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Home My WebLink About95-06808 1 ,~ , ):: I,' .,'~ '~~r:~j ',~ , /~ ~ j ," 'i .. .."','"......,...-.""'.'>'."ti.".,......"'\.,~,"".".."".~.,:;...,.,...,..,.._~_...,....--.......... . . .. . ',. .. DANIEL P. WILSON and SHARON M, WILSON, Individually and as Parenls and Natural Guardians of AMANDA WILSON, A Minor. · IN THE COURT OF COMMON PLEAS · CUMBERLAND COUNTY, PENNSYLVANIA . . · NO,: Q5.l4ffOg cwJ~ . · CIVIL ACTION - LAW . . PlaintiffslPetitioners v. DAVID 1. GANTT, Defendant/Respondent PETITION TO SETILE THE CLAIM OF A MINOR The Petitioners, Daniel p, Wilson and Sharon M, Wilson, husband and wife, individually and as parents and natural guardians of Amanda Wilson, a minor, respectfully represent: I, The Petitioners, Daniel p, Wilson and Sharon M, Wilson, husband and wife, are the parents and natural guardians of Amanda Wilson, a minor, The minor Plaintiff, Amanda Wilson. resides wilh her parents, They have a mailing address of RD#2, Box 116, Milroy, Pennsylvania, 17063, 2, The minor Plaintiff, Amanda Wilson, is currently 12 years old, having been born on June 15. 1983, 3, The circumstances giving rise to the instant action occurred on January 21, 1995, on Route 114 West in Silver Spring Township, Cumberland County, Pennsylvania, 4, At that time and place, lhe minor Plaintiff was a back seat passenger in a vehicle operated by her falher, when the vehicle driven by Defendant, David 1. Gantt lost control on lhe slipperylicy roadway and crossed into the lane of travel of the Wilson vehicle, A copy of the police accident report is attached hereto as Exhibit U AU, _. ~ . .- .......:--..-.'- _....~.- .'.'"- -. . _._.".,,"'~'~"'I'l_~_..~ . . ~,,--,..~, . . . . ~.. . S. On the date of the accidenl, the vehicle driven by Defendant, David J, Gantt, was ~ owned by David J. Gantt and David E, Gantt. This vehicle was insured through an automobile policy issued by the Allstate Insurance Company. 6, As a result of lhe accident. the minor Plaintiff, Amanda Wilson, sustained a head trauma which included a left maxillary fraclure, fractures of the fronlal sinus area, and some facial lacerations. She was hospilalized overnight at the Hershey Medical Center. She was intubated overnight due 10 an episode of vomiting with ailWay compromise. Attached hereto as Exhibit "B" are copies oflhe pertinent medical records, 7. To settle this claim, the Petitioners, the Respondent and Allstate Insurance Company have agreed upon the sum of Nine Thousand Five Hundred and 00/100 Dollars ($9.500,OO) for the settlement oflhe claims of Amanda Wilson, a minor, 8, The Pelitioners believe thaI the settlement enumerated in lhis Petition is fair and equitable under lhe circumstances and in the best interest of the minor Plainliff. The Pelitioners are unrepresented. They understand and waive their right 10 obtain counsel to advise lhem regarding the appropriateness of lhe selllement. 9. The Defendants have offered 10 pay the sum of Nine Thousand Five Hundred and 00/100 Dollars ($9.500,OO) 10ward an amicable solution oflhe claim, and in exchange for Court approval, a Release of all claims. and a discontinuance of the above-captioned matter, AlIached hereto as Exhibit "C" is a copy oflhe proposed Release. 10. The Petitioners request thaI the selllement sum of$9.500 be deposited in an account with lhe Pennsylvania Tuition Account Program which had previously been set up naming the minor Plaintiff, Amanda Wilson, as the beneliciary, The account number is 0000027979. Attached hereto as Exhibit "D" are copies of the Statement of Account for Amanda Wilson with lhe Pennsylvania ~~"" , -. ~~II-"""2,--Jl! ~-..-~; ,.,-~.,-.>;~., ..o:.......c.-_"."...~. ",_,',' __"",~.".~.I"'al.'("_""_'_"";,'_co"",,,.,",e'" I r._........ ........'.....A.'....._,_>_.'.,._..,. .' . 4 . .... " Tuition Accounl Program, a brochure describing lhe program, and the minor Plaintilrs most recenl report card for her first marking period of sevenlh grade, WHEREFORE, it is respectfully requested lhat this Court enter an Order approving the foregoing compromise selllement, directing lhe dislribution of proceeds lhereof as set fOrlh above, authorizing the Pelitioners, upon payment oflhe aforesaid sums, to discontinue the action broughl and to execute a good and sufficient Release of any and all claims arising from or as a result of the incident referred to above, Res ectfully submilled, By: Dated: November 30, 1995 606<< .-~j '-.-;.;Y'c '!- '/~,:;~~. ~,<"',-; . "-'->-~.!iWl.=~;~~'"-'""I~~'t!~':i.:j~rJ . . .' ". ',-~" - -"'.r'~~~~~:":-"L .' . . . VERIFICATION -:._,,',~ .,'. 