Document 4JeLjM253aGvdX17j5ZrZ6RNx
SELF-INSURERS
Supplemental or Final Report on Occupational
Injury or Disease
Check appropriate box: ___ Supplemental} X| Final | |
Reopening
Aluminum Company of America Box 221
Wenatchee, WA 98801
Claim Number S598522 55-L Firm Number 700,002-01-9 Soc . Sec . No. 534-28-6412
Form must tie filed at the following t'ves on all claims:
a. On the date the first time loss compensation is paid.
b. On the date the time loss compensation is terminated or the rate thereof changed.
c_ On the date a determination is requested.
d. On extended claims at least every 180 days.
A medical report need not be submitted with your request for determination on non-compensable claims (medical only).
PLEASE ANSWER ALL QUESTIONS
Workman: DONALD L. CONRAD
Date of Injury: SePt. 1953 - Sept. 1973
AHrimss: Spouse-Almeda Conrad 4773 Saturday Ave. Malaga, WA 98828
Date first compensation paid: _
Marital status:
CX Married
Single
Divorced
Widowed
No. Dependent Children Under Age 18:_____5________
(and/or under 21 if enrolled In Compensation paid from:through: accredited school) Use (a) or (b)
(a) Temporary Total Disability at the rate of $ _________per day fordays totaling $
jr- '
'
-
' (b) Temporary Total Disability at the rate of $per month for__________________ months anddays totaling $.
(For any Temporary Partial Disability paid during this period, show dates and
amounts paid and method of calculation based on claimants earnings in the
"Remarks" section below.)
Date physician approved workman's return to work: Deceased - 05-13-83____________
Date returned to work:________________________ :_____________________
Will the claimant be able to return to his former occupation?
Yes * O No
Undetermined
Has medical treatment been completed? Yes -No
Names of treating physicians:
Is condition medically fixed?
Yes O No
-
Is there any permanent impairment? O Ye SO No O Undetermined
4
Medical report ^ attached previously submitted X-Rays
Thomas W. Mai pass. M.D 820 N. Chelan Wenatchee. WA 98801
Determination requested?
O Yes No
Remarks: Death certificate included. - Carcinoma of Unknown Primary
Workers Comp. Adm. -- -Title --I-- _
Date 83-11-10
If this is a FINAL REPORT requesting determination, submit one copy to workman, one copy to Department of Labor & Industries.
!< *!'" !* * SUPPLEMENTAL REPORT only, submit one copy to the Department of Labor & Industries. If inis I* a Supplemental REPORT showing termination et eompemetion of ehenge in the fate
thereof, submit one copy to the workman and one copy to the Department of Labor 0i IMMlp.
WENS 013482
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WNS 013483
Labor & Industries. Attention: Accident Report, Claims Section, Olympia, WA 98504. Detach the Physician's Copy (3rd Copy)
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for your files and promptly mail the balance of the form to the employer (this includes the bottom portion of the Original
Fall of the 2nd copy).
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< employer.
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i EMPLOYER'S COPY
DEPT. OF LABOR & INDUSTRIES
CLAIMS SECTION OEYMPIA, WASHINGTON 98504
TYPE OR PRINT IN INK - REPORT WILL BE MICROFILMED.
ACCIDENT REPORT
HOUR ACCIDENT OCCURRED A.M. P.M.
SHIFT HOURS
YOUR JOB TITLE WHEN INJURED
SEX
GATE-Of-BIRTH
luv-uace. &sTa~ a
GIVE DATE RETURNED TO WORK. IF SO were you doing
Ocftffr
YOUR REGULAR WORK AT TIME OF
yjHZPZ CUD RMPLOYER'S -JOB SITE OTHER
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ACCtOENT^ .
OCCUR? '
m' 9W
HEIGHT
til
WEIGHT
"GO-WORKERS
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WHS'HURT? LF ANVi.%^-.
EMPLOYERS BUSINESS NAME ONLY
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.
EMPLOYER'S BUSINESS {START TYPE OR NATURE OF)
r -STRSt ADDRESS
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. *
1 ' * i fV/V^.1 . 1 *
WAS THE ACCIDENT IN YOUR OPINION
CAUSED IN ANY WAY BY SOMEONE NOT EMPLOYED BY YOUR EMPLOYER?
YES 9
LF EMPLOYER WAS NOT
NOTIFIED THE SAME DATE AS THE ACCIDENT-GIVE REASON
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lld/lslJfNWO { \_/ MfWXAA^*'***
a*- maNO DATE YOU REPORT ACCIDENT TO YOUR EMPLOYER -
*
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wjjuia^/______________ -
TO WHOM REPORTED:
. _ ^NAMEBTITIf)
fiouje bejL)ma3V- tiotr.mdLO
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CMTCR VMM RATE Of MY M 0W.Y OME 6CK OaoVf. JJO NOT MCUJOC OVERT***. W1U YOU RECEIVE
PER HOUR
'"`"iirais3PER DAY
FUU SALARY FROM YOUR EMPLOYER?
