Sample Workers Compensation Report with 100% Economic Loss/Total Permanent Disability

Transcription

1 Sample Workers Compensation Report with 100% Economic Loss/Total Permanent Disability Mr. Joe White Attorney at Law 111 N. Robinson Oklahoma City, OK RE: Jane Doe SSN: Dear Mr. White: At your request a comprehensive vocational rehabilitation evaluation was administered to the above mentioned at the PRC Vocational Testing Center in Bethany, Oklahoma on this date. The client arrived early for her appointment. Testing was begun without delay or interruption. She was accompanied to the evaluation by her husband, Randall Doe. The purpose of the evaluation was to determine her ability to engage in gainful work activity in the competitive labor market as well as the need for and practicability of vocational rehabilitation services. Medical records were reviewed as provided by your office. A comprehensive battery of vocational aptitude tests and systems were administered. A job analysis has been conducted as well as an assessment of transferable skills. The clinical interview consisted of taking a personal history, educational history, medical history and work history. Both Mr. and Mrs. Doe participated in the interview. The test results are considered accurate and valid. Personal and Social History: Jane Doe is a forty-nine year old female who was born and raised in Houston, Texas. She presently resides in a two bedroom house in Podunk, Oklahoma that they own. They have no telephone, no television and no hot water in the house. They have no indoor plumbing and the house is heated by a woodstove. She lives with her husband of seventeen years, Randall Doe, Jr. He is fifty-four years old. He is a disabled carpenter. He last worked in January He is not able to work because of tumors and blockage in his intestinal system. They have no children. This is her only marriage.

2 Her father is deceased. He used to work for the postal services. Her mother is a homemaker with a twelfth grade education. She has two brothers. Robby Doe is forty-seven years old. Billy Doe is forty-five years old and works as an architect. She has one fifty year old sister, Linda White, who is a housewife. Hobbies and recreational activities were noted to be attending church. She attends the Lighthouse Baptist Church. She can drive with the only restriction being corrective lenses. Her only source of support and income at present is her weekly Workers Compensation benefit in the amount of approximately $ per week. She has applied for Social Security Disability. She has been denied twice. She will have the opportunity to soon meet with Administrative Law Judge based on an appeal of the previous denials. Educational: This client completed her high school education last attending Furr Junior and Senior High School in Harris County in Houston, Texas in She completed school when she was eighteen years old. She stated that she was in Special Education classes from the fifth to the twelfth grade. She never learned to read or do math very well. She attended the Texas Dental School in Houston, Texas from 1974 to She paid for the training herself. She stated she received a Certificate as a dental assistant, but never learned anything. She indicated she did get a job as a dental assistant for about six weeks in a suburb of Houston, Texas. She stated that she was fired from the job because she could not do the job and could not read. She has had no other formal, vocational, technical or educational training programs. She has never been in the military. Work History: (as reported by client) Length Name of Company Job Title Wages Unknown Courier (delivering teeth for a dental service) Reason left: She utilized a company car when driving, but she lost her own personal transportation /78 South State Optical Lens Polisher $4.00/hr Reason left: She was married and moved to Alaska. 2

3 Length Name of Company Job Title Wages 1980 Sea Catch Fish Glazer/Freezer $5.00/hr Reason left: Job ran out. 9/ Groff Optical Shop Lens Cutter $5.00/hr Reason left: Laid off Optical Shop on 9th Lens Cutter $8.00/hr Reason left: Quit before she was to be fired personality conflict with boss. 6/84-9/84 Seahawk Seafood Fish Cleaner $5.00/hr Reason left: Job ran out. 3/85-6/85 Mr. Green Optical Dispenser Fitter $5.00/hr Reason left: Could not do the job--laid off. 6/85-10/87 Pegasus Optical Lens Cutter $8.50/hr Reason left: Got a job closer to home. 10/87-1/88 Spectacle Optical Lens Cutter $8.00/hr Reason left: Fired--could not do the job. 2/88-4/88 Sunland Optical Lens Cutter $8.00/hr Reason left: Became pregnant with complications. 4/89-6/89 Burger King Hostess $5.00/hr Reason left: Better job. 6/89-9/89 Inlet Salmon Fish Glazer/Bagger $5.25/hr Reason left: Season over. 5/90-9/90 Inlet Salmon Fish Glazer/Bagger $5.50/hr Reason left: Season over. 6/91-9/91 Inlet Salmon Fish Glazer/Bagger $6.00/hr Reason left: Season over. 9/91-9/94 Did not work. 9/94-11/95 General Food, Inc., Sprayed vaccinated chicks $6.00/hr Heavner, OK 3