'fL-' ..... " I, Daniel P. Wilson, individually and as parent and nalural guardian of Amanda Wilson, a minor, verifY that the averments made in the foregoing document are lrue and correct. I understand that false statements herein are made subject 10 the penalties of 18 Pa, C,S.A. 4904 relating to unsworn falsification to authorities. e P. Wilson Individually and as parent and natural guardian of Amanda Wilson, A Minor 00"'+/15 I 60617 n~';;>"""''''<'''''''''''T~~'''''''';1r'.!{~_.-.-..."...."......."-,,._.~.~_';'''-.~~~_.---:..i.'..;:-"-__'___~"h'. . . ,! .... VERIFICATION I, Sharon M. Wilson, individually and as parent and nalura! guardian of Amanda Wilson. a minor. veritY that the averments made in lhe foregoing document are true and correct. I undersland lhat false statements herein are made subjecl to the penalties of 18 Pa, C.S,A, 4904 relating to unswom falsification to authorities, ~~-~\~ Sharon M, Wilson Individually and as parent and natural guardian of Amanda Wilson, A Minor Dated: \\- \~-o.,,~ 10657 --.....--....',.~-~.. . ~-......r.~_.."__..."'.".......".,... .';~'i;:'-;~11_ct~~:rm_Joi,_.,;..:<\..""_.-_.~..."'.,~..........,""'~,....":,,.,.:.iloO.>~~~..........~.;., ~.;,..ib...;.; _'~ . '.. . ID 1. 'DUl .,. .LOOM"'LD.'A 1111' " .. MAilE TDIDlA 45 Lt~l . "40r BOOv !>rEI " 800., . TVPE ID USAGE 50 ""HAl "'P^cr 1 I. ~HaE ro.", SIATUS -- ~-~ ., , \'CII't:lF ,,1IonIVFA - OIMO'EIH ' - PRESENCE .... onl'Wtll ~.!ER --1.17Iml ~, onl\'[I1 NN.'E DAVID J GUTT ~,- ,. DRIVER IIOOnUS II l~JI 'SO ClfY, SiA,! HIPCOOE .n .LOOM'IIlD, 1A 17m " ~EII . 120AfECW . BIRTH ~ cou... 'IEH 85 onIVE" 'I t:J N CLASS ,151 CAnnIER ~ cAnn'En AOOnUs ~ err.... Sf AlE . llPCOOE n usaor. ;JVir.-. f...~!Q No or .~lES . 1~I"o7) 41 OWNE" - AOO~US -'D..~1. lor III - ..,. en.,.. srAre 11IPCOOE 1I11DI. 1A 17m '2 VE"" " ".IolAIIE 'D'fUe ., AIODE'L . (Nor UN. 0 BOOv "'" I .7 ~ " J5 :::;::'~lIMPAcr 11 VEHIClE O~N' 51 DnlVER 1M.I1IER 51. OIIIVER ~ - 51, DnIVER -~~ IJO ClfY. ,rAre 11IPCOOE MIlIDI ,. ""J 13 P'IDNfi, m'ml II SEll M 12 ~,~~~ OF DJ/1I/lI .. COM", VEH IS DnlVER II D<l'VER v NOI ClASS e SS, 81 CAnnIER I Il-t -:. i!')nr.rrn 100vrnIA.."u,. ~ POLIce INFORMAtiON ' ::':r.~;" TItJ'1ll ;A~ ~ "1", "".G ,., i iTA110ijj III P~~I ;- .......1(lA 10ft mM. I, J. (DUll. I A~rdrll' 7 IN\irlllQ.\Io. DAlr . PA'ROl. ~ aAOOi NUroIlIrR IIAOOi """'BEn ,/",," · ~AL ACCIDENT INFORMATION 10 DA. OF lVtrll / I , . I .. AcCIDENI ..~!.=--~ " I~.or "..-;' "" ._-~..~-- 'J · killED 0 14 "NJUneo - - II l>O vr"octr '''VI' 'OBr nC"DvrD 'ACN.t "It $(t,-.:, UN" I " """erR OF UNlIS I ., ""'V PROP 0 ACCIDENI . 7 VE"ICIE DA"'AOE o ' NOllE UN" , , .IIONI , , IoIOOERATE 3 . SEl/(nr UN" 2 '~NO I, ltAZAnOOUs &4.\ IlnlALS UN" , V@NO O ~ · rrNNOO, · N~ ~R" UNIT' 1 I,",JlIl .0 - 3t lfOAll Y Y N PARllro'OD ]. PA I,-it E 0" oUr'OI"SIAlE VIN iO OWHE" 31neo PLAlE 4' OWUER ADOnESS 4~. C"y. StAre I l!!'CooE :;, 'YEA" " 1/t1/lDD1 D.VID J. , DAVID I. CA'lT . I COMMONWEAL TH OF PENNS Y" .-ANIA POLICE 4CCI{lENT REPORT nrron'ABU NoN, nrron'AIII CJ 'r~1 USE 00.1. . ' " Ate/DENr LOCAtION - C"IIIUID COO( ; " "UNOC"'AL", Ill", "'''~ COOi I; PRINCIPAL ROAOWA Y INFORMA nO", ii 1IOij,. NO Oft ~"nrrT~ u ....ro Il I.., - ii" COU,.r y 0/11 1100' 11'01 - /Ill It 1 N~ CiJ CD N~ Ii noo"[l NO Oft IInrEl HAIoIr " SPUD L...." · r.PE AC~fSS '- HlOHWAV COIflRIll IF NOT A T INTERSECT/ON: 30 ~~~~~~~ ""'mTl " 3. ~~~~ N S'e w 21r~~,~ " '" OlSTANCE WA 0 /QI "'EASUREO rs~AlrD ...J,g, s rAA,,,c 'RINCIPAL INJE'1SfC r COIflnlll GJ GJ orVICE ,. CONSIRUC,l()Oj lONE Q 3t SI"il --. 31 IEOALL. . N 27, nED, P"""E07 DO PLAIE 39. PA IOrIE 011 OUT.QF'SIAlE WI 40 OWNER UNIT' 2 'Hlm I1BI111lD1 'BAlD' M fl UD' ICe. PUC. ,. oVWn " Allusr \l!."^l w.u. 'U NU UNILU 147684-1 I D.'I.l '.TIIC' "l'D. 1ft, 'D1 13 PHONIi, ""1111 ~ II CAnnIER _ ADOnrss - ". C"', B'Alr I llPCOOE 10, USO(jl , ICe , 'I. VEN COrtroo, " No OF AXLES ~--- " nUEASF ~ "~11"'" . v r 1 . PUC. '4 own. rA~r . 14 1W~"IIIf"Nt"'.'M"AI~t:.,:, "'- ... ,. ""IJII~AI. 'At'It.., "'~""'_1IIi'17""I.II1Uo\l' I Aer.OtfOHAIAf ADUnrsS HIJIlLU ,I~. ,1.1,11/ ' .~ j' . o-'-ii,i.GiiiT':"uu ii'oiivli" 0_0__..-- 0_'...._-.-- j'~ j'~ r ,0_ T r I I , It I I I -CiiLTowrIITiOIiiilioomiL6- ____0___' - 'r 1- T '. ,-..,- ; I " U I II .um '~IILm:-;UI-,in'lm - ..-.-- --- - I IT. I r .-- -. -~.; ~-- I I , '/1 I I 11l1O. lIifoi;liifiliiiiil I I , I \ . J i: j'L.i o!1 _~, 1... ! IU." "UDI, 111I1 II 'l\Vi~- I I I C I I (i)LLlNlllAIIlJt4 I~ @Wl!AIHI!A[!J II OIAOIlAU 0 IiilAoAosunrAr.1r'jI I...... ,-:J U'iLVii lliii4,iAMl611 UMUtU ' J .;uENr I: ,. -,.. '1"'111'-'" --16f. .,III",mttlllf/IllUII mlm '. . - __rll\~cI5ENf bt.'ii: - "'---11121'11 - ,,- It "''''IS'LV'' 0; 1(;11OOL DtIlIllCI ,..