneration of the L4-5-disc with mild bulging centrally. Subsequently a lumbar myelogram was performed on 11/16/93 at Northside Hospital. This film was available for review today and was reviewed also with Dr. Shah of Neurpradiology here at the Florida Spine Institute.. This appears to•reveal a disc bulge at, the 4-5 level. This was apparently interpreted as a small disc herniation by Dr. Anderson. Subsequent to this, an MRI of the•lumbar spine done on 09/10/94 at UDI in Tampa was also available for review today. This scan revealed a mild disc bulge at the L4-5 level. It extended slightly more eccentric' to the right than the left, but is more in the inidline area. -There was no disc herniation apparent. No spinal stanosis appeared present. Also as part of a work up Dr. Sena' had done, electrodiagnostic studies had been performed. These consisted of nerve conduction studies which were done on 08/12/93, which apparently revealed evidence of early.peripheral neuropathy. There was some slowing of the H-reflexes which could represent an L5-S1 radiculopathy. However, there was no needle EMG study apparent for review at that time. Somatosensory evoked potentials were performed in the lower extremities. This was interpreted as there being some increased latency of the L4-5 dermatomes. This was read as being indicative of a large fiber sensory conduction deficit by Dr. Borges. Over the course of his conservative treatment, epidural injections were tried without significant relief of pain and symptoms for any long lasting period of time. He' also had numerous sessions of physical therapy and has also had a functional capacity evaluation performed at the request of Dr. Sena at kehability Center on 01/25/94. It is the recommendation of this capacity evaluation that the patient was at the light-medium work capacity, lifting 35 pounds on an occasional basis, lifting 15 pounds on a frequent basis and lifting 7 pounds on a constant basis. Since this time, he has had several independent medical opinions which have been rendered through Dr. Ibrahim of orthopedic surgery in St. Petersburg, Dr. Gene A. Balis of neurological surgery in Tampa and also Dr. Rydell of neurological surgery also in Tampa. Currently, Mr. Revello complains of lower back pain with pain in the, right buttock and posterior hip area. He also complains of an aching pain down the right dorsum toes. He denies any. current numbness or tangling in the extremities. He says his pain gets worse when he tries to do any strenuous bending'', twisting or heavy CONTINUED: C? INDEPENDE PATIENT: CHART BATE: PAGE: XT MEDICAL EVALUATION, CONTD. REVELLO, STEPHEN 18925-WC 05/03/95 1,3 ' lifting. He, says that: his symptoms get worse if he does any prolonged sitting or bending, stands more than, ten minutes or walks more than two'blocks. He says he gets relief with ice compresses. There Is no history of recent fevers, night sweats, chest pain, nausea,, vomiting, bowel or bladder incontinence. He does report some recent weight.loss. j PAST MEDICAL HISTORY-' Past back histo .1, status post old injury in 1990 with a. full recovery. ALLERGIES`: NONE. MEDICATIONS: None currently. REVIEW OF SYSTEMS: He reports a weight loss over the last year of about ten pounds. Otherwise unremarkable., SOCIAL HISTORY: The patient is married and has two children. He smokes about a pack of cigarettes a day. He drinks about three beers a day. He is currently unemployed. He used to work for the City of Clearwater. He,apparently•was laid off on 03/24/94. No history of drug abuse or alcoholism. THERAPY TO DATE: He has had electrical stimulation, TENS units, ultrasound, hot packs, cold packs, home exercises and injections. He has gotten no long-term help from any of these. He stall does &, therapeutic exercise program which has been taught to him in the past through numerous physical therapy sessions. