Claim Stumpf, DonaldCLAIM 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: Donald Stumpf
2. Address: 1989 N. Grandview Ave. Dubuque IA 52001
`
3. Telephone Number: 583 8273
4. Date of Incident: 12/7/05
5. Time of Incident: 3:05 P.M.
6. Location of Incident (Be specific): 1989 N. Grandview Ave. in alley near driveway.
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.)
(See attached statements)
Don arrived home on RTA bus drive by James Mellory. When unloading from the bus the
lift guard did not funciton properly. Don had no where to put his feet, brakes not completely applied. Don's momentum caused to fall of life approximately 3 ft to ground..landed feet first into ground and fell out of wheelchair.
8. What were weather conditions like? Very cold, snow on the ground.
9. Give name and address of any witnesses: RickSanches, 633 W. 3rd St., Dubuque IA 52001
Sherry Lutgen, 840 Walker St., Dubuque, IA 52001
10. Did police investigate? (If so, give names of officers.)
No
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Yes, Donald Stumpf, 1989 N.Grandview Ave., Dubuque IA
Abrasion top of head ; sprained ankle. Paramedics called.
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?
Emergency Room & X-rays
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?
All medical bills (as of 1/18/06 this includes Mercy ER $483.00 and Mercy Radiologist $24.24)
16. Why do you claim the City of Dubuque is responsible?
The driver failed to ensure lift guard was working properly before moving Don onto lift and driver failed to ensure brakes
were properly applied.
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 day of , 20 .
/s/ Donald Stumpf
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
, ,'/:}1 //,4;S/
' ~
t 'CLAIM AGAINST THE CITY OF DUBUaUE;'IOWA ~~AU.
This written report constitutes your claim against the City of Dubuque, Iowa. YO~Uld
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: J')ono.J d ,<::; t u vn p..f
2. Address:~9C6LN, G-rO""Y1(\v~eV\J ~C ~bu.iL.te. '"TA. 52-001
.5n3- 0"13
3. Telephone Number: /5 0 oL
4. Date of Incident: \ ~ II I 0 5
5. Time of Incident:
3~o5 pm
6. Location of Incident (Be specific): I q SCJ I\J. Ll/l1.nd \J I ~ VJ A-ve.. I VI ~
'(\€-D-Y dn II~WO\..'1
7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give
full details upon which you baslj! your claim. If a City employee was involved, give the
employee's '.lame.) .Au.: O:tlrlJud-..- -4t1d1'1k;5 -r::- !V" '/ ,
\'"n-.tec\. \r\o~ \/e.n va es It! n
~-hombtts +tv- IlfLg/J1J1d did VlDf fuYlc.hon pr()pJr/~. ~Dn hM
, , s at l ':Dm ') momen./urY}
C!.Clu-<,t.c -\D fa...lL,..J.. lit-\- 0 pYOY-im(.t.kI . i+ -IV nro4.Y1 .I..-a...nde<'l
8. What were weatlier condHions like? (" , " -j -re.et -Ri +- into I
QroLlh(t-l-iel \ Ollt-
<-.J of- L.WV\eeldltt\r-,
9. Give name and address of any witnesses:
/033 Wt~l1J fubu~if1h
, 52.001
10. id police investigate? (If so, give names of officers.)
Or1rl Snerl LuJjen 84-0 WalKo- 5t- 1 bu.bu~u~ 17\
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Yes I JJooaJd "~+UrY'lPf. lqeH N Grarld\Jiew ~, b-ctou~,W--1 !lL
Atx(L'::,\DYl b~ of he(l(L ') -5pro--; ()e~ Clnl.z\.e....
~ro- rYIe'cLcs CD.J\ Qcl .
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.)
JD
13. What other damages do you claim, if any?_bnu-5enc,,\ RoofY\ ll.Y1 cl
'} ~~S
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? All ty)frJiuiL bills
(Its otJP~fD& -Hu~udts rvttr[~ f;R t 4-&~.DO ami.. ~ifCLI RoditJ/{J::l5~ ,;Pf
16. Why do you claim the City of Dubuque is responSible?:fh.e, dn Iter" J,4 :J
'\etL+o WfL lift Ullftl rktl\ YO L re.- m6vi
to '0 'IeLL ()J{e~ ~re- t
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
IJD
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
day of
,20_.
1'1\'" ~
fuN s -r\) \'"
(Signature)
DonaIiJ ,Shun ,/:1
(Print Namei
(Rev. 1/00 & 7/01)
, , .