~..... ~ ,#~J,oI /AlY"'W1 .. DlSC....'IOI. u; IlAUAOED PROPtIlIY OWNER ADDRESS P11llHt! ., ,,^"nAllVE .IDEN'.,., rnEClrnAtlNO Evt:NlS. CAU~'ION rAtIons. SEOUENCES Of EVENtS. WlINFSS ST.'E"'EN'S. A'40PAOVIOE ADOIllOfrfAL MIA..,. L"'E INSURANCE INrOAMATIOH ANI) LOCAllOH OF lOWED VEIlOCLES, r 1lHOWN. THIS ACCIDENT OCCURRED ON SROll4 WEST IN THE AREA OF THE INTER '-- 81 OVERPASS. THIS DAY ROAD CONDITIONS wEREtlET-FROn A W4V... ""un -- CONDITION. THE OVERPASS BRIDGE WAS ICE COVERED. SROU4 IS POSTED EAST" WEST, BUT RUNS NORTH" SOUTtr'l'RROUGH BII;VEJrSPRINu ','Wr. WIT 1 STATED HE WAS IN THE RIGHT LANE OF SROll4 EAST. HE STOPPED FOR THE RED LIGHT AT THE INTEIfSEcTION orBRuu, AIW .I.-II' l:luunt Uh RAMP. UNIT 1 WAS STOPPED IN THE LEFT LANE. THEY PULLED FROH TH~ TRAFFIC SIGNAL WHEN IT TURNED GREEN. WIT 1 STATED HE FELT THE ICEY BRIDGE AND SLOWED, LOOKING BACK IN THE MIRROR HE OBSERVED UNIT .I, -- FISHTAILING THEN CROSS OVER ,\'HE T~rFIC BARRIERRnIJlh'K.l.l\iS u..... c. WIT 2 STATED HE WAS BEHIND UNIT 1, IN THE RIGHT LANE. STATED SAME AS WIT 1, UNIT I'S BACK END STAIfTEU TO GO oU'r UN ,\'HK lC~ cuIIERE.. UVDn INSURANCE COMPANY ULSTArI IHSUIW<<:E COIM'AHY nUl rAIl '''0llMA lION H"onr.IAllON UNIT POl":.... mUDm --.lior- roroCY' ---,mll71mR- I I~ 1 NO "^mAUU IOKOIDS tII T100ICIISl Vi'...." mCft\1'lfSlll<; 101 1lI'0Ul PHONe III W11NESHS N^'fiCRAIL IIINII lU I ml ST CAlum, t -1II~RE5f1j ''''liii PHONe 'It VIOl^'JONS IUOtCAIED I ~fIJH ."''''BEns ION\.Y. CHAROEDI Ie HIe IINIJ , DIIVlle VII AT SA'I 00 00 ~SU111 DNO IESI .. IlMiSllGAIICN o % 0 AEFIISI COMPlETE' ,.... 0_- 0 \11II YE10NOU CEHIEIl 'OR HIGHWAY SAFUY ~ sflla 'n., J ~nolI^8LE USE iiiifi I M..;j.Ii7!- - E rz-r,.,.. Pim ~l/IY'" I~IESI I ~SU111 DNO IESf ~ US!! 0, % 0 IlHU$E I iiiiii -- Ell \11II 1470841 PAO;:I . ~.ri"n IUOII'RlA, ~"EII 0; flflrH"ln""'nt..1. COMMON WEilL TH OF PENNSYL. "N/II PAR CONTlNUATIONSHf:Er NI'OII'AnU tD NUHl'fl'OfllAl1lf D .......!""fiii 'U1 IA~::'" r~~' -11 Ili~~Al III ~v.nI00l"'0.".1I0N ,IISL UVf'~A' lUlU' rune:oulI IcorroNAW Aounnl " , J . I .. , . , II I I . 111111 lllllVllT, 10 " 111101. PI llii, I , , C , 1 - - - . II NAfI'''''1I/l PASS. UNIT 1 LOST CONTROL, CROSSED OVER THE LEFT TURN LANg & TRAffIC BARPtER INTO THE PATH OF UNIT 2. UNIT 2 THEN ATRUCK THE PASSt;IiGr.R SIDr ("RONT OF UNIT I WITH tKUIiT uFlm 1 'I' ~, - UNIT 1 STATED HE WAS TRAVELING EAST ON SRDll., HE HAD JUST PULLED FROH THE 'I'RAFFlC SIGNAL AT SJrolTIE AND 1-81 soIJTJrOrFll~HP. lit; A~CEtl:RI\TEu 'IU APPRull. ":J I1PJt:-flE:--rRSR-t;OS,.-coNTROC-OF.ll'h I ~ uN"""TI1E- ICE COVERED OVERPASS, HI> WEN'I' AND CROSSED OVER THE TRAFFIC - BARRIER & WAS STRUCK IN THE PASSENGERS IDE OF UNIT I BY UNI'I' 2. UNIT 1 STATED HE WAS IN THE LEFT LANE OF SROII. E:AST, UNIT 2 STATED HE WAS TRAVELING WEST ON SROll., HE WAS IN THE RIGHT LANE: STOPPED FOR THE TRAFFIC SIGNAL AT SROl14 AND 1-81 NORTH OFF.RAMP. THB SIGNAL TURNED GREEN & HE PROCEEDBD THROUGH THE INTERSECTION. HC THEN HADE A LANE CHANGE TO THE LEFT LANE SO HE COULD;ENTER 1-81 SOUTH. - HE HAD ACCELERATED TO APPROX. JS HPH, SUDDENLY. UNIT 1 APPEARED CROSSING THE TRAFFIC BARRIER DIRECTLY INTO HIS PATH. HE STATED UNIT 1 WAS IIROADSIDE. UNIT 2 COULD NOT REACT & STRUCK UNIT I IN TilE --.- PASSENGER SIDE FRONT WITH THE FRONT OF UNIT 2, ------. - INVESTIGATION REVEALED THAT THE BRIDGE WAS ICE COVERED. THE ONLY SKID HARKS LOCATED WERE FROH UNIT 1 CROSSING OVER THE MEDIAN TRAFF~ --- --' BARRIER. THE SKID HARKS WOULD INDICATE THAT UNIT I WAS SIDEWAYS WHCN IT CROSSED THE MEDIAN. THE POINT OF IMPACT WAS IN THE LEFT LANE OF -- SROl14 WEST APPROX. 25' PRIOR TO THE BEGINNING OF TH! OVERPASS BRIDGE. , , . UNIT 2 HAD NOT YET ENTERED THE BRIDGE. UNIT 1 HAD COMPLETgLY 'CROSSeD THE BRIDGE BEFORE CROSSING THE MEDIAN BARRIER, UNIT ;2 CAME Tq REST IN THE RIGHT WEST BOUND LANE. UNIT 1 CAME TO REST ON THE WEST BOUND II lJ( scnlOE VkJt.AIICINS 00 SECIKHMJt.Uln5C~YFCf,^I1CiEUI Ie: Nle: . . --.!.-=- UNIT' 0 0 UNTZ o 0 ~.i.:;.;. ~fiOiWi. I~!~ ~}'(SiJ.ft DNO.ESI :f~ ~ USE ...:r- ~~~ ~1(su.1i CJ NO Irs, .. IMSIIGA'~ lmE lEST o '% CJ ~'USE: '.~' o ~<ll'lt ClM\E1E , UNI" '-- D lHC lINIn 0.__". D I.NC 'UOHO[j M"SClllllll 0 l PAIlE' .3 C1:HIEn FOA HIQHWA' S"ElY I C/7 8 II i . (!) JOMMQNWEAL 111 OF PENNSYL(. PAR CONTINUATION SIIEEr ~:'::"-!""'''~!.'!' '\.:; ~~..., Ii! ~ ,,~'m. D c TAli. III IA~~::NI r~",~Y 1."~'n'oN INrO....IION .UlIF,UVIICAY IUIII,I'CllICUI'" . C 0 I r a _ Auonrss 1111 II "'''''''"lltV......' 11oI~:,;~1 III II I J n l IA - -- -'" - - -- ---- ,-- '''HA"M'''''' GUIDE RAIL FAc:.