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: GENERAL: The patient appeared in no apparent distress, being alert and oriented. Patient' s height is 61 111 and weight is 174 pounds, GAIT: The patient is able to ambulate on his heels and toes without any difficulty. He is able to-do unilateral ankle pumps without difficulty. He is able to squat to 65 degrees and arise without assistance. UPPER EXTREMITIES: Cervical spine range of motion is full in flexion, extension, lateral bending and rotation. There is a negative Spurling, Lhermitte, Tinel, Hoffman and Adson signs. CONTINUED: ice`... ... . INDEPENDENT MEDICAL EVALUATION,,CONT'D. PATIENT: 'REVELLO,'-S TEPHEN CHART, # : '18925-WC " DATE: 05/03/95 PAGE': 4' ' ...REFLEXES:, R. qht Left Biceps 2+ 2+ Triceps 2+' . 2+ Brachioradialis 2+ .2+ SENSORY: Right Lett Anterior arm (C6) Normal Normal.' Lateral arm (C5) Normal Normal.. Medial arm' (T2) Normal. Normal. Posterior arm (C7-8) Normal Normal Radial forearm (C6) Normal Normal Ulnar forearm (.T1) Normal Normal ' Index/Thumb (C6) Normal Normal . Long (C7).. Normal Normal Ring/Little (C8) Normal Normal MOTOR' STRENGTH Right Left Shoulder shrug (CI-S) 5 5 - Arm abduction. (C5) 5 5 . Elbow flexion (C6-7) 5 5 Elbow extension (C6-7). 5 5 Wrist extension (C7-Tl) 5 5 Wrist flexion 5 5 Finger abduction 5 5 Shoulder range of motion is full bilaterally. Shoulder impingement signs are negative. Shoulder apprehension te st is negative. There is no scapula winging. Palpation over the cervical paraspinals,. trapezius and latissimus muscles reveals no tenderness. LOWER EXTREMITIES: Lumbar.'spine range o f motion' is full in flexion, extension, lateral bending and rotation. In the fully flexed position the fingertips were 5 cm from the floor. Straight leg raising in the s itting position elicited no pain or tenderness' in the leg or back bilaterally. Pulses were 2+ throughout the lower extremities.' Capillary refill is intact bilaterally. REFLEXES: Right Left ` Patella 2+ 2+ Ankle 1+ 1+ CONTINUED: V .. MA•IENT: RE-VELLO, STEPHEN CHART# 18925-WC DATE:' 05/03/95. PAGE: 5 LONG TRACT SIGNS: Babinski'sign' Negative Negative Clonus Negative-' Negative SENSORY: Right L. of Right medial thigh (L4) Normal Normal , Anterior thigh (L5) Normal Normal. -First-web space (L5) Normal. Normal Posterior calf (Si) Normal Normal.• Lateral, foot (Si) Normal. Normal Perineum (S2-SS) Normal Normal .Proprioception Normal Normal Vibration' Normal Normal MOTOR STRENGTH: Right Left Hip flexion (L2-3)' 5 5 .Hip extension (L4-5) 5 5 Knee extension (L3-4) .5 5 Knee flexion (L5-51)• 5 5 Ankle dorsiflexion (L4-5) 5 5 Ankle plantar flexion (L5-S l) 5 51 EHL (L5) .5 5 Straight leg raise was negat ive bilaterally . FabereIs test on both hips was negative. Hip range of motion wa s full bilaterally.. In the prone pasi.tion Ely and Ober tests were negative for quadriceps and iliotibial band tightness. Palpation elicited some minimal tenderness in the paraspinal muscles today. All other areas are normal. X-RAY'S: 1. An MRI scan of the lumbar spine, 04/21/92, from Morton Plant Hospital was r eviewed. This revealed disc degener ation at 4-5 wi th disc bulge. 2. An MRI scan of the lumbar spine at Morton Plant -Hospital., dated 10/29/93, was ,reviewed. This revealed dis c degeneration at L4-5 with a.central disc bulge. CONTINUED: ` .i.LVL2'+E'Z:i1VJJL" LV ?" A'Sx.i]1.1:/?L YiYHL4JHl1VCi ? LVAf 1 - LI . PATIENT: REVELLA, STEPHEN CHART # 1892-9-K! DATE:" 05/03/95 PACE:. 