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IF MACHINERY WAS INVOLVED, NAME MACHINE AND DESCRIBE
ITS FUNCTION. WERE YOU LIFTING, PUUING, PUSHING OR CARRYING? FALLS SHOULD BE DESCRIBED AS INDOORS OR OUT. DOORS ANDIAST OBJECT STRUCK BE NAMBX NAME OEMICAL INVOLVED. W APPROPRIATE.
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Qbhcsipg-s ~tor Y\
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V --JiAs-.h emplOyment-do you work
MOlCTbAN 440 HOURS PER WEEK? IF WSCJPIVET---O--T--A--L-*--HRS.--PER WEEK.
GIVE NAME ANND BIRTH DAATES OF YOUR CHILDREN UNDER 18 SUPPORTED BY.YOU.
TODAYS DATE
RELATIONSHIP
RBATIONSHi
T
W DIVORCED AND YOU HAVE MINOR CHILDREN SUBMfF A COPY OF THE COURT ORDER SHOWING LEGAL CUSTODIAN OF SUCH CHILDREN. ALSO GIVE PRESENT ADDRESS OF SUCH CUSTOOiAN.
FULL NAME OF SPOUS| AT TIME OF INJURY
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_I HEREBY AUTHORIZE MY PHYSICIAN. HOSPITAL,' (WORKER'S SIGNATURE)
AGENCY OR ORGANIZATION TO DISCLOSE TO THE DEPARTMENT OF LABOR ANO R4- ? OUSTRIES, ANY MEDICAL RECORDS OR OTHER INFORMATION REGARDING TREATMENT l WHICH HAS PREVIOUSLY BEEN FURNISHED TO ME.______________________________________________________
IF DIVORCED, GIVE FINAL DECREE DATE I HAVE READ LEGAL WARNING ON REVERSE SIDE OF ORIGINAL
(WORKER'S SIGNATURE)
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PHYSICIAN'S REPORT
oate or first treatment
HISTORY t SUBJECTIVE FINDINGS
HADDEEMMPnLdOyYffiWWEER BEEEENN
TYEOS NO ifyB
START HERE..(.ty..p.e..o.r..p..r.i.n.t..in...in..i.q.!..2..-.2...8..-.8..3...... .He
Is
a
S3yo
man
who
has-tiever
smokb TREATED BY ANYONE FOR TgSENf OR:SIMUAR CONDITION?
Cigarettes or drunk alcohol* had some asbestos exposure Over many i>atfs
.In the past but not In the paslrl5~years, *ho has beeri\found to ha 825
I THERE ANY -RECORDED . IREtEXISTMG IMPAIRMENT ^
>F 1HE AREA INIUfiH>? *
ATTAO REPOR
OBJECTIVE FINDINGS diffuse abdominal carcinomatosis with grosstescites, siei^mgbR WILL 1tfS OR ANY OTHER '
IF EXTREMITIES INVOLVED,
( peritoneal surfaces, mesenteric Implantation^; exteinstcGIVE RIGHT OR LEFT
. PRE-EX^TING CONDITION COMPLICATE bOWe^l TREATMENT OR RETARD RECOVERY?
lesions withtou anything Intrinsic.
YES PROBABLY POSSIBLY NO
X RAY & LAB FINCHNGS
^
SEE-ATTACHED>DICTAITlON
WHi THIS EMPLOYEE BE Off WORK'-OUt TO THIS INJURY?
PROVISIONAL DIAGNOSIS (USE BOTH STANDARD DESCRIPTION AND ICDACODE)
.'
Adenocarcinoma, unclear primary, metastatic diffusely within abdomen. "flefatfw'wof'ftup for metastatic tumor from upper GI tract
ESTIMATED TIME LOSS Patient
ATT PHYSICIAN TELEPHONE NUMBER
SEE ATTACHED DICTATION
If CASE REFERRED TO ANOTHER DOCTOR, GIVE FULL NAME ANO AD0RCS5;
-663-87]3
REFERRED PHYSICIAN PHONE NO.
T. Malpass MD
820 N. Chelan
If HOSPITALIZED
NAME OF HOSPITAL
IN PATIENT OUT PATIENT
J& - Central Washington Hospital
WEnatchee. WA
98801
HOSPITAL TELEPHONE NUMBER
Same
LAI USE ONLY
ATTENDING PHYSICIAN: {PLEASE PRINT OR TYPE YOUR NAME ANO ADDRESS.) __
ADDRESS
Z1PXOOE
0.Hotter MD
820__________ N, Chelan
WEnatchee, WA 98801
LICENSED PHYSICIAN
SIGN^TURC--^
MUST SIGN BEFORE
REPORT IS ACCEPTED
4---
DOCTOR: TEAR ALONG PERFORATION AFTER COMPUTING IN FUU.
OLYMPIA, WA. 98504. -
DATE
#*30-83
PAYEE ACCOUNT NUMBER :
30773
IIT TO DEPARTMENT OF IABOR 8 INDUSTRIES, ATTENTION: ACCIDENT REPORT CLA^'
WENS 013484