~ WEST. (TilE FR~t!.T OF.I!NIT_LWA5_0N_:r"Ul!.!~E RA~~ Till REAR OF THE UNIT WAS ON TilE EAST SlUE OF TilE RAIL,) BOTH UNITS TOWED FROM SCENE BY MILLER r. si\H'i'TOH'iLLER&"SAH"'S'-- SERVICE STATION. BOTH OCCUPANTS OF UNIT I WERE TREATED' RELEASED FROH 1I0LY SPIRIT HOSPITAL FOR MINOR INJURIES. AMANDA WILSON WAS TREATED AT POLYCLINIC THEN TRANSFERRED TO HERSHEY HEDICAL CENTER. SHE WAS REPORTED IN CRITICAL CONDITION. ON 1/22/95 AMANDA'S CONDITION WAS STABLE. ALLISA LINTHURST WAS TREATED AT POLYCLINIC' IS IN STABLE CONDITION. SHARON WILSON WAS TREATED' RELEASED FROM POLYCLINIC. WHILE UNIT I (DRIVER) WAS AT THE HOSPITAL CONSENT WAS GIVEN FOR BLOOD TO BE DRAWN. I DID DETECT AN ODOR OF ALCOHOLIC BEVERAGES ON DRIVER'S B~EATH AT THE ACCIDENT SCENE. HE STATED HE .WAS DRINKING BEER EARLIER; HE STATED HE HAD APPROXIMATELY 3 BEERS AT A BAR IN PERRY COUNTY, BLOOD WAS TAKEN TO BE TESTED BY PSP LAB HARRISBURG. ONCE THE RESULTS ARE KNOWN A SUPPLEMENTAL REPORT WILL BE FILED. --.-. ..----.-.-....-. ~~ : : , :~l....'t n DEM:nIREVIQlAlIUNS , .,...;,. -~. to SECllUNM.JtofIEnSIOh\.YIFCllAROEDI Ie Hie UNI1 I U 0 O_JL .. IIMSllGAllON COfollUlf 1 YES 0 NO OJ ---- UNIll . ;. "TflUO.iiE ~,~ ---' USf. UN" , M,45C I'M) rJ!Y:~ rACE ,,_ IlllVI'( '-"IUI '":\i'" ., .' l::',.: J ... ~... - USE ~sU:IS ONOIF.SI %[J~FU!Il! 0,__ ,0 \HI ~SoJlIS DNOIESI o ~rUSE 0,__% 0 l.NC LCtll l COOEA FOR HIGHWAY SAFETY \I . J ,. I , )/'":t ~. ~ ~ ~I::::' ~ ~ ,~ ------ , , I I - , I : , I ! , '- , ~ I - - g',', '- - -- I J' -{)I 5 I \ , -.--'- - -0- ~~ fiYAI , I l}, - - -- / 0, ~\\ ~ , . "- . , I , , ' I . I I I - I . ., ,. . \', I " I \ I ,. '. I . I I I I ,GJ 7/1 9r-();?;2 O/-QI'9'J /l/7tJ8 tlv PM,i) 'i ..h........... ... ~ . aH "".-11- ._m... H.'. NU'.:I.UI (i) ~ I I i II , II ,I II 'I :1 I :1 '1 :. ., i ,I :j . I ( . . PE~NSJATE ., Cull~l:!~ Ill' M~dicin~ lrl1lv~r\ily H,"pilal' Chlldr~n'~ '-IU\pilal Th~ Millon S. Her\hey Medical Cenler p.o. 80X ISO HERSHEY, PENNSYLVANIA 11033 RE: WILSON, Amand. NARRATIVE SUMMARY PATIENT NUMBER: 1335280 DATE OF ADMISSION: J.nu.ry 22, 1995 DATE OF DISCHARGE: J.nu.ry 23, 1995 ADMISSION DIAGNOSIS: 1. ~ultiple tr.~. DISCHARGE DIAGNOSIS: 1. Left maxill.ry fr.cture. 2. Fr.cture of the anterior table of the frontal sinus on the ri9ht. 3. qight eyelid superficfal laceration. OPERATIONS OR PROCEDURES: 1. CT scan of the head. 2. CT sCln wfth f.cf.l cuts. 8RIEF HISTORY: The patfent fs an ll-year-old white female who w.s fnvolved fn a motor vehfcle .ccfdent. The patfent was. backseat passenger wfth a lap belt only when her car T-boned another car which had crossed fnto thefr lane. The p.tfent was fnftfal'y awake and .lert on arrfv.' at Polyclfnfc Medical Center. Apparently, the patient ~fted sever.l tfNts at Polyclfnfc and becaMe apnefc, requfring fntub.tfon there. The patfent received v.rious radfologfc studfes and was transferred to Hershey Medfcal Center for further evaluatfon and care. PHYSICAL EXAMINATION ON ADMISSION: Vftal sfgns: He.rt r.te 119, blood pressure 139/86, oxygen satur.tfon 1001 on ..chanfcal ventflator. HEENT examfnatfon: There was a laceration of the left eyelfd approxfllltelY 3-4 01, whfch was sterf-stripped on arrival f~ Polyclinfc Medfc.l Center. Extraocular 8Otfons were fntact. The pupfls were 4 _. equ.' .nd reacthe to lfght bflatel'llly. . ThI... WIS perforbftal swell fng of the len Qe. The tynlpanfc 1IIIIbI'ln..... tile right WIS clear. The tyIIpanfc IIIIlIbl'lne on the left was not visualfzed due to ceruM8n. The Mfd f.ce w.s stable. The IIIndfble WIS stable as well. TtIe patfent had .n endotracheal tube fn place. Neck: There WIS no obvfous step-off 01' fracture. Chest: Clear to ,uscultatfon bflaterally without evidence of wheezes. I'.les. or rhonchf. There WIS no . evfdence of external tl'.... to the chest. B.ck: No obvious frectures 01' step-offs. Heart: RegulaI' rate and rl1Yt. with no "nIUl'S. AbcIOII8n: Nondistended with ne.-l bowel sounds. Rectal: Nonul tone .nd hetIe-neg.the stool. Pelvis: Bflateral eccl1Y8Oses of the .nterior superior flfac spine consistent wfth seatbelt fnjury. Otherwfse. the pelviS was stable. Extrellftfes: Good distal pulses fn the uppel' and 10.1' extrellftfes bflaterally. Neurologfc ex..: The p.tfent was fntubated; howevel'. she was .wake and alert .nd responsfve to various questfons. Hel' 8Otor exufnation WIS wfthfn nol'llll If.1ts and there were no sensory deffcfts noted. LABS ON ADMISSION: Whfte blood cell count 16. hetIoglobfn 13.2. helIatocrit 38, platelet count 308. Sodfu. 