4 Reason left: Injury. Medical History: (as reviewed from medical records provided and the client's comments) This client was reportedly injured on November 29, 1994 while employed with General Food, Inc. in Heavner, Oklahoma. It was her job duty and responsibility to spray chicks for bacteria. In this physical area twelve different women were vaccinating about three thousand chicks per hour. The vaccinated chicks were placed in boxes, stacking them ten high and a hundred chicks in a box. It was the client s responsibility to push or drag the ten high boxes of chicks to her work area, which was about fifty feet away. Each box weighed approximately twenty-five pounds. She had to pick up the top box, twist and turn and place that box of chicks in another box-like area triggering an antibacterial spray. She removed the sprayed box of chicks and set it on the floor. The sprayed chicks were stacked and were then pushed by hand to a loading dock approximately one hundred feet away. She moved anywhere from two hundred to two hundred and fifty boxes per hour. She was given one break every three hours for thirty minutes. On November 29, 1994 while working in the morning she felt like she pulled a muscle in her low back when she was picking up the boxes. She stated she was afraid to really tell anybody and went ahead and worked for a couple of more hours. She finally told some co-workers, who then told the lead woman, who reportedly put her in a light duty position vaccinating chicks. She took a break and went to her car but could not hardly get out of the car. She toughed out the day. She went home, remaining in her bed with a heating pad. She could not get out of bed, and she was in significant pain. When she was finally able to get out of bed her legs gave out on her, and it was difficult for her husband to help her get back up. She took some pain pills. The next day she said she still could barely get out of bed, but she went to the job and reported the injury. She was sent to see the company physician, Dr. Blue. He took her off of work for a few days. He also prescribed some pain medication and muscle relaxers. She returned to work about three days later and was placed on light duty mopping and cleaning. She did this for about three weeks. When her back problem continued to worsen she returned to see the company doctor who ordered an x-ray. He took her off of work for about two weeks and expressed a concern if she returned to her regular duty she might have increased chances of having a significant back injury. Therefore she returned to work on light duty after being off about two weeks. She was referred to a neurosurgeon, Dr. Black, in Ft. Smith. He examined her and ordered an MRI and physical therapy. 4

5 She returned to work with different job responsibilities. She was cleaning chicken hatching trays with a high pressure hose. She had to reach up high to wash the stacked trays. The job required not only reaching but repetitive bending and stooping. Apparently she hurt her back again. This was the second injury that occurred on February 7, She saw Dr. Black again, who indicated her diagnosis to be degenerative disk disease with an abnormal MRI. He ordered a CAT scan and myelogram. In his report of March 6, 1995 he made mention of her re-injury. He recommended physical therapy and work that required no bending and stooping or lifting and carrying weights over ten or fifteen pounds. In his May 18, 1995 report he suggested consideration for surgery. She was off work for another three weeks. When she returned to work she again was placed on light duty cleaning windows and mopping. She was off work from May through September. During the interim she saw Dr. Christopher Yellow, a neurosurgeon, in Tulsa for a second opinion. He indicated she had lumbar radiculopathy. He ordered epidural steroids and trochanteric bursa injections. He reportedly told her that due to the injury affecting multiple vertebrates and consequent narrowing of the spinal column that surgery was not a good idea. In his report he indicated that it was not wise for her to return to any type of labor that required repetitive lifting, bending, stooping or overhead work regardless of whether she had surgery or not. She returned to work on September 9, 1995, as her employer reportedly created a job for her. She was placed in a room and told to sit on a chair and watch through a door for delivery trucks that never came. She stated she sat there for three weeks watching for any truck, and no truck ever came. She was in a hot room. She was taking pain medication. It made her extremely drowsy. Sitting for long periods began to reaggravate her back. The company then gave her a job counting chickens in boxes. Two boxes were placed directly in front of her, not side by side. She was required to lean forward, take the chicks out of the box of greater distance and place them in the front box, counting them. At this time she began developing pain in her left arm and shoulder area. This job required extended periods of standing and leaning forward in an almost constant manner. This job lasted approximately three weeks. She was not able to tolerate this job. She returned to see Dr. Yellow in November, He took her off of work. She saw Dr. Yellow in January, 1996 who recommended water therapy and physical therapy two times per week. She recently saw Dr. Yellow in February, He recommended water therapy and physical therapy three times per week. 5

