Claim - Ansel, Sandra
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
This written report constitutes your claim against the City of Dubuque, Iowa. You should complete this form in full and attach any additional information that supports your claim.
The Claim must be filed with the City Clerk at City Hall, 50 W. 13th St., Dubuque, IA 52001. It will then be referred by the City Council to the appropriate department for investigation. Once that investigation is completed, a report and recommendation will be submitted to the City Council. You will be provided with a copy of that report and recommendation.
THE FINAL DECISION ON ALL CLAIMS IS MADE BY THE CITY COUNCIL. NO EMPLOYEE OF THE CITY OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY REPRESENTATION TO YOU AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID.
1. Name of Claimant: Sandra L. Ansel
2. Address: 1920 Amelia, Dub. IA 52001
3. Telephone Number: 563 582 9476
4. Date of Incident: 9 27 01
5. Time of Incident: 12:35 P.M.
6. Location of Incident (Be specific): n 11th & Main St. (1091 Main)
7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give full details upon which you base your claim. If a City employee was involved, give the employee's name.)
Stepped in Pothole on City Street
8. What were weather conditions like? Sunny & Fair
9. Give name and address of any witnesses: Shirly Lange, 1951 Lincoln
10. Did police investigate? (If so, give names of officers.) Yes, Officer was sent to hospital
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Sandra L. Ansel, 1920 Amelia St., Dubq. IA.
Chipped bone, severe sprain on right ankle.
12. Was any damage done to property? (If so, describe property and the extent of damages. Attach estimates of damages or describe basis for ascertaining extent of damage.)
13. What other damages do you claim, if any?
14. Have you been compensated for any part or all of your claim by any insurance company? (If so, give name and address of insurance company and amount paid.)
No
15. What amount do you claim from the City of Dubuque?
$360.00
16. Why do you claim the City of Dubuque is responsible?
Hole in Street not properly filled in.
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
No
18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount?
Dated at Dubuque, Iowa this 15th day of October, , 2001. .
/s/ Sandy Ansel
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
This written report constitutes your claim against the City of Dubuque, Iowa. You should
complete this form in full and attach any additional information that supports your claim.
The Claim must be filed with the City Clerk at City Hall, 50 W. 13th St., Dubuque, IA 52001.
It will then be referred by the City Council to the appropriate department for investigation.
Once that investigation is completed, a report and recommendation will be submitted to the
City Council. You will be provided with a copy of that report and recommendation.
THE FINAL DECISION ON ALL CLAIMS IS MADE BY THE CITY COUNCIL. NO EMPLOYEE
OF THE CITY OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY REPRESENTATION TO
YOU AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID.
1. Name of Claimant:
3. Telephone Number:
4. Date of Incident:
5. Time of Incident: II D-'. % S
6. Location of Incident (Be specific):
7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give
full details upon which you base your claim. If a City employee was involved, give the
employee's name.)
8. What were weather conditions like? ~ %
9. Give name and address of any witnesses: ~J'~ ~J~ ~0 {~'
10. Did police investigate? (If so, give names of officers.)
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
12. Was any damage done to property? (If so, describe property and the extent of damages.
Attach estimates of damages or describe basis for ascertaining extent of damage.)
13. What other damages claim, if any?.
14. Have you been compensated for any part or all of your claim by any insurance
company? (If so, give name and address of insurance company and amount paid.)
15. What amount do you claim from the City of Dubuque?
16. Why do you claim the City of Dubuque is responsible?
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
18. If the answer to Question 17 is yes, have you received any payment from that source,
and if so, in what amount?