140. pot.ssfu. 2.8. chloride lOS, bic.rbonate 23, BUN 7 .nd creatinfne 0.5. glucose 217. ~1ase 37. total bflfrubfn 0.7. ~.. alkalfne phosphatase 199. AST 52. ~~. tQU.IA.~'''''''''TMAC'nQIIlIUII'\O'rU ~ V PENNSTATE ., CullCLlC ul' Mcdidnc Uniwr\ily Hospilal.ChihJrlln:, Hmpilal Thc Millon S. Hershey Medical Cc:nler P.O. lOX ISO HERSHEY. PENNSYLVANIA 17033 'I II '1 II ~ARRATIVE SUMMARY PATIENT NUMlER: 1335280 RE: WILSON, Amanda Page 2 Plain filM chest x-ray revealed no evfdence of obvfous trluma. Thlre was no pneumothorax noted. The C-spfne had no evfdence of dislocation or fracture. The pelvis had no evfdence of dfslocatlon or fracture. CT scan of the head revealed no brain Injury; however, there was a left Mlxlllary fracture noted and a fracture of the anterior table of the frontal sinus on the right. CT scan of the abdomen revealed no fntra-abdOMlnal Injury. HOSPITAL COURSE: The patient was evaluated fn the trlunl bay fnftlally. After receiving the above .entioned studies, she was transferred up to the Pedfatrfc Intensive Care Unit for further care. The patient had a relatively unremarkable hospital course. The patient resafned fntubated and ventflated overnfght secondar,y to vomftlng and questfon of aspfratlon and not befng able to protect hiI' afrway. The patfent was extubated the following MOrning wfthout dlfffculty and Mafntafned her saturatfons well on roOM afro T~e patient was then started on a clear Hquld dfet later that day. By the second hospital day the patfent was toleratfng a regular dfet and was ambUlatory wfthout dffficulty. There is no further therapy requfred for the patfent's facfal fractures. The patfent was stlble for dfscharge on the second hospftal day, 1/23/95. DISCHARGE MEDICATIONS: Tylenol as needed for pafn. The patfent will follow up fn the Plastfc Surger,y Clfnfc wfth Dr. Banduccf fn two weeks. The patient wf11 also follow up wfth her local pedfatricfan later this week. She will follow up with Pedfatric Surgery IS needed only. DICTATED BY: ATTENDING PHYSICIAN: . ( . Steven Zgl.szewskf, M.D. SZ:sdu D: 1/23/95 T: cn/23/95 ID: 843(20-21) cc: Patrick Allende,., M.D.. Getsfnger Medfcal Group of Lewistown. 300 HI ghland Ave.. Lewf stown, PA 17044 ICIUA4~""""'TPw'I&C""'~O't'U1 ,.A(;.., i \~J. Y PENNSTATE' ., ..._.I...II.,'....I\I.-.J~".., --. 11"""'1" '1"~llll.1I ('hlltl"'". H."".,..l rh..' \hlh'll' 1I,'"hn \I".""".II.~"I!o" . , , ;J 'T ..J ,. ~ w'/Su>\ I ~A. - TRAUMA HISTORY AND PHYSICAL EXAMINATION '" 'I \? ZU I . ~ : J '" ., ,n I - Amnesll' 0 Yes 0 No O? Prlmlry SUrYI, AlIWIy: 0 PSlent 0 Obstructed Bru'h,"O .:1 A 6 CorcullllOn BP ""'" P ':b Oz 511 lOb U'SoIbil'ly 0 VClC.II 0 PJIRlul 0 UnresponslVf (_potur. J.;.<. PrOUdults 0 NG. Tullt "":~IJt 1v1, o A.hllt: Chesllullt: 0 nohl 0 left OOPl. Secondlry SUrYe, VilJls: Temp: HEENT Head ~ C"~' ,. Eyes Pupils L (!OIOI( Eal1 TM's "-;.:a Sante's Face MlllillaIMandible ~ Nose Time 01 Arnvallo E.R.: Trlle 01 Trluml pl.MVA Sealbell?lil' Yes 0 No 0 Pedestrian o Airbag 0 Slab 0 Assaull o Fall 0 Burn 0 Eleclrical o GSW 0 Dlher: Fllld Rllulclllllon Airway: Field Vilals: BP: loss 01 Consciousness' 0 Yes 0 No Immobilizalion: Trluml Hlatory Intu~led, [70T 0 NT 0 Trsch AlItrO," fJ~o" MedS .( " III' t; , '1.. o ~"I '7~ IV'S: P: Fluid: PMH OUnlllryCltlWt MbuI,' OCVP(sJ: last MUl: tli..' ( P: l'lr. BP: IlJ/'77 RR: ,. ld,~ ~/!., ~"',.,..l e .."..~ L c'''''''.' I..4...f. ''I Oz Sal:~ WT .. ~.!-J...l ~, /....,p. , :,..,~"""" ):z - ... ;' ~ '.' "t\ \ " A if:'~:..,~\1 )i <(; )'Z;-' ~~.t . \ I ~ ) I ~A\ i \) '-, '. , . I Chesl: lungs: . . Sack: ! Heart Abdomen: Rectal: Tone ..~ PelvIS ~ " -).) ".I,~p Vascular Eum: Radial RiQhVlell ,V. I. Sign.lulI ~kIH. , \ '. .. ~ ~ ., ., ..J .' ~ ,I.,,, J.p..... Ulnar iV,1. IIR 11111'I4 rltle M> MA HISTORY AND PHYSICAL EXAMINAnON Femoral .1/,t M S.iiT:' Popll1eal "IIr. Dorsalis Peel. ~ll f1. PoslTib. tl/H. 0030 rllllt y TRAUMA HISTORY AND PHYSICAL EXAMINA1ION Slcondl'" SUIYIV IlIlII.1 EIItI.."y h... B,lly ,ndlo' Soil rlllU.lnlUry SlIOulda, A I L Arm R' l. flbo.. A , L FOIllrm A I L Wnsl AIL _ AIL HIUroloolel' Ellm eN 2.12: Malo< d.nllOCl lIic'p Al\lh~," ~ IV l., Sonsory C5 CI C7 Al\lh~," I :"".,,~ ~'I\..r;> !,lolo'lI.5) PSOU hip,,, Qu.ld. AlQh~.1l ....NL .- SonSO/'f L2 L3 Al\lh~.1l I l.'"" lofty J"'~O' SO" r.uu. lr'IWfY HiP A I L rhIQh AIL KnH A IL ~ AIL Ankl. AIL Fool AIL n ~ , 'IV . ,tJ l ..nlf." Inc.p Qnp .irA. ~~..~ CI Tl \1( :J/" " . " r 11Im. lib ani ...""Iono O""oc , L5 51 OrA'. ,0. w'llIfttl u (Jt ....biItlIdlll ~13.Z. 01" ~cro 1oS" "1 /'..D nr ~,1 U ~V vc. '2.6 0. AII.1lI1 Blood GistS UA l-"'.> 0Ihtrs rCG llIwya I CXR ". C.