6 This client takes Naproxen medication for inflammation. Her complaints are limited ability to lift and carry weights in excess of ten to fifteen pounds. She has difficulty standing and walking for extended periods. It is difficult for her to stand in one place for over fifteen to twenty minutes. It is difficult for her to sit for over one hour. If she can alternately sit and stand she still has pain after one hour, as she does if she is standing and walking around. She has pain and discomfort climbing stairways and steps. She would be precluded from climbing ladders, scaffolding, ramps and the like. She complains of having balance problems. She has complaints of pain and discomfort when performing bending, stooping, crouching or crawling. She has complaints of having pain in her left upper arm area around the bicep and tricep area. Cold and wet weather gives her discomfort. She stated that the pain is primarily in her low back. It reaches down into her buttock area including her left hip and radiates into her left leg. She has difficulty sleeping. She has trouble performing many activities of daily living including sweeping, mopping, cleaning toilets and making beds. She can cook some and do light housekeeping for limited periods of time. She also complains of having some difficulty breathing chemicals, fumes or being around dust and odors. Job Analysis of Previous Employment: (Utilizing U.S. Dept. of Labor data) Dictionary of Occupational Titles, Revised fourth edition, 1991 and its supplements; 1992 Classification of Jobs and the Handbook for Analyzing Jobs and the client's description of duties. Job Title: Poultry Laborer D.O.T. Code: Physical Demand: Medium Work Skill Level: Unskilled Employment Job Title: Lens Cutter D.O.T. Code: Physical Demand: Light Work Skill Level: Semi-Skilled Job Title: Lens Polisher D.O.T. Code Physical Demand: Light Work Skill Level: Skilled Job Title: Hostess D.O.T. Code Physical Demand: Light 6

7 Skill Level: Semi-Skilled Assessment of Transferable Skills Acquired from Former Work: Since this client s former work with General Food, Inc. was unskilled work; no skills have been acquired that could be transferable to other skills. The occupation of poultry laborer is unskilled work. No skills acquired from that work activity. She did not work long enough in the occupation of lens polisher to acquire the necessary skills as per SVP. The occupation of lens cutter resulted in skills requiring precision work and using cutting instruments. The occupation of the hostess required some very limited skills in working with people. Test Results: A vocational evaluation should include academic achievement testing, intelligence testing, aptitudes identified by the U.S. Department of Labor, temperaments and interest assessment. A vocational evaluation should also include a job analysis. This evaluation center has achieved these goals. Percentile scores reflect a comparison with others, and a fifty percentile is considered an average score. The Wechsler Adult Intelligence Scale-Revised (WAIS-R) verbal section was provided which is the standard for clinical assessment of intelligence. The test produces data that reflects global intelligence functioning, verbal performance and sub-tests performance. On the Verbal section the client scored a 76 IQ at the 5 percentile. This score places her in the borderline range of intelligence. Specific intelligence testing utilized the Shipley Institute of Living Scale. It is more of a verbal intelligence system measuring vocabulary and abstract reasoning abilities. On this instrument the client scored a WAIS equivalent IQ of 74. This score also places her in the borderline range of intelligence. She learns best through concrete, hands-on processes and/or on-the-job training. To better learn of the client's level of general educational development academic achievement testing utilized the WRAT-3. It evaluates the retention level of acquired academic skills. This instrument is a measure of performance in the basic school subjects of reading word recognition and pronunciation, written spelling and arithmetic computation. This client reads equivalent to a 3rd grade level with a 63 standard score at the 1 percentile. This client spells equivalent to a second grade level with a 52 standard score at the.09 percentile. This client performed arithmetic equivalent to the 4th grade level with a 64 standard score at the 1 percentile level. This client is functionally illiterate. She does not have the capacity to read, write or work with numbers in the competitive labor market. 7

