Frost (2) , f�����j'�L,A
NOTICE OF �A�Il�Vp�+1�RM to the City of 5aint Pault��ne�ota
Minnesota State Statute 466.05 sta t ' '`" '°�y��erson..,who claims dama es rom an munici ali slla��au�e�b��r�ented to the
���� ��k..�ds�S g .f Y P h'... p
governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating,th,�tir,t�,�r�Z�ce,and
circumstances thereof,und the amount of compensation or other relief demandeaa���j 4; a�`�.i�►��}
Please complete this form in its entirety by clearly typing or printing your answer to each question. If more space is
needed,attach additional sheets. Please note that you will not be contacted by telephone to clarify answers,so provide as
much information as necessary to ezplain your claim,and the amount of compensation being requested. You will receive a
written acknowledgement once your form is received. The process can take up to ten weeks or longer depending on the
nature of your claim. This form must be signed,and both pages completed. If something does not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PALTL, MN 55102
First Name � �,�/( �� Middle Initial � Last Name ��S �
_____.__ - ___---
------- --
_._
_ __ --. ___ _._____v_____:___-_ _
Company or Business Name ��" ' - -- �" -� � �`"'
Are You an Insurance Company? Yes/(No) If Yes, Claim Number?
`� `J
Street Address� T� ��(%J � � ��-
City ? ��G State � ( 1(�(1-�'�j �Zip Code � �Z�
Daytime Phone �Z $l�-`'lZ`1 ell Phone�`�� �/Z vening Telephone(_� -
Date of Accident/Injury or Date Discovered �uC��/ ��- Time�am/��
`„J
Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you
feel the City of Saint Paul or its employees are involved and/or�responsible for your damages.
S � �.' � D� G " lQ(c�
-Z rt� eh ' �n .
(� d
2 ( p S
GP(1 -e D�� 6
a e.r rc,� �
Please check the box(es)that most closely represent the reason for completing this form:
❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow
Y C7 My vehicle was damaged by a pothole or condition of the street CJ My vehicle was damaged by a plow
❑ My vehicle was wrongfully towed and/or ticketed �I was injured on City property �
❑ Other type of property damage—please specify
❑ Other type of injury—please specify
In order to process your claim vou need to include copies of all applicable documents.
For the claims types listed below,please be sure to include the documents indicated or it will delayfthe.handli.ng of
your claim. Documents WILL NOT be returned and become the property of the City. You are eineot�raged to kEep a
copy for yourself before submitting your claim form. - • -
O Property damage claims to a vehicle: two estimates for the repairs to your vehicle if the damage exceeds
$500.00; or the actual bills and/or receipts for the repairs �AR — � 2��2
O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt
O Other property damage claims: two repair estimates if the damage exceeds $500.00; or the actual bills�.�-:�^
and/or receipts for the repairs; detailed list of damaged items
� ��;�.� �
.. :�_ .-
O Injury claims: medical bills,receipts
O Photographs are always welcome to document and support your claim but will not be returned.