$pifte: AP Lal oil \ 0cl0n10ld pr PTT AmyIaIl~r CPK IHCG Tol. Bill ALP AST Mb flOH crs- I Had ,- '. . PtMs Q) ~ .r I . . " . fJlrllllllics (, loT I ~..... ....>e0(... fo_ 011II11 ..... tl ,1. .__~AnQiO .L,ftl..f~' U,J AbdO/llln d\1 OlJlall "..... UaI I \..HI I" l..c. . JI""'LI 1.Y ,1 t=:., n:.. J.- J..:J..t; L. L n ...., J PIa , I' -.... · ~o.J..ft,r, J "" AI. L " tU/' GL.~ J. ~ ~ I. -lU, . Jll.SI-: ~,... ~l';....r v U -- A_n'SlQNlura' I' / 'L... 71 UJ ,.Of ,",^^ .., AnlllClillQ SlQnaturt, Clr MR In ..... ) TRAUMA HISTORY AND PHYSICAL EXAMINATlON GII.gow Coma Selll E,. o,.nl"l t 'Nona 2 ' Open 10 P"n ",.. DllIn 10 ComlNnd (Y $oonlln.ou. V.".. AlI,oOll I.NolII 2 . Incompllhlnllbl. 3 . InapP'op'~1I ,)..( Conlulld (j/AJ.rIIO,"nlld Molor AlI,oOll 1, Nona 2 ' DlClllb'lll 3 . Dtcortall 4 . WilllClrlWl X Localllt. Pain C)DbIyI _ TOIIl: Is Trauml Score All', IIatI .IP 0.0 0.0 1.1.9 1'~9 2 . .36 2 . 50-69 3 .25-35 3-711-90 4 . 10.24 4 ' .90 oca 1.3-4 2.5-7 3-1'10 4.11-13 5.14.15 TOIIl: ~ .. ...... J'n'I'\ - .. t v "'''" ..u PEN NSTATE . C"lIr~r "' Mr~l~ Unl'rf\IIY HII'pllal' (,hll~n:n" HII'pll~1 Th~ MIII"n ~ Hrf\h~y Mr~I~~1 Crnlrr , .' J;.:'~ ~~~~ ~3S~80 f;r~:~' .l)Jj/~",- ~. CONSUL TATION REPORT 'is O~ ~El ~~ ~EQ.~Sl41 lOP .. 00 C') ~dJ REASON FOR REOUEST (/ IN(!!) L cJ 0tA led H-tJ./ ~ f~'5~. Y ''---(Jt..-.,) jI.' /. u.1 : 0'-1.' ~ l- Jo ~ "J.d.",!, . (..I ~ f}. <v<'-f J..e.(-6luJ1, G'eS 15 ~ f....~ ~'^ o.)fJ;r~u-- ()jlt1t~ ,...... ,Jv.. ~~ -") I.JAR . 7ROVISIONAL OIAGNOSIS REaUESTING PHYSICAN'S SIGNATURE PLACE OF CONSULTATION o BEOSIOE 0 OTHER o ROUTINE o EMERGENCY , I ( CONSULTATION REPORT l I ~ (I- ~.~~e.. ~~~ (f)r~#;G/bl'?J ~ . &JJ;., l.J 5 c v---t~ c C1 .I..J f l.t...f')f" b J"-') '2. () c..... t"b A.\ Iit~ ~ all ~c~ .5~ ~~>~ 01/L1 /AA)~phFL ~~ ~e5 jJ ~fl G-c...s 10( o CONTINUEOON REVERS TIME OF CONSULTATION O~T OFcolsULTATION 1 'J--"!If r CONS LTATION REPORT SIGNATURE OF NsULTANT '\ A,'. P.\ PAGE " "--. . . . . CONSULTATION REPORT ICONSU~ '"N''' SIGN"'UA. ,",un ""I"A AT INO 0' A.'OATI C1 W & ~c9 5-':..} ~ ~,:r' ",.JI ((~ : {tL-J f.4 ..,..1( @G-\~ rY/~lr & ~.7f{ ~ tf~J /;<v~:J iJhr.-../c~ ().~ ~ cJf~ c - ~pj-.L ~/I; ~J evL,)~ f t~1 JntlJc....l,\r- ~r75 }f' t.. L{} ~ I J ~~/.,;'~) k r ~ -: }f1I"--- ~, ~c(~ ~~ dt~J-JA@) rtetM'nj ~f cY clv Lf'lo ~~ f(Jf~ J ~ ~. 4 . I . ( <- J , PEN NSTATE .- (.'"II..t III' Mt~'.'''' L'nl\t"'ly HII\pll~I' Ch.I~~n" Hu\pilal The M.lllln S H.,\hty Mt~I.~1 Ctnltr 33~2~8 ~a22 335280 ',..L:;', &"'~ . . : . . ". .. . 7: . CONSULTATION REPORT ~ ~ :.. . . ~I1.S FROM fC.fJr. DATE OF REOUEST TIME OF REOUEST TO .lo' p' REASON FOR REQUEST PROVISIONAL DIAGNOSIS ACE OF CONSULTATION o BEDSIDE 0 OTHER o ROUTINE o EMERGENCY PAGE J ( CONSULTATION REPORT l' 1/ '1.() w~ jJ f4,f/'4 '" ff"":' IV~" ,IS' P,I> c G.... Nl v I.... (IL -=:. ,{/Ide ;-./ ,.I4JJ..,;< "'.f~ ~ cr--;' - #to ~ '-"I Pi ...l,.l..te'.'l:' ~ST .', tVlIIJ ,.'1 1M JAw ~ N~ f" 'i ""!' "c::"'\\.II.. III It >, AT1\I'- ; ,I.J, ~ oJ., 'j"M, r ~ ,,:A..t ,V-< IitIA .'hl.l I..... IN it ~ "'f 1/ oI~- ... I ........r 1''''''''''".4' ...t~....I ~'y,,,- ?~' ',Z/h ~-, c..-.._ ~I !It') ,t~J", ~t... ....v~~.......,ll ".Jh'.r~ ~t N -S- ~ .......)......... .. , 10 ~ -t.J Iur, 4- ,.v.... 4-I~ -0 " 1 1"'\f ,."....~..... VI' J,4, - ,,~., -1"'''' /';f1 'it OC~"",I'J ~ Ntld. r~ -.,i-A c;...J. ,~ I~L....... tf-.:.J 6"'" ~~.:~~"I foe hvdt;... 1-'-1 'J~.,.j . M" 11 .." 8^'Uv ~" DATE OF CONSULTATION i 2Z /1f CONSULTATION REPORT cT ".,~'J....j(.-J cSoVo - r,::!.J 1':":1 Q fIN~'J ..... ~ o CONTINUED ON REVER TIME OF CONSULTATION A.' 1-- ',I) p . SIGNATURE OF CONSULTANT CONSUL TA nON REPORT ICONIUL TANT'IIIONATUIII MUll A"IAII AT INO 0' ""OITl '" I I ,. /~ I...... '-('1'0 AoU c,t........,' ~...~', -f ,It 1 ~oN4,i). ,r., .../ c". ...u,"'...... D a> ~:' 1/.... f~ ~-./ () .~ Ot\W4. 6 p&l4J . . ~ J ,lAh/ ~""/~ t- % jft,_.'y . "1.2.-\CI, '> {)l'L1) a~ flt "PV\ ... ~ ~ . tJo ~\,,~ ch~l~J ~. ~ ~ "^c:>-1t\\\"', M~ I~' - for ~ 1",~Io~-kd ... G ~ ~ ~~.. - ..,.. . Of"VCl~ -he ~"lI.4\....ed ~ ~ <)~"'r ~ ~ X\\""-<l. ~ IV'!- 1 . I{ P.ENN5.w.E ., College of Medicine Unlvenily Hospil31.Children's Hospital The Mihon S. Hershey Medical Cenler P.O. lOX ISO HERSHEY, PENNSYLVANIA 17033 .rt J..