8 The Flanagan Industrial Test for Coordination was provided. This instrument measured the individual's ability to coordinate gross motor hand and arm movements smoothly and accurately with their right dominant hand. The client performed at the 85 percentile level. She also indicated that this task gave her some pain and discomfort in her low back, as she had to lean forward from a sitting position. The Purdue Pegboard Aptitude Test was given and measured gross movements in the arms, hands and fine finger dexterity, coordination and skills. It measured the dexterity for three types of activities: one involving motor movements of the hands, fingers and arms; one involving primarily what might be called fingertip (touch, feeling sensation) dexterity; and one involving eye hand coordination. This test is related to jobs involving the worker trait factor Handling such as found in assembly, packing, operation of certain machines; and other manual jobs including keyboard work. She is right dominant. With the right hand the client performed at the 80 percentile level, and with the left hand the client performed at the 50 percentile level. When using both hands the client performed at the 80 percentile level, and when performing the assembly subtest the client performed at the 69 percentile level. She had pain and discomfort in her left upper extremity when performing the left hand, both hand and assembly work activities. The SRI Numerical Perception Aptitude Test measured the ability to scan for accuracy regarding symbols and numeric figures as well as the ability to differentiate and handle accurately matching numbers, symbols and signs. It measured the ability to quickly distinguish differences and incongruities between sets of numbers. It also measured the ability to identify critical features as well as focus attention. It is an important skill required of certain clerical, record keeping or bookkeeping tasks. Stanine scores range from zero to ten with zero being low and ten being high. The client's stanine score was 2 which is a noncompetitive aptitude. The General Clerical Aptitude Test was given. The aptitude test measured the client's ability to perform basic clerical tasks such as filing, alphabetizing and error recognition with speed and accuracy. This client's score was at the 3 percentile which is a noncompetitive aptitude. The Whole Body Range of Motion Work Sample was provided. This instrument and work sample is a nonmedical measure of work capacity, endurance and agility a person has in gross body movements while performing different transfers when standing. The transfers included performing bending and stooping, working at waist, chest and over-the-head levels. The client had limitations and difficulty in performing the bending and stooping and overhead work activities. She 8

9 was observed to be able to sit for up to one hour before having some pain and discomfort. The Lifting and Carrying Work Sample was administered. This is a measure of lifting/carrying ability. The client was asked to lift and carry different weights in a box structure for a distance of 25 feet and return the weights to their original placement. The starting place was at desk level. The subject was naive about the weight loads, and the loads were alternated and changed after each trial. The results are: 1.0 Kilogram Transfer (2.2 lbs.)...no limitations 2.0 Kilogram Transfer (4.4 lbs.)...no limitations 4.0 Kilogram Transfer (8.8 lbs.)...no limitations 6.5 Kilogram Transfer (14.3 lbs.)...she had pain and discomfort in her low back and the work sample was ceased. Occupational Motivations and Values Assessment indicates the client seeks the following elements for job satisfaction: Good Salary Independence Be well paid for your work Do work that lets you be your own boss and do the job the way you want without someone watching over you Work with Hands Have a job where you can use your hands, machines, or tools to make or repair things Interest testing utilized the California Occupational Preference System. The client reviewed, ranked and rated interests in many different occupations. On the California Occupational Preference System elevated scores were only found in the outdoor clusters. The Clinical Analysis Questionnaire, Beck Depression Scale, Incomplete Sentences Blank and the PRC Adjective Checklist were provided. These instruments measured the client's present preoccupations, current conscious conflicts and subconscious concerns. These instruments are useful as diagnostic/screening tools for evaluation of psychological overlay. Her 21 score on the Beck Inventory indicates moderate depression. In terms of personality traits she appears to be a reserved, quiet, submissive, shy and somewhat timid individual. She is practical, conservative, traditional and down-to-earth in her thinking. Discussion: 9