-=R I'U( Smc.hLz, sWf
"
December 15, 2005
Re: Don Stumpf injury
December 7, 2005
Submitted by: Sherry Lutgen
Second Shift Primary Caregiver
On the afternoon of December 5,2005, at aprox. 3:05 p.m. Don arrived home on the
RTA bus. As Don was being unloaded from the bus I turned to attend to a meal prep on
the stove. When I returned to open the door to greet Don and staff I saw Don lying in
the snow ejected from his wheelchair. I imrtlediately called 911 because I knew that the
fall Don took was at least three feet or more from the ground. When I asked what
happened, Rick Sanchez (first shift staff) reported that the lip guard on the lift
malfunctioned and Don rolled of the lift. I was instructed by dispatch not to move Don. I
then passed this message on to the RTA driver and another gentleman (name unknown)
who witnessed Don on the ground. They immediately said, "We can't just leave him lay in
the snow. The then took it upon themselves to put Don back into his wheelchair. Don
was brought into the house and'" at about 3: 11 p.m. EMS arrived to do an assessment of
Don. EMS checked Don allover, Don had an abrasion on the top of his head. The
abrasion was later cleaned by myself EMS asked Don if he needed to go to the E.R. to
be examined. Don replied, "No, I'm fine." Don signed a waiver stating his refusal. After
EMS left I notified my supervisor by voicemail of Dons accident.
Later that evening at about 7:30 p.m. Don stated that he needed to use the bathroom.
Don stood up to make the transfer and shouted, "Ouch that hurts I can't do this." I then
assisted Don with removing his shoe and sock and found his left ankle swollen and warm
to the touch. I then assisted Don with his transfer so he could use the bathroom. After
Don returned to his recliner I put ice compressions on his left ankle for twenty minute
intervals for two hours. At bed time Don was still experiencing pain and refused Tylenol.
I contacted my supervisor ofDon's condition at 9:00 a.m. Thursday morning
December 8,2005. Don's family was notified by supervisor and it was suggested that I
take Don to the E.R. at Mercy to be examined. Don was diagnosed with an ankle sprain
in his left ankle. Don returned home in a air-splint on his left ankle, and instructions to
stay off his feet while at work, and to were the splint for two weeks. Don was also
excused from aquatic exercise for two weeks.
,
, " .
Key~ine Transit 2401 Central Ave
Or Mllli bus # 563-690-6464. . Dubuque IA 52001 Phone # 563-589-4196
INCIDENT REPORT
Date: 1:2..-7-0..s-Timc: .!I;~S'
Vehicle#: ,!)S t I
Location: t Q <>-<> .1 ' i)
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Descri~tionOfincident: !ls:r u.>a-S IGI.AY';~ r<!""'f 0+ DoT\. s+"....p-F'
jr.e.::h".je'lc_~ wl~.e..lc.~o;1- 1llOSel1ed q"J lWl<:?Y<e.~ ve..-y
S/;jhfi'i Cl-....d ~-e -t'dt 0 v-\ O-T h", s cJ...o;..... +0 J vo\Jl1..../
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~e wn:>\Ip. 110+ ..s-l-r"'Ft"" d I'\. (LoA. <;> ,'h , i-l-e Q-o'1A f 'b; Il~
<3-+' so....e. ~~o-d 0 1'\.'- dE'l'\.+ ~ t' I' c ci. r-So"\. O-I'l d ~
l'!>\.e.Il'>'\kl-- f?:c.i, 1 rv-l- h.~ ~ .boc..-k: ~~ C!-kQ; V' al.l-\..d
-R ~c..1\ +Oclt h; M-\, b o.c- -It- ; 1\ -1- 6 A. () US-<::- ~O-"s c.. 1I>"t-
ee> I d <LOY'.cl;'+; artS. S ~v;Sl>'r- 01- h.OWll\.Q!.. SlCl,'d. --t l~
S(e \.VaS' oo;"j += c.a.1t St>Ml-i' 0VIe... a.bll.rr l\I1.eJ.<2...\ d~c.I(.
Probable cause: v A.. 10. c/o' v...J 0..+ s La ",+cd. fOS;+; l>t\,. ffl s+-
>>-h.ok;~ ",,,-,,;+~ J~. ..'3Vrc. +h.o-1 '\O~--t ~QSv. b~'a.~.s.
LvQV'e.... <2.ofl-t'l~l'e-le 1'( 1t>vk:-c...J. Cll\ ci tlto Ss:>.+ he.H-
e> l\. eh.o; r... r: J~\r'
Driver signature:
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