~O _ 1/21/95 ~ ~ '5 PEDIATRIC SURGERY ADMISSION NOTE ~ PATIENT NAME: WILSON, Amanda PATIENT NUMBER: '330248 This ll-year-old f..ale was the rear seat belted passenger fn a car Involved in a IOtor vehicle accfdent. She was Inftfal'y evaluated at Polyclinic Medfcal Center and had evfdence of head trau.a and had an episode of vOlltlng wfth af rway compl"Olllse requi 1'1 ng f ntubltion. She was transferred to The Milton S. Hershey Medical Center for treatment. On arrival, she was intubated with obvfous signs of head and facfal trau.. on the left. She CI.. with a heed CT scan which deIonstrated sinus fractures wfthout slgnlffcant Intracranial fnjury. Her catalog of Injuries Includes: 1. Closed head fnjul')'. She has been seen by Neurosurgery. She is behaving approprfately whfle intubated and is able to write notes to her parents. 2. Sfnus fractures. She has been seen by Plastfc Surge!')' and no operative treatllent for this is requf red. She is acllllftted intubated ovemfght to, the Pedfatrfc Intensive Care Unit. Our plan is for extubatfon tOlOrrow. Thfs plan has been dfscussed with her 'lIIfly, ~'BY: R~Cf11~, M.D. RC:eep D: 01/24/95 T: 01/24/95 10: 2204(4) .. . ,..~ . I . IOUM. ~IAIftIlIII""" ACTIOII QIIIlLO...... J~N ~ '1 1995 \' Jrt:1t!5'~ PENNSTATE ., Collelle of Medi~lIle Univenily Hospilal' Children', HOlpilal The Millon S. Henho:y :\Iedkal Cenler 00335280 19B-012295 WILSON,AMANDA R 15-Jun-83 EMER 2 RoItJllIlll~~ '"",\1\,''''' I'll II", ,,~t1 "~hhl.'~. "to'nn,~h.I"I" 1'lIt.1 Date of Exam: 22-Jan-95 KYM A SALNESS MO EMERGENCY liMe, .. ..... Exam: CT ORB/SELLA PIF UNENH-PED CT FACIAL BONES CLINICAL HISTORY: MVA. TECHNIQUE: 3/3 mm axial sections through the facial bones. DISCUSSION: There are several fractures of the frontal sinuses, on both sides, with at least one depressed fragment. The posterior wall of the right frontal sinus is fractured, i.e. the fracture extends into the anterior cranial fossa. The fractures extend into the roof of both orbits, greater on the left. There is a fracture of the left lamina papyracea. There is a fracture of the right nasal bone, without significant displacement. An additional lucency is present in the right superior alveolar process, which may represent an additional but undisplaced fracture. Material of soft tissue density is present in the frontal sinuses, both maxillary sinuses, greater on the right, and in the right sphenoid sinus. A skull base fracture is not identified. IMPRESSION: 1. Comminuted fractures of the frontal sinuses, extending into both orbits and into the anterior cranial fossa on the right. 2. Fracture of the left lamina papyracea. Reviewed & Signed: SIMON WESTAOOTT,M.D. SW/rv I . ( . DICTATED: 22-Jan-95 TRANSCRIBED: 23-Jan-95 SIGNED: 27-Jan-95 An Equal Opponunlly U...cnlly I PENNSTATE ., CoUele or Medicine Uni\C:r1il~ Hospital' Children', Hospilal The \lilhlll S. Henhey Melli,:al Ccnltr 0033S:280 19A-01:2:29S WILSON, AMANDA R lS-Jun-83 EMER :2 R.h.h"ht.~ '\.:r\ h,'-:' P II n", ~~n H\'hhto'\. P.."nn,\I'.lnIJ 17f1.'.' Date of Exam: :2:2-Jan-9S KYM A SALNESS MD EMERGENCY IIMC, .. ..... Exam: CT HEAD UNENHANCED-PED CT HEAD CLINICAL HISTORY: MVA. PROCEDURE: Standard unenhanced head. DISCUSSION: The brain and ventricles are normal. No extra-axial hematoma is present. No vault fracture is identified on bony settings. There is evidence of facial trauma, however (see separate report). IMPRESSION: There is no significant brain injury. Reviewed & Signed: SIMON WESTAOOTT,M.D. SW/dmd , I ( . DICTATED: 22-Jan-9S TRANSCRIBED: 23-Jan-95 SIGNED: 27-Jan-95 An Equal OppoIluollY lIoi..nory II PENNSTATE ., ColICIIC of Mcdklne UnI'Cr\ll) Hll\pil3l' Chlldrcn'\ HOlpilal Thc \lilllln S. Htrlhty Medk31 Ccnlcr 00335280 158-012295 WILSON,AMANDA R 15-Jun-B3 EMER M...JII.I.,~~ -;""\I~"" I'n R,I\l(CII ",,'r,hl:~ 1\,"1U'~ h .UII.. 1"1111 Date of Exam: 22-Jan-95 KYM A SALNESS MD EMERGENCY HMC, .. ..... Exam: OX C-SPINE 2-3 VIEWS - XTAB, AP , Exam: OX PELVIS 1-2 VIEWS - AP , SUPINE, Exam: OX CHEST 1 VIEW - AP , SUPINE, Exam: OX SKULL 1-3 VIEWS - AP , XTAB, MULTIPLE FILMS DISCUSSION - CERVICAL SPINE: C1 to the C7-T1 region have been shown on the lateral view. No fracture or dislocation is identified. Vertebral alignment is normal. An endotracheal tube and nasogatric tube are present. CHEST AP: Minor linear atelectasis is present in the right mid zone. The left lung is clear. No pneumothorax is identified. An endotracheal tube is present, with the tip at the level of the medial ends of the clavicles. A nasogastric tube is present, with the tip projected over the stomach. PELVIS: The film is underpenetrated and a fracture cannot be ruled out. Contrast is present in the bowel and bladder, presumably from a recent CT. ! ! SKULL: Facial fractures are identified (see separate CT report). Air fluid levels are present in the maxillary sinuses and one of the sphenoid sinuses on the lateral view. IMPRESSION: 1. Evidence of facial fractures. A skull base fracture cannot be ruled out on the available skull films. 