Dated at ~ubu~ue, Iowa this
,200(
(Signature~
(Print Name)
(Rev. 1/00 & 7/01)
~]~I'H E FINLEY
I~'lrtOSPITAL
~llm
!~ANDRA L ANSEL
35o NO. CRANDV,EW ITEMIZED STATEMENT
DUBUQUE IOWA 52001
3191582.188i~· ,~ .~-'~
OTOOLE OFFICE SUPPLY
MAIN ST
~UBUQUE, IA ~EO0t
1 I 0/0~/01
ADMIT DATE DISCHARGE DATE
ST^Y09/i~7 / 01 09/~T/O1
000000441 I
NOTE: TO INSURE PROPER CREDIT - RETURN THIS PORTION WITH YOUR PAYMENT . -
THE FINLEY HOSPITAL 350 NO. GI%~NDVIEW DUBUOUE, IOWA 52001 319/582-1881
DATE ITEM~ DESCRIPTION
ACCOUNT"O.~OE;O~ 1 ~. 01 SERWCE FROM'09/~7/0 I[m~OUG' 09/P-7/01 eAGE
GTY ~ ^tIOUN"F
09/~7 ~07 AIR ~PLINT ! 70.0~
**~74 PROSTH/ORTH DEV
TO. O0
09/~7 ~7~670
Og/~7 33100~
09/~7
*-981
RAD ANKLE - RT
DIAG RADIOLOGY TOTAL
EMERGENT
EMERGENCY DEPT PROCE
PHYSICIAN ~;ERV CE~LEVEL 3
PHYSICIAN TOTAL
TOTAL
- I
9~.00
80.00
80. O0
11B.00
11~.00
~GO.O0
360~00
· PLEASE KEEP THIS ITEMIZED BILL FOR YOUR INCOME TAX AND OTHER RECORDS~ THIS IS THE ONLY ITEMIZED BILL YOU WILL RECEIVE
' YOU ARE RESPONSIBL.,E FOR PAYMENT OF YOUR BILL, IFNOT PAID BY YOUR INSURANCE'COMPANY_
~ FEES FOR PHYSICIANS PROFESSIONAL SERVICES WILL BE BILLED DIRECTLY BY THE PHYSIC~NS.
AIq,'SE~I ....SANDRA L .920 ~1'117,1...I~ DUBUC4UIE I~ 52'Z001
25878
:1. O7'~3 IqAIN o ¥
DI BIJQUE. :fA 52_'OO1
EMER ROOM
FRO F [~:~ER
._ t.~5o 70 ~00
F'a I of :L TOI'AL CHARGES:
560 iO0
WOR Kli-ZRS COMF' 0000000
AN~:~EL, SAI'qDRA L 000000441 WORI< COMP
62 INSURANCE GROUP NO.
t'JOl:,. KCOi'II
O'¥0OLE O 'FICE DUDU~UE, .IA
It
~ ABM. DIAB, CD. 77 E-CODE
o4 ~ ,),)
947
~,~ 688531 FROST ANDRISW M
UB-92 HCFA-1450
OCR/ORIGINAL Ci...A I i¥1Sl-~r~
THE [? NLE¥ HOSPITAL · 350 NO. GRANDVIEW AVE. · DUBUQUE, IOWA 52001
;, CONVENIENT cARE CHART
PHONE 563/589-2460 EMERGENCY / TRAUMA RECORD '? ~
#2 Safe~ #3 Knowledge Deficit #4 Airway Ineffective #5 Cardiac ~ LO.C.
#11 Elimination ~] 2 Psychiatric #13 Thermo Regulation ~14 Sexual As~ult
~AT ~T NO. J A~M ~AT~ TIME ~ "AT~V~, ~ ~MCL
I
#7 F~k~,'olume g8 Tissue Integrity #g Mobility
#15 Pediatric #16 Trauma #17 Fever
I
X-Rays: X-rays will be reviewed bv a radiologist IF any additional x-rays or treatment ara needed you will be Contacted.
Cultures: CulVures usually take 48 hours for the resultS. I___F additional treatment is needed you will be notified.
