Claim Deutmeyer, CarlaCLAIM 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: Carla Deutmeyer
2. Address: 2110 Pasadena #6 Dubuque, IA 52001
3. Telephone Number: 319 556 6734
4. Date of Incident: 8/14/01
5. Time of Incident: 2:30 P.M.
6. Location of Incident (Be specific): In Parking Lot of vocational Services Center at 2455 Kerper Rd.
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.)
Carla was exiting bus when door closed on her hand which was squeezed by the door.
8. What were weather conditions like? Fair
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
No
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Carla received a red mark on right hand and wrist that was painful for a couple of days.
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.)
No
13. What other damages do you claim, if any?
Medical bills
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?
$478.78
16. Why do you claim the City of Dubuque is responsible?
$478.78
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 14th day of November , 2001. .
/s/ Theresa Dressler, Supervisor/IPC
Area Residential Care, 2455 Kerper Blvd.
1 319 556 7040 (Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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. 13t~ 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: ~SF'
2. Address: c~l~) {~S~c~Pz)& ~ ~}o~.,~,-~"~ ~'~)
0
3. Telephone Number: ~}c~ ~ ~c~-~o-7 ~-'~
4. Date of lncident: ~'/l')/~)/
5. Time of Incident:
6. Location of Incident (Be specific):.~x~ ~O=c)c,'nq Io'~ ~[
~ U
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
e~ployee's name.)
8. What were weather conditions like? ~L~
9. Give name and address of any witnesses:
10. D~)golice 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 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.)
15. What amount do you claim from the City of Dubuque?
16. Why do you claim the City of Dubuque is responsible? ~L~-~', 7~
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.) J~O,
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, lowathis ~/.~-FL dayof ./~/0~-e~r~b~o~F- , 200~ .
~..~ (Signature),
(Print Name)
I-'3i q - ~
(Rev. 1/00 & 7/01)
AREA RESIDE2'qTIAL CARE
Accident Report Form for Non-Work Related Injur/es
Complete this form for any non-work related injury and any marks o/undetermined origin such
as bruises, scratches, bites, erc,
Date of Report ~5"r / ~ __
Nameoflnjjzred C',4-~'LCo+- .O~.cc'7-r't? c--NC~F~. DateofBirth ~/~-~' 3C~ --
Address ~ l [ (~ /9/4-3 ~ ~Y q- _/J~-~ 3-- ~
(COMPLETE TI-lIS SECTION IF YOU KNOW FfOW TIlE INJURY IIAPPENED)
Locationofaccident (_A 'CT z%-~ S Date oc>-/7_/ Time ~.,,
Describe accident or injury, including specific body parrs /e,.I GtC'Y- l~-q~'-D G ~
How did the accident or injury happen?/~.zz% /,Z..d-~/~ q2~-~ 7~/-'~ c-,-7-X J~<~,...7-
Was ~e injury related to a behavior (o&~m or someone else's).9 ~/ No (circle one)
............. 27. ................. . ...... ......"..
(COMPLETE TiqlS SECTION IF YOU DO NOT KNOW HOW TIlE INJURY HAPPENED)
Dare injury discovered Time A/VI/PM Location
Descr/be injury, including specific body parm
How did you discover the injury?
Action steps taken to determine possible cause
Forward to nurse by the end of shift
Sigaamre of person discovering injury Date
TO BE COMPLETED BY NURSE Guardian notified Yes / No ,'circle one)
If yes, date notified
Suspicious mark/hzrther follow-up needed Yes /~ircle one) £f yes, complete other side
4la/&/ yno. route,o
~narare of N~se Date
(Signarure~ on back)
August 2000
(COMPLETE THIS SECTION Il* FLrRTI-LER FOLLOW-UP IS NEEDED)
Nursing comments
Signature of Nurse Date
FORHARD TO ASSOC~TE DIRECTOR HFffHIN 24 HOURS
Associate Director action steps
ASSOCIATE DIRECTOR it/IAY FORWA~ TO DEPT. DIRECTOR FORADDFFIONAL FOLLOF/-UP
(O 'T ONXL SECT ON
Department Director action
Department Director Signature ~0 ./~_J2/~ ~ Date
DEPARTM£NT DIRECTOR RETURxV TO ASSOCIATE DIRECTOR
Associate Director final determination/actions
Associate Director Signature
Date
Associate Director Route to QMR. P or SUPV/IPC
QMRP or SUPV/IPC Signature~ . ~'k Route to Department
Director
Department Director Signature r'~ ~k~.54.J~ Route to Executive Director
Executive Director Signature ~ ~ Route to Administrative Secretary
Administrative Secretory: Original to Central File/Copy to Nursin~Copy to Trainers if behavior-related
Trainers: review and. if individual is from ][CF/MR, forward to Behavior Intervention Specialist