Page 1 of 2—Please complete and return both pages of Claim Form
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims-please complete this section
Were there witnesses to th�incident? � No , Unlrno ( ircle
o 'de eirnam s, addresses dt l�phon num rs: � a �(1��5� ��'������- �
� �' tr � � - ��
Were the police or law enforcement called? Yes No Unknown (circle)
If yes,what department or agency? Case#or report#
Where did the accident or injury take place? Provide street address, cross stxeet,intersection,name of parl or facil' ,
closes andma k,etc Ple se b as detailed as possible. If necessary, attach dia,�am.'� ' ��-'
c.`�� I �l S �rrc.�e Wt 5 Se
Please indicate th�mo�t you are seeking in cQmpensation or what you wo}�ld like the City to dLo 1to r olve this claim
to your satisfactio _�C�1 � � �-'- 8�� � 1�' � � �P
'�'���'� ��' _ -- __ — -- ------
Vehicle Claims-please complete this section �check box if this sectxox�.does not applv
Your Vehicle: Year Make Model ' , ,
License Plate Number State Color �
Registered Owner
Driver of Vehicle ►A�R -' � 2
Area Damaged
City Vehicle: Year Make Model °°�'�"
License Plate Number State Color ' 's'�
Driver of Vehicle(City Employee's Name)
Area Damaged
In'u Claims- lease com lete this secti n ❑ ch ck box if this section do s not a 1
How wexe you injured� �,.. St 1 �t� a �—' � ` �b �--'r1
Gi, fi�� I(�
What p (s)of your bQdy were injured? (.�1�fl � `�-
(�C��r�S ��l CGt
Have you sought medical treatrnent? es No Plannin to Seek reatment(circle)
When did you receive treatment? y i�- f (provide date(s))
Name of Medical Provider(s):
Address Telephone
� Did you miss work as a result of your injury? Yes o
� ,- � _ rovide date s -----
, When did vou miss w�..�_ __ — ___ -- (1� � ))
IName of your Employer:
' Address Telephone
❑ Check here if you are attaching more pages to this claim form. Number of additional pages
By signing this form,you are stating that all information you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date form was completed ��'"/��' � � �2'
Print the Name of the Person who Completed this Form: 1 "��/b �� � � ��
Signature of Person Making the Clai� � �
Revised February 2011
� Met odistiHospital MRNS�875R�J
DOB: 3/10/1988, Sex: F
Enc. Date:02/14/12
R@�t��
�e�a �e�� I��s�� ir��c�
_..�..
��;ft�a: f�at� St�`u� _ LC�t llpr�te U��r L�sA��:E����: �af�ll"i�n�
Shabana Siddiqui, MD Signed Shabana Siddiqui, MD 2/26/12 12:48 PM
i�,tsCfi�criz�:io� If�fc�r�at:���
Authenticated by Shabana Siddiqui, MD on 02/26/12 at 1248
NAME: FROST, TEARA J MR#: 48875124
CSN: 459348683
AUTHENTICATING CLINICIAN: Shabana Siddiqui, MD
CONFIRM #: 1405646
LOC: 502
CLINIC PROGRESS NOTE
DATE OF VISIT: 02/14/2012
DOB: 03/10/1988
CHIEF COMPLAINT:
Follow up for sprained ankle.
HISTORY OF PRESENT ILLNESS:
Teara is a 23-year-old lady who today came in for followup for ER visit .
About a week ago patient twisted her ankle, slipped on the ice, and after. that
she was unable to bear weight, with a lot of pain in the left ankle, so srie ;
went to the ER where they did the x-ray that was negative for any fracture .
According to the patient that she was given Percocet, which she is unable to '
take it because it causes nausea. She still continues to have a lot of oa�ri. ;
The pain has been constant, 7/10 in severity. It is like a dull ache with �
occasional sharp pain. There is no associated numbness. Sometimes she feels
tir�gling in the anicle area, and she is still unable to bear weight . In the E�l
when she went on 02/09/2012 they did a 4 inch Orthoglass splint. Today came j
in for followup. j
�
REVIEW OF SYSTEMS : �
i
Negative. ;
PAST MEDICAL HISTORY:
None .
MEDICATIONS:
Zoloft .
ALLERGIES:
NKDA.
Printed on 3/12/2012 12:55 PM
'� Park Nicollet FROST,TEARA J
�� Methodist Hospital MRN: 48875124
DOB: 3/10/1988, Sex: F
Enc. Date:02/19/12
P��t�� ����#���a�d}
Pleasant female in no acute distress. Examination of the left ankle shows
her to have some swelling about the lateral malleoli . She is quite tender on
her ATFL. She is nontender at CFL, PTFL. She is nontender at the deltoid
ligament . She is nontender on the medial malleoli . She is nontender
throughout all the tarsals, metatarsals and phalanges . Skin and sensation
are intact . Her strength in all directions is intact . Anterior drawer test
shows there to be no laxity.
ASSESSMENT:
Lateral ankle sprain.
PLAN:
At thi.s time we discussed ASO splinting. She was put. in this and does sti7.1
have a limp afterwards. V�le will have her doing physical therapy to help
working with range of motion and strength. See her back if her symptoms a�-e
not improving in the next 2 to 3 weeks .