Tile medication may make you drowsy. DO NOT DRiVE. OPERATE MACHINERY, OR USE ALcoHoL~
P~scrintions: You were given the following perscviptions:
Name Of Drug
Dose Number prescribed
Number of refills
The Circled Home Care Instructions Sheets Were Given To You:
AduR Gastro
Crou~ Medication Il Gyn/GuGERD
Burn Care Ear Pain I
Cast Care Eye: Abrasion
Headache
Nitroglycerin Shin~IRSV es' J Suite Beglunlngs
~ j Slm~l~ u,,t,~ Cash Cae
Follow-up Care
Uriflar~ Tract In~
Vaccine Sched~tle
not improving as expected or develope new problems contact your Dr. or return here.
If you are having pain that is NOT reasonably controlled by medication or other interventions contact your physician.
Make an appointment in Business Health.
You have an appointment in Business Health on- (Date) At: (Time).
Make an appointment with the following Specialist
.an appointment has been made for you with Dr.
On: (Date) At:(Time)
OTHER INSTRUCTIONS:
~ig~a~ra of Patient or
have received and understand these instructions:
Relationship
Reason for visit:
You were seen by:. Dr.
Norse:
i If you feel unsafe or threatened in your relationship you may call: 1-800-332-5899
DISCHARGE TIME:
Sex: Female
Chnlcal Work-up-~?=~ ~,* =,~ ~,~.~, ~ -~1~ r :~ ~ .....
............Cardiac Uoflitor'-F ..................... ~ Rate~:'''~-V'--'~;*'':'~:~;'~' . /Rhythm: ............... NSR ':"'~"'"-~""-'--'"'~"~;"~:~;~-*'~"~ ~' ~ ~ .................... ?~"~"~:"~'~"~/STTA- E~opy ........................................................... ·
EKG ~ ~ Rate'- / Rhy~m: NSR ~ ' ~' ' ~'-IS~- E~opy. ' '
~PR:NL IQRS:NL I~:NL~ ~ /PrewousEKG:~Y~Uncha~/ /EP:lnte~eview
,CBC [ NL ek~pt: WBC ~lHgb / ~ ~/Pl~e~ '~ ~ ~- I esgs / bands r~l ~phs / mones lees
Cardiac Enz~es NL ~pt: CK ~ C~B ~ I Troponm / ~ I INR .',wi p~
UA : NL e~pt: WBC -*~ I ~Cs '- ~ ba~e~a ~ / dip '~,,, ~
Course (Timing, Reas~ri, Ir~tervention,*'a~ Re, tilt)
Recheck 1
Calls Placed
DiscuSSion
Records Reviewed i Nursing Notes / Flow Sheets I EMS £ NQr~ingHor~ !~Prloi'ED I lnpa~ent' ! lnpationt Ordered ! Inpatient Unavailable
L ...........................................................................................................................................
FXFIBULANO~ CI~gSED
FX ~ET~TARS~ CLOSED
FX TIBIA WIF~ULt NO~ CI, OSED
~R~SON HIP~LEG
CONTUSION OF ANKLE
FXtN;(ZE NOS, CI.O~D
ptilN IN ~'OINT. ANKI~./FOOT
(~,~ P,t~ OF z~YKLE NO$
Disposition
Location
Condition
Prescdpfions
Plan
NH or ALF I LWB$ I AMA I Transf For Work Injudes
Follow-up Physician
Instructions
Limit Ac'~vities for Daya I Referral in Days
~1o Work for Days 1LimEed Duty for Days
PMD I On Call MD / Other.
Counseled
'~Associaf~ Pr-~)-vide. r: //~7/ ~
Attending Physic,am/~ ~'~ ~-'~/0 '
L~x ~ ~stems. tnc
Clinical Work-up t Diagnosis I Treatment Plan
~ Resident/,PA/
' Additional Dictation
ed at
Pdnted 9/27/01 at 12:28 -Page 1 of ~
ANSEL. SANDRA (40 - 55 yr F) Right Ankle tnjur~ (f)