10 This client has a very significant vocational handicap. Some of her vocational limitations are pre-existing. For example, she has a history of placement in Special Education classes. She falls within the borderline range of intelligence. This indicates that she learns by hands-on, concrete repetitive processes rather than through academic, lecture or books. Her best method of learning is on-the-job training. She requires simple noncomplex instructions. Additionally, another preexisting condition is that she is illiterate. She reads at the third grade level. She spells at the second grade level, and her math is at the fourth grade level. She does not have aptitudes for clerical or numerical perception type of work activities. With these limitations she would not have the ability to engage in vocational technical education training programs. In terms of her functional limitations as a result of her two back injuries and left upper extremity complaints, she would be severely limited in her access to jobs in the competitive labor market. She is not capable of engaging in sedentary work activities because she cannot sit for more than one hour at a time. Most sedentary work is professional, technical, managerial, clerical and benchwork. She does not have the education, training, expertise or experience in performing those types of work activities. She is not capable of engaging in a full range of light work. She cannot stand in one place for over fifteen to twenty minutes at a time. She cannot stand and walk for distances for more than one hour at a time. She has vocational limitations in lifting and carrying weights over fifteen pounds which would further preclude the light work. She cannot perform work requiring repetitive bending and stooping, crouching and crawling or overhead work activity. Twisting and turning activities are limited. She would be precluded from performing work requiring quick movements to get out of harm s way in hazardous work conditions. She would have vocational limitations in climbing such things as ladders, steps and scaffolding. She has difficulty with balance. Cold and wet weather gives her discomfort. During the testing on this date when she had to reach and extend forward with her left upper extremity she complained of it being tired and she was in pain after five minutes. Consequently she would not be able to perform extended periods of time in work requiring bilateral reaching and handling occupations. This counselor has assessed occupations within the poultry industry to search for less physically demanding work. No jobs were identified as being sedentary by the Dictionary of Occupational Titles. Of course her employer did provide her an opportunity to perform sedentary work when she was asked to sit in a chair looking out a doorway to watch for trucks. This job gave her pain and discomfort in her low back. Other jobs in the light nature in the poultry industry are identified: Job Title D.O.T. Code Work Description Chicken Sexer Light; Semi-Skilled Debeaker Light; Semi-Skilled Caponizer Light; Unskilled 10

11 Poultry Dresser Light; Unskilled Poultry Eviscerator Light; Unskilled Poultry Boner Light; Unskilled This client is unable to perform those work activities since light work requires the physical capacity, strength and stamina to lift ten pounds frequently and twenty to twenty-five pounds occasionally. A job is considered light work when one has to stand and walk on their feet for extended periods of the work day. These are the precise vocational limitations this client has; therefore she would not be capable of performing any of these jobs utilizing any of her acquired but limited transferable skills. Of course several of these jobs are unskilled. Additionally they do not exist in large enough numbers to be considered reasonably available in the competitive labor market. Her former occupation as a lens cutter, lens polisher and hostess are all considered light work. She would not be able to return to those occupational duties for the same reasons. Based on this client s education, functional academic limitations, borderline intelligence which are pre-existing conditions, as well as her own physical limitations, vocational skills lost and inability to retrain to other skills, and her limited capacity to care for many of her own personal needs in order to be employable, her ability to earn a livelihood is totally and completely diminished. She has suffered a one hundred percent Economic Disability and a Total Loss of Earning Capacity. This forty-nine year old female would have a work life expectancy of approximately twelve years according to the U.S. Department of Labor, Bureau of Labor Statistics data reprinted from The Use of Worklife Tables in Estimates of Lost Earning Capacity. In my opinion Jane Doe is permanently totally disabled solely as a result of the onthe-job injury of 11/29/94 and 2/7/95 and is unable to earn any wages in any employment for which she may become physically suited and reasonably fitted by education, training or experience, including vocational rehabilitation. I declare under penalty of perjury, that I have examined this report and all statements contained herein, and to the best of my knowledge and belief, they are true, correct and complete. Sincerely, Cary L. Bartlow, Ph.D. Licensed Professional Counselor Certified Rehabilitation Counselor 11

12 Certified Vocational Evaluator 12