D: 02/19/2012 03 : 09 :38 pm T: 02/20/2012 08 : 13 : 14 am IM: 02/19/2012
03 : 15 : 09 pm MT: 18
Printed on 3/12/2012 12:55 PM
� ParkNicollet FROST,TEARA J
�� Methodist Hospital MRN: 48875124
DOB: 3/10/1988, Sex: F
Enc. Date:02/19/12
f�c�t��
�r�a r��� �s�t� Br�fe�
,��;ft�o; i�at� :;t���as €���t lJpart� ils�r L�s4 U���E� Gate%7i�n�
Heather D Thoerner, MD Signed Heather D Thoerner, MD 2/24/12 09:33 AM
r"�,�_:thc�iz�:io� I«fc�rrai::�:�
Authenticated by Heather D Thoerner, MD on 02/24/12 at 0933
NAME: FROST, TEARA J MRN: 48875124
VISI'I': 459539431
DICTATING CLINICIAN: HEATHER D. THOERNER, MD
JOB: 343368 Med JOB: 71783
LGC: 37i1
CLINIC PROGRESS NOTE
DATE OF VISIT: 02/19/2012
DOB: 03/10/1988
CHIEF COMPLAINT:
Left ankle injury.
HISTORY OF PRESENT ILLNESS:
This is a 23-year-old female who injured her left ankle on 02/09/2012 . There
was water in the street and she slipped, twisted her ankle and sat down on
her ankle. She was seen at Fairview Emergency Room where she had radiogr.apns
taken. No fractures seen. She was then seen at Park Nicollet in Burnsville .
Again, radiographs were taken and no fractures seen. She has been walking
on it, having pain 3/10 at rest, 5/10 with activity. No previous injury to
the area.
REVIEW OF SYSTEMS:
No fevers, chills, rashes, sk.in changes, numbness or tingling .
SOCIAL HISTORY:
She is a student at MCTC in her sophomore year.
PAST MEDICAL HISTORY:
None.
PAST SURGICAL HISTORY:
None.
FAMILY HISTORY:
Diabetes.
PHYSICAL EXAM:
Temperature : 98 . 8 . Height: 65 inches. Weight: 155 pounds .
Printed on 3/12/2012 12:55 PM
`,� Radiology Report FROST,TEARA J
MRN: 48875124
Park Nicollet DOB: 3/10/1988, Sex: F
i����`sr�g ����ar��t��a� �����i��a�d�
����rs €�afr�����i�e� �a��a�i�aa�d �.._...___.__.
��;r�c�rn��� Prc���w��:r� ;�;�,�y �at�tas �:;g�� �ir�:;; .:�r�:n ��i�V?F:
XR ANKLE" LEFT 3+VIEWS (STANDARD) Final Tue Feb 14, 2012 N/A
10:14 AM
���ff Ba�f�r���tac�� �. �.�._......
T�c��oi��:i�t Tr�nSC�Errio�i�t �s�i�i��� �'h��:;:iarr;s) As�i��r:��f Pr}G�;s;�..�
Rad Tech Edi Rad Results In Edi N/A N/A
�°��€f6��t�e�r� ��e�a�r��ti�r�a �_
�i�.�r:�� �3,, ait�r���.� �� ^��arn�ii d� �'rw:�r�: E3�,; PJ��!'K�'i� a�s �':��'i:�; _,
Jonathan J Sudberry, MD Feb 14, 2012 Jonathan J Sudberry, MD Feb 14, 2012
Pe�tienl Narre: E:errin Unte/Time: Pl�ane 1F: MRN
Frost, Teara J 952-374-9290 48875124
DOB: Age a!Ernm: Sex.' .Aceorrn!N:
3/10/1988 24 yrs Female
Pn(ient C/nss: Accession#: Order#.' Pe(nrmin,q Depni7ment:
13969509 517043403
Primary Cnre Provide�c Attenrling Physicinn: Admitting PGysicinn:
}Iutchison, Leann G
Orderir�g Physieia�: Orderrng Plivsicinn Address: Ordering Pliv.sicinn Phone N:
Shabana Siddiqui 14000 Fairview Dr 952-993-8700
Burnsville MN 55337
Printed on 3/12/2012 12:55 PM
� Park Nicollet FROST,TEARA J
� Methodist Hospital MRN: 48875124
DOB: 3/10/1988, Sex: F
Enc. Date:02/14/12
I�t���� ��ta�����s+�d�
SOCIAL HISTORY:
Patient does not smoke. No risk of pregnancy, per patient .