6 3 A CT myelogram was reviewed from Northside. Hospital, dated 11/16/93. This appears to reveal evidence of- a disc bulge, although it appears to' have been interpreted as a disc herniation at"the 4-5 level by Dr. Anderson. The same' CT myelogram was reviewed with Dr. Shah of Neuroradiology here today,at the Florida Spine Institute, who also felt" that this.is".a disc bulge. 4. MRI scan, dated 09/10/94,.at UDI in Tampa revealed a mild disc bulge at L4-5 and disc degeneration. .IMPRESSION: STATUS,POST ON THE JOB INJURY, 4/8/92 AND 7/2/93. 1`. DEGENERATIVE DISC DISEASE OF THE LUMBAR SPINE. 2. LUMBAR SPONDYLOSIS." 3 . DISC" BULGE'. 4. CHRONIC LUMBAR MYOFASCIAL PAIN SYNDROME. RECOMMENDATIONS: I,feel at the present time, the patient has clearly maximized all conservative medical treatment options for his lower back pain. I do feel that he has a component of mechanical back pain which is probably related to his disc degeneration at the L4-5 level. I do not see any evidence of neural element compression based upon his. imaging studies to warrant or indicate any kind of surgical management for his condition. MMI: I do believe that the patient has reached MMI with regards to his job injuries sustained in 1992 and 1993. PPI: His PPI, based upon the Minnesota.Guidelines, which would be applicable to his initial injury which was prior to November of 1992 would be based upon Page 402, under the subtitle Item #2, Pain Associated with Rigidity or Chronic Muscle Spasm which would be a total, of 3.50. Using the Florida Impairment Guide, Page 12, Impairment of the Whole Person would be based on Item #2 , Intervertebral Disc or Soft Tissue Injuries at 301. CONTINUED: 11!•, ,: ,r-. •(i .. .f',j r.' ??,. ;II' ? ? ., ., ? 1 i.. to ,_ ;'t `> ,1, , r.ral.,. ,. .. .'a '.' 1 '' .. ,, a <'i ., •, ir`•. +'?r: .??^ ,fir. ,'1 '. r.1? i? .. <' .•: r .. f , 1 ,, 1.? ,r volt .?,''?'f„ ?.4'_ •. f.'',t ISIv ?V 'V' ..y ?r`Mnw;. r.>.,,, ,.?+•?„_.<?l.enFri-.,.M'««.. rya .i'-...... ,. ......., r... ....%. .. ...,-.?n.tha .fE•.4%•":rY??:':??. .. j ... , , ,. ,???•,:•.Gr 1..p, .. ? 1 }•- ;:r•+.??•,r r'!°•:.."'s,b INDEPENDENT ;:MEDICAL EVALUATION, CONT D . PATIENT: REVELLO, STEPHEN CHART #: 18925-WC. DATE,: Q5/03/95 : PAGE 7 , ? , Wi'th . re jards' to ;work restrictions, the patient would be' able to work at the` light/medium work capacity; which would mean, lifting 35, pounds 'on, an. occasional basis, lifting 15 'pounds on,' a ' frequent basis and lifting 7 pounds on a constant basis ..' These physical, demands should not be exceeded. Kenneth P. Botwin, M. D. ',' Diplomate, American Board. of ; 'Physical Medicine and Rehabilitation. ' KPB/,f al d: 05/03/95 t : 05/05/95 CC: Debbie Ford, Adj . > City of Clearwater , 112 S . Osceola Ave. t Clearwater,, FL 34616 . r TRUSTEES OF THE EMPLOYEES' PENSION FUND Item # s ?? • Agenda Cover Memorandum Meeting Date: 7117195 Subject: Pension to be Granted Recommendation/Motion: Gerald Klinske, Gas 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. M and that the appropriate officials be authorized to execute same. BACKGROUND, Gerald Klinske, Gas Technician II, Gas Department, was employed by the City on January 13, 1992, and began participating in the Pension Plan on that date. On January 3, 1994, he was involved in an automobile accident while on duty which resulted in a back injury which is the basis for his request for this job-connected disability pension. Mr. Klinske submitted letters from Dr. William H. Dodson, dated April 5, 1995, and Dr. Dennis M. Lox, dated April 25, 1995. The letter from Dr. Dodson states, "He has an L4 L-5 disc herniation. His current work restrictions are no lifting over 25. pounds, no repetitive lifting, no pushing and n o pulling. He has reached Maximum Medical Improvement and his current signs and symptoms are permanent. Review of his job description... shows that this job involves much bending and