OBJECTIVE:
VITAL SIGNS: Blood pressure is 102/60 . Pulse is 70 . Respirations are 18 .
GENERAL: Patient is comfortable, in no acute distress .
CARDIOVASCULAR : Sl and S2, regular.
LUNGS: Clear to auscultation bilaterally.
MUSCULOSKELETAL: On the left ankle patient does have tenderness present and
slight swelling present on the lateral malleolus. Pulses are palpable . No
calf tenderness is present .
ASSESSMENT:
Left ankle sprain.
PLAN:
I did the x-ray of the left ankle, and it is negative to my reading. Will
await for the final report from the radiologist . Since the patient still
continues to have a lot of pain and unable to bear weight, the appointment has
been scheduled with the podiatrist for this afternoon for further management .
SS:MEDQ C:
D: 02/14/12 12 :20 T: 02/14/12 14 : 54 CONFIRM # : 1405646
XR ANKLE* LEFT 3+VIEWS �t���;s Final resu�t
(STANDARD)
Results 2I14/2012 11:04 AM
�,�� �+ate ----------
W 2/14/2012
@����I# �3�a'r�tiv� _----_._-__
CO1�iPARISUN: tvone.
FINDINGS: No definite fracture or dislocation is identified. Ankle
mortise appears intact.
f���a.�i� ��'a r��sita� .-----._ .-�
IMPRESSION: Negative left ankle series.
�..��x��3�i �°,43E1���[t?�
XR ANKLE" LEFT 3+VIEWS (STANDARD) on 2/14/2012
�e���t �-la��€�� -------
XR ANKLE* LEFT 3+VIEWS (STANDARD)on 2/14/12.
�r����a�� {ra��r�a���i�sr�
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Printed on 3l12/2012 12:55 PM
FAIRVIEW RIDGES HOSPITAL FROST,TEARA JERVON
201 E Nicollet Blvd MRN:0031826910
BURNSVILLE, MN 55337 DOB:3/10/1988, Sex: F
Pertinent Info Acct#: 13000146307
Adm 2/8/2012, D/C:2/8/2012
A►dmissi4n 1n#ormatic�ra
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..;.�;��: ..;��r., ...�:��:. 02/08/2012 8:53 i'�c::;:� .�:�:4:`;i,;.:. None �_ :�.,�r�. None
PM �.a't�''T'�r^�
�:33r:ias:ic;r:TZ�:�:: Emergency ��:�:°E:<>S�Jf'E�v��ur�;+:�: Ernergency Room F,�:Itr•i: i;�::��;Fr,r}: None
��.:.�._. ., .'�:..Y�.: Car .-:n;.-?y ;'e:�:;:a Emergency :�:�:_:^::,��:�� N/A
Medicine :f�rvic:F��
Tr�h:i�`:sr a=:�Ear�,F:: None £,�::��:ti:�s,:�.�3 Fairview Health i�r;:1; Rh Emerger�cy
Serv ices Dept
A�li�ri: F':��lir.;e:; Shapin, Ryan P, ��;t�ri;iir:i$ ?rc;�,r:J^r:Shapin, Ryan P, RF?'f��:�irt� F'rori��:r: None
MD MD
i�9saha e Infiarma�tian
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02/OS/2012 11:54 PM Home Or Self Care None~ None Rh Ernergency Dept
�i�3�� i.�ri� i3��ic`�
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_ �_. :�_ i-`.! -
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i``�� 845.00 SPRAIN OF ANKLE, UNSPECIFIED SITE
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��::F��c�: Warns, Carrie A, RN �;+:�r��ic��_�: (none) �F:;t:�c,�':"���F?: Registered Nurse
i�•b:^:i: 02/08/12 2057 :tit�,� -i:tl":�: 02/08/12 2057
Slipped and fell on ice tonight twisted left ankle. ABCD intact in triage.
n�,.•`,. nN: ,nr•_��; F.,; P1 .�,.- _.�r ^; >.t�•r 1aS��x
��;__ t. .ii„ II; fii .r_ �,�a� ..�; z=�. iF-�\ ��?�._='? .�.:?,�::tx ....
EfJ Presvider Nate�sir�ne� bw Sh�ni�. R�r�� F". MQ at tY�109.''f 2 013'4
---------_......._.-----_........�---�......___�_.....a.._._._.__.—.............�_..�__....._.._.._.----•_....._.._._.---.__..�_.._..__....------..._._._._...__._.._..
.�i��y��,r. Shapin, Ryan P, MD :.�:'I4iG°, �nO�� tt��t���:1r :ypt:: Physician
:=::�::`,: 02/09/12 0131 �i:'e ±`;:':: 02/08/12 2208
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Chief Complairrt:
Trauma
HPI
Teara Jervon Frost is a 23 year old female who presents to the ED for evaluation after slipping on some ice.
Just before coming in for evaluation the patient was walking around Saint Paul when she slipped on some ice
iwisting her left ankle. She did not hit her head and did not lose consciousness. Immediately after falling she
had the onset of pain in her left ankle that would radiate into her shin. She denies any foot pain. Due to her
severe pain she decided to come in for evaluation. Currently she rates her pain as 8/10 and describes it as a
sharp, stabbing sensation. Putting weight on her leg or movement of the left ankle will e�cacerbate the pain.
Movement of her toes does not exacerbate the pain. The patient denies any fever, chills, nausea,vomiting,
shortness of breath, cough, headache, rash, hematuria, dysuria, weakness, numbness,tingling or any other
physical complaints at this time.
Allergles:
No Known Allergies
Printed on M6/2012 1:27 PM Page 1
�
FAIRVIEW RIDGES HOSPITAL FROST,TEARA JERV�N
201 E Nicoliet Blvd MRN:0031826910
BURNSVILLE, MN 55337 DOB:3/10/1988, Sex: F
Pertinent Info Acct#: 13�00146307
Adm:2/8/2012, D/C:2/8/2012
��: �€�:t�s �����i�-����j
Medications:
The patient is currently on no regular medications.
Past Medical History:
Denies any significant past medical history.
Past Surgical History:
History reviewed. No pertinent past surgical history.
Family/Social History:
The patient denies any relevant family history.
Marital Status: Single [i]
Social History:
The patient denies any tobacco or alcohol use.
Patient presents with her mother.
Review of Systems
Constitutional: Negative for fever and chills.
Respiratory: Negative for cough and shortness of breath.
Gastrointestinal: Negative for nausea and vomiting.
Genitourinary: Negative for dysuria and hematuria.
Muscu bskeletal:
Positive for IegJankle pain.
Skin: Negative for rash.
Neurological: Negative for syncope, weakness, numbness and headaches. �
Negative for tingling.
All other systems reviewed and are negative.
,�:.{� 1� q
Y'lF�+ii.l�i �'��' 'o .. :.,, � ��.�-. w _ ♦ \`` . ` \4 ., _;.``,, ``\ �:�`y \`, <;.., -�`y �.. , �„\,,�:,
First Vitals:
BP: 101/68 mmHg
Pulse: 81
Temp: 99 °F (37.2 °Cj
Resp: 18
Height: 162.6 cm (5' 4")
Weight: 68.04 kg (150 Ib)
Sp02: 99 %
Physical Exam
Constitutional: She appears well-developed. No distress.
Muscu bskeletal:
Tenderenss to the leit lateral malleolus. Non welght baring. Otherwlse ankle has full ROM passtvety
and actively.
Printed on 4/6/2012 1:27 PM Page 2