lifting which he cannot do now, nor will he be able to do so in the future." The letter from Dr. Lox states, "Mr. Klinske is seen today for evaluation of injuries sustained on 113194. While in the course of his employment at the Clearwater Gas Company... He. was diagnosed as having a left-sided disc herniation at L-4-5...I do not feel that he is capable of returning to work in a full-duty capacity in his previous work at Clearwater Gas Company as a gas technician 1I...I do feel that he has sustained a permanent injury and has a permanent impairment...." Mr. Klinske's pension was approved by the Pension Advisory Committee at its meeting on June 8, 1995, and is e ffective on a date to be determined. Based on an average salary of approximately $20,855 over the past three years and the fo rmula for computing job-connected disability pensions, this pension will approximate $15,641 annually. Charts from Finance which take into consideration mortality rates and age reflect the "present value cost of financing" this pension will be approximately $261,648. The estimated pension cost (cash payout over the life of t h e pensioner and his/her spouse) is $782,853. Reviewed by: Originating Dept: Human Resource; Costs: $261.04_8 Total Commission Action: Legal _NA Budget NA Purchasing NA User Dept.: Risk Mgmt.. NA CIS ACM Advertised: Other NA 1 Dale. Paper: 0 Not required Submitted by, Affected parties ? Notified 0 Not required City Manager Current FY Funding Source: ? Capt. Imp, ? Operating Other f?onsion Appropriation Code: 04 6.07410-5 14200-58 5- !f ? Approved ? Approved w/conditions ? Denied ? Continued to: Attachments: Letter(s) ? None :cil% -? Human Resources Npanment ' • 8151462-6870 WWI .... C I T Y a E C L E A R W A T E R POST OFF ICE BOX 4748 CLEARWATER, FLORIDA 34618-4748 To. 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; Risk Management SUBJECT: Pension for Gerald Klinske--Job-Connected . Disability Pension DATE: June 8, 1995 The Pension Advisory Committee (PAC) received an application for disability pension from Gerald Klinske on May 2, 1995, Mr. Klinske has been determined by the Pension Advisory Committee: to meet the requirements of the Pension Plan for a job-connected disability pension. He was employed by the. City on January 13, 1992, 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 (lie PAC. By motion made and duly carried at its meeting- of June 8, 1995, the Pension Advisory Committee approved/recommended . the granting of a job-connected disability pension to Mr. Klinske 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. Klinske:'s pension will be calculated by the Finance; Department according to the formulae in the Pension Plan for job-connected -disability pension at such time as his last five years of service and salary can be computed. I hereby certify that the Pension Advisory Committee has approved the granting of a job- connected disability pension for Gerald Klinske and (lie above dates are correct. Ch 'man, I e Ion Advisory Committee ''Equal Employment a.nd Affirmative Action 'Employer'' PENSION. REQUEST FORM l? Gerald T. Klinske do hereby apply, for retirement from the City of Clearwater General Employees' Pension Plan. My benefits date is January 13, 3 992 (Entry date into pension plan) IM 'y date of hire is January 13, 1992 My. birthday is August 18, 1956 My job ciassification is Gas Technician II and I• work in the _ Gas Department, Division. Vi y resignation date i5 to be determined The type of pension for which I am applying is (check only . one): Regular Pension based on years. of service " Sob-connected Disabil ity Pension Non -Job-connected Di sability Pension My spouse's name is: Lisa L7/22/?Q Dependent children under the age of IS' and -residing in my -household are: Jessica Lee 8/7/87 _-- {?ri t Child's Pull dame) l a (Child's Date of Birth) Kat yn Nlco ette 9/2I/9d I hereby certify all of the above co be true and correct: (Signature) May 2 , 1995 (Date) STATE OF FLORIDA before me this a fore oin in trtiment was acknowledged COUNTY OF PINELLAS ' . %? ?by_????l cL Xll7s __ , who. is per,?onally knoFvn to me or who has produced asldeatification a who did/did not take an oath. c-- Notary Public ;. .•= trtY torw,ws,i?:y # W411Jss EXpiftg Commission N'o. 00X-4m IM inted) P r _ (Name of ;tout of 3 /. .• r •! . • , .. . ' r CITY OF CLEARWATER GENERAL EMPLOYEES' PENSION PLAN OPTIONS'-. GENERAL EMPLOYEES OPTION 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 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 1011190.) k !k k k !k * M? * * 1t k k k Ms V? * f[ u M It M k %e ?e N * >le * k At * * ? de h A M k * W * k It M i11 * w w[ N It W he M H W I, Gerald T. K] inske an employee of tke City of Clearwater, hereby apply for pension benefits under the City's Employees' Pension Plan, I hereby certify that I fully understand the Ewo options offered to me. I choose to retire using Option r ` z and wish my benefits to be calculated under this option. I understand that once this form is signed, my decision is irrevocable. E1'IPLOYEE S SIGNATURE: 30CL-.L SECURITY 383-68-6374 1239 Palm Street tiVIT?TESSES: , ADDRESS: Clearwater, FL 34615 r jr? [ L DATE: May 2, 1995 x6/07/1995 14:19 813-529-0521 ALL FLORIDA ORTHO PAGE: 02 A? ALL FLORIDA ORTHOPAEDIC ASSOCIATES Robert 0. Hamilton, M.D. Lawrence M. Linage, M.D. Brett R. Holbofner, M.D. Dale G. Bramlet, M.D. Clinton A. Davis. M.D. William W. Dodson, M.D. Jorge A: Rodriguez. Jr.. M.D. April 5, 1995 I I John Mazcin, WC Adjuster Johns Eastern City oi: Clearwater E':0..'. Box 4748 C1'earwater., FL 34618 RE: KLINSKE, Gerald PT#: 41.97 Greetingsl D?SABTLITY LE?xxER Gerald Klinske is,a patient that has been seen at All Florida Orthapaedic Associates. He has. an L4 L-5 disc herniation. His current work restrictions are no. lifting over '25 pGUnds, no rerpptitive lifting. no nt!shinn .and no pulling. He has reached Maximum Medical Improvement and hic current signs and symptoms are permanent. His symptoms include: back pain which radiates into the legs with weakness and numbness which is worsened by certain activities. Review of his job description which is: Gres Technici.ari 'II : shows that this job involves much bending and lifting which he cannot do now. nor will. he be able to do it in the -f+ature. Sincerely, William W. Dodson, M.D. WWD:emc T: 04/07/95 P.O. Box 76330 - St. Petersburg, Florida 33734 4600 4th Street North - St, Petersburg, Florida 33703 - (813) 527-5272 • Fax (813) 522-7412 r _ .Y KLINSKE•, GERALD CLWTR Florida ?? ? Spine & Sports Medicine Center Physical,Wedicine and Rehabilitation Elecrromyograph% + main Management INITIAL EVALUATION' 04/26/95 Dr. Lox PRESENT ILLNESS: Mr. Klinske is, seen today for evaluation of injuries. sustained on 1/3/94. While in the course of his employ- ment at Clearwater Gas Company, he was in a company truck, a car pulled out in front of him and he struck a telephone pole. He 'developed neck and lower back pain as 'a result of this and numbness and paresthesias in the left lower extremity. He was diagnosed as having a lef t-sided disc herniation at L4by MRI. He has had an EMG by Dr. Dodson on 9/16/94, which was normal except for poly- ohasics'and decreased recruitment in the left EHL. He has-been prescribed therapy at All Florida Orthopedics, as well as Morton Plant Hospital, which did help.. He has been unable to return to work in a full-duty capacity. Apparently, there is no longer any light-duty work available. PAST MEDICAL HISTORY: Noncontributory. SOCIAL HISTORY: The patient was employed as a gas technician 11, at Clearwater Gas Company. He is no longer working. MEDICATIONS: Darvocet, Robaxin and Ibuprofen. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: Physical exam revealed limited lumbar flexion at the end range. Extension and side bending were full. Neurologically, manual muscle testing was 5/5. Sensory was dimin- ished in the left L5 distribution. He was able to stand on his heels and toes. He had good EHL strength. Reflexes were 2+ in the knee and ankle. Straight leg raise was negative. PalpaL•ion of the spine elicited diffuse trigger points in the lumbar paraspinalis. Dennis .I. Lox. I.D. ,•ar7il,rC M IRr imrnrin b0utl erl 1'1••,,., Vrdrrinr rn0 Rrhob0i io" Bmini Rie,el, M.D. • ,,,. +l. nrn n. .nt) R. na P•?ilatnn . Clearwater 1e« Fnrt Riche' St. Petertbur; 1 rneI M. i3 Finn. i.D. - N C:? t ; 4,V .j PAGE TWO „. RE: Klinske, Gerald 04/26/95 Dr. Lox IMPRESSION:' L4-5 disc' herniation. PLAN: At this point, I would recommend that he continue with a home'exercise program. I do not feel that he is capable of.return- ing to work in a full.--duty capacity in his previous work at Clearwater Gas Company as.a gasr technician IX. I 'feel that he is going to be more suited for a sedentary or light-duty capacity, where.he is not doing any heavy lifting over-twenty pounds and any, repetitive bending, twisting, stooping or squatting, activities,' as this will increase his symptoms. Additionally, I do not recommend driving 'a truck all day long, as this will exacerbate a disc herniation. I do feel that he-has sustained a permanent injury and has a permanent impairment .of 9% of the whole person, based upon the Florida Guidelines.' In'the future, he may require surgical .intervention if his symptoms should increase 'or he develops neuro- logic symptoms.' At the present time, T will recommend continuing., him on a home exercise program and I will reassess him depending upon his,symptoms . Dennis M. Lox, M.D. DML:opt (dictation,hranscribed but not read) M'. . 20 'd L4TO 19v £T8 T 2113 a3W SINOdS 3M14S IJ - N° THIS ' ?CIRT " SENT TO INSURANCE -•-• Ail S,'1 ?- ??,_ OMOX)N %4K:r4OFXU 0. CAMc A ..- -r----?-'""^ jtLfle FLORIDA DEPARTMENT OF LABOR "AND EMPLOYMENT SECURITY '•r'i1iY: ',l it}„':'r,".: DIVISION OF WORKERS' COMPENSATION ;"I % -800-342-1741 (or) contest your local office lo.. r assistance - ; ,.• .. •. r-• NOTICE OF INJURY- ?.?...,-„- 'wr ?.•. Report all deaths within 24 Hours (904) 488-3044.:*?1e.?...._,r•a PAX01 twirl= IrJCn93UA'rtnM T FOR CARRIER'S DATE STAMP RECD BY CARRIER SENT TO DIVISION -it P.0'.4 I W NAME (First, Middle, Last) Social Secunty Number Dale and Time of AoGident . Gerald T. K-linsf-e .. 12 " 83-68-6374'. - 1/3/94 approx. 2:30 Ptf HOME ADDRESS (include ZIP) 1239 Palm Street Clearwa tfai;-'FI:, 4' , fi15 EMPLOY 'S DESCRIPTION OF tnrNT WIV0,010-Cl, 111 all LO ..: 1.1 .,,. ••1:" - • , a .., .... ?. • . ,Ci?yw7etu::le,. , - TELEPHONE 813 r342-2801 DES RIBS N•IURY OR•DISEASE•AND iNDICA E PART O BODY AFFEC ED (a on orri dex fing r at sownd Joint fractured ribs oisonin ht I load etcj (e CUPArfON Service Gas -+ ,1 75OJ lec g g , •, .g ? p g , p g, DQt1jj ggs in pain 7708IRTH 08 ! 18 I 5G. SEX .,> w y „?,., ;u • XY)A ? F .DID YOU REQUEST MEDICAL CARE?_. . ?9 YES ? NO • _ IF YES, DID EMPLOYER PROVIDE MEDICAL? %,ffYES ? NO y .r,x!_ -• . EMPLOYER INFORMATION FIRM'S NAME AND ADDRESS FEDERAL I.D. NUMBER DATE AND TIME FIRST REPORTED City of Cleat ater :........ i 59-60;)02891,,, 1/37/94 2:30 iii P.O.a Box 4742 W.C. COVERAGE BY POLICYIMEMBEPI NUMBER _ Ciearwa ter r FL 34618-474S ? INSUHANCE CO, ? SELF-INSURED NAME, ADDRESS. TELEPHONE OF INSURA CE CO O ERVICE C P NY QL4TtNUE I LL YOU C TO PAY TELEPHONE; ?,,cea. 9 j :mac. 462-6754 N . OM A R S r' Johns Eastern Com an Inc -i A LARY AD YES S [3 NO p y, . , PLACE OF ACCIDENT (Street, ciry,CouptY, Strata ) Post Office Box 3318 -•••'•... ,,, .. LAST DAY PAID THROUGH ••, , .A)rew,.,5treeL . EaSL Ofd'L1.S.' kiWy.:19<<'r- Sarasota, R: 34230>-z'- Clearwater, Florida 1 -800 -749-3044 RATE OF PAY ? HP I' ? WK Pinellas COUIlLy "- NAME, ADDRESS AND TELEPHONE OF PHYSICIAN OR HOSPITAL- ? ? - S • PER ? DAY ? MO ' - • • • Number of hours 010 THE EMPLOYE(: KNOWINGLY REFUSE TO USE A SAFETY : 'PICA,, Fami1' 7-,-0=_a t:er''``' •` S! per day Number ur hours APPLIANCE PROVIDED BY YOU, THE EMPLOYER? ? YES • N NO i1R6 ad k_' per week - . DATE EMPLOYED LAST DATE EMPLOYEE WORKED :' C1earwa ter ber of da Num ys pe r week • OZ 113 I 92 01 ! tQ: ! 94 =. "-..r. ?....::. =; , ,.. .' PAID FOR DATE: OF INJURY RETURNED M WORK • KT YES ? NO ' - -•• -. AUTHORIZED BY EMPLOYE=R • ,1c YES ONO "YES 0 NO ? IF YES GIVE DATE ')11071 LOCATION ADDRESS , ' WAS INJURY FATAL? ? YES ?ii1N0 em Cloa Clear-water 'Gas '"?ys t IF YES, GIVE DATE OF DEATH E (LOCATION # ;•, IF APPLICABLE) AGREE WITH DESCRIPTION OF ACCIDENT? NATURE OF BUSENI=SS."• •; ., •-; • • ' r., . !',.._' •.. " . bTYES ? NO IF NO ATTACH EXPLANATION Gas Lam. Y Any person wl,o, knowingly and with Intent to inium, detraud or deCewu any empiarer or employee, insurance company or self insured program, files arty slalement Of ' -dam containing any false or misleading information is guilty of a felony of the third degtoom;.•, •::t ::. I have prav?ded the employee their copy of this notice:: ?r(] In Person p By Mail ,, - EMPLOYEE SIGNATURE 4t av A*W* to w7ij DATE EMPWYER SIGNATURE; / GATE :riac,. L:AHH1I:K 11V!-10MMAI JUIV Carrier Audit Location •Service.Co. # _l., --- .Carrier File # - - ? 1. Controverting Case-OWC-12, NOTICE OF DENIAL'A1 l'ACHED ? 2. Lost Time Case-Date of First Payment I I AWW Comp Rate First day of disability I I -Date of First Contact with Claimant I I ? In. Perron' ? Telephone 6] Mail ---Notice Filed Due to Multiple Periods of Disabiflty, Dates Covered by First Payment ? TTD. ? T•P•D• Date Form Aec'd. I I ? Catastrophic ? P.T.D. [ Death ? 3. Medical Only which became a Lost Time Case. (Campiete all Inforrrlalion in rlem 2 above) REMARKS; CARRIER NAME, ADDRESS 6 DATE: 1 1 LZS Form OWC t (1191) EMPLOYER COPY Communication Workers of America AFL-CIO Local 3179 July 14, 1995 CLEARWATER LODGE 10 P.O. Box 1743 • Clearwater; FL 34617 t813) 441-4744 City Manager, Betty Deptula. P.O. Box 4748 Clearwater, F1.'34618-4748 Of Fire Fighters JUL 14: 1995 CITY MANAGER Dear Betty: We are notifying the City of Clearwater that the Presidents of the Four. Unions representing the majorityof the Pension Plan members sincerely wish to continue negotiations on Pension Plan changes. As you are aware, Pension changes are a mandatory subject of bargaining and-must be negotiated in good faith per Florida Statutes 447.501 - .504. None of the four Unions have waived any rights to negotiate this subject. Employee representatives have met with Deputy City Manager Kathy Rice and City Staff on June 23 and again on June 29th at which time the City gave their amended Pension Fund language and a second further amended P.F. language. The Union representatives and their attorney Lee Dehner have made many demands and suggested language changes much of which was submitted to the City on June 19, 1995. We request that meetings for the purpose of trying to finalize negotiations of pension changes be set up again as soon possible for all parties. Yours Truly, zai-? Z?:7 Peter Fire, President FOP #10 Zesident Patterson Supervisors Union Van Horton, President FF li^^YWDou Wlasiuk, President, CWA International Association CLEARWATER POLICE SUPERVISORS UNION