2. Normal cervical spine, unremarkable chest. 3. Non-diagnostic pelvic film. sfl/rv Reviewed & Signed: SIMON WESTACOTT,M.D. DICTATED: TRANSCRIBED: 23-Jan-95 SIGNED: 27-Jan-95 An Equal Opponuniry Un.,"c",ry v 'i9T; .;,,:T: : :. -: ." . t .:'t i:~:~S :'...., : 1 ,~'. "" . '':':: "E9T: \iNITS: L.O-H =: o. I:.. .,., 0'::45 OIIZJ/9S . "445 TEST: UNITS: L.D-H I: OI/2:':~:5 . C.ll4~ ~EST : ,:~J I T~: LO-HII 01/2::/9:1 n45 I ( . ..... IJ,. i, ;;.. "'-9-L ~' .a-II ~:_50h.4~~NO. ~ -, '3J!::S~ ~~".I ....r o. ",.; ''It :. .~:$"i' .E::::.ao :~..t .~ lit , ~. [" ~ tl 'i : : 1,1 A', \. :. ". C , , ..:. . : .:: i.... ~ . ~ ~ :! LO:: ~S.a: ,.:;,:,.., iI101'.' AC.~' I:f jEll s: ...Ct. .'. ~\I_ '.-r.C':''!' f ____,-00""1 ::~I"~C' .... ......... ...... .........., f'" ~E"ArO~O~V "~r. RP~ wCP ~CT "CV ",\I. "'/I.'L, :.t"'.. t =L 4.3-J:.! ~.C-!.S ::-!- '0..4. '.-4~ ..........c.................. 111.1. 4. "6 37.9 so 13.9 ~ , . . 4.4: ::.1; J~.' 83. lie,", Fo" ;"..:-r. f'1I;HC ~ ~e-~4 :z9. :: 36.'. "e .. - .- j! '3. ...................". ...., If' ELE:~~OLY!ES ......~.......,~.......t... U~E~ N C~IAT N. K C02 IIIjl01 119/dt 1II1101'L. IIIIIOt,L. 1I11:.1/L g-!8 0.3-0.5 :36-:44 3.'-4.8 ~2-32 6. e D.S C ;olO CAP 138 C 3.4. CAP 23 CAP 24 C 3.8 C 0:1 aN!N "" "1I/;'1/L. "'1IC11/L. 0;8-106 '-14 105 lZ CAP CAP 106 8 C C ...............t.~.~.~....tt... GLUCOSE ....................~..,.....- GLUCOSE "S/d1 'O-I:!O 104 C ..~.......,.............. CHE"19TRY-RDUTINE ......................... B:L.I r ALKP A91 SGDT ~G!DL. U/L U/L 0.1-1.2 80-240 10-40 . 0.7 CAP :12. CAP 199 CAP ---"COTNOTES--- C CAPJLLA~Y 9PECI"EN l ":LSON. '''A'J!). R END OF ~EPORT 'uc.~ .,~"" "'C"'" "a' '::' ....:~: "'" ... ......, ..,.. .... 4 ~ ..; FA ('E DIICRIPnON/TlMEilNInALI 7{1~ ~ ~C.JC_ yllI_BS ~NN Amytl.. _ _ TT_HCO ".. RoulInt ThIOlI cunu" IC_PC_WI UlA _ UlA CIS _U_1It _WIIIlIIP ORDI!RSfTlMEilNInALS ,"'" 'to. . hi. .;,I"LI I I IIIC:tJll"""'L.I~~\",..Jt",,",,.. ~ 01 N. 3RD ST IRRISBURO. PA. 17110 DESCRIPTIONlTlMEilNInALI AVI , : ~nc. KII ~1I1Vbe y.... _ ~ 0"""01 blO t1v_- VI" ~. .". IVI. _ lJM I.C1IOn ~a EMERGENCY DEPARTMENT RECORD - -. . DATI! . .' .. ,.",T Y T FROM _ PAl LCIleIl _POIICIleIl _ SIlul ~.,- _ POIIC,S_ _KUI !IN~. DD TETANUS I=l~... . ~. _ TOllod 0,5cc 1M LOll 1=1........ - efT 0.5cc 1M .... "".. 1.Q 0KI'I0CWft1VORT ltV. _IIIOH' hi '"' , _ OPT O.Sec 1M Eap. Dill: - Hyptrlll 250u 1M (l y~~^ /1e.tt:~yJ.~A~j 1~h'v<J4Vf.~4 ~ /1 U A G TO -- TlME: PHYSlClAHS REPORT COHTlMJED ON 8AClC r... RESULTS DY 0 NO AM"MSI ~ CREAT. tJ t " "'T, HCCI '" ACCIDENT 0 RECHECK sa PIlYSIClAN'S _1IHEE1' fOR AllOfl1OIW. _ _ $U IUlSn NOnS_ OATH - VOiO<D 2.5 uAM ACT. Ala_AU AJR_O. ..RAY co, sa, 01.000 3 BUN ... wac: pO. OI.U OI.u Rae 0,"" .... CASn oCO, El<Q ..,. IIU IlACT ICO, ... LEUK EST NlTRITU ... IEDICAL EMERGENCY f!~' : 51.... I L....... . WONO. .... S-~. Eos. :lHOST1C _ ,$ ~.r ~E 01 - ~'IC.. OOSO<, -.. >l)Mtf (""'IC) ..g ..., 11IO !HlaQOlllUI ""T'MOAII ....,,~..GO"f1 :clClI .tCC0A~ u.lt'" ..0 ~ ~. f1C!=""~ .~ COHt ...... """' """''''1Ql'n' .....-, ~"'...oc..~ ... OlD IIIC: "0' o;.ol'COUf'\."JI"" C IOOHUIlOtNT C UROENT C E"EROENT ARRIVED WITH _~l c; . C I-<C 2 HIID 0 _ROvED 0 N()T.,.PACloIr SUIIJECTIVE J DA. f.lo1c:>.."". ^Q.~ G> s..1~+ ~LCl.L....ll& c~' /' r- "0 .. ClIICT... '12 ",,1 /1'" ~..s~~ ..... ""A"" I,",,~f @ ~_cnw P 11-",-...-1- ~ ~~J,~~,:L.':.~~1, ~ l;~__::::-C-:-C:----- ~ !:;: ~,-L1;< ==~~~ ~:,l~~"m:.~~ ~~-~a: rt(o.:ar N.~. .. A~ , ~l_DeoOAEHTtO~ ~OW ~TO.STMU. -~ olAllDRED ' ~oCYAHOTlC 0MEE2lNCl 0 lOR l<=o. oDUSICV oRETRAC'TlONS ~DAlH OPAl! 01lAL5llHOHCH oloR oSTlffIECX oflUSllEll oCDUllli oDlZlMSS oHOT oEllPECTORATlO O_SS; ocoa. oHOlCPlYSlS 0DW'HORETC 0DTHER; o~ oJAlHllCE 0_ ~ /I oGU9:l:MCOLISC.Il.E: 0_ I.- U..v 0OMR: SENT 0_ EIIOTIOIIAI. ~TIVE , of. 0_ ot.tCClOPEllATIVE QI oDDIES r-NA [J~ oANlDOUS oll'lSl'llAGlA '~ oCDlollATIVE oAAllOREXlA Om' 01ll'SlERlCAl. oNAUSEA O",-..-~n., 01lAll'f o~ EEHr oDEHES DNA -~. ~- - 0 VlSUAl.ACOOY: OOMR: DWREA O ClU: COHSlW'ATlON CD: olEllATDlESIS os: oAllllDllEN oaUIHDVISIDN oSDfT oPlClTDf'ltDlllA 0_ oSDAE1IflCIAT o 0ISTEIClED o NASAl. OONGESTDI o TVClEIt 0 EARAQE OR ol 0- SOUIIlS: oEI'ISTAXIS OR oL . ~~ - 0OMR: - ,. TUoIE OF I~RV I ONSET OF S"",",OMS: 1-'2.1-9)' _ Dille DNA o N()TltNQ VISllU 0_ ~TIOIt. I~~D SMmYer<n'_1 - -- 1 Z Z . S . 1 . . '0 I OCOHSTAIIT II.AI!l 0 tlT'EllIITTtHT 0Cl8V'iCUS 0Ef0RII1Y oRAlXATNl: ~~o_ oOTIQ '~oew. o HEAVY 0_' =~pNA lmtER: - . , " I - o\LUlOQIR A~.~... lq.30 (2) ..... GU D- O FllEOUEHCY o UIlClENCY o RE'lOOlCN o DYSURIA o IEIlAMIA o INCOHT1NENCE o _IIAL 0IS0WlGE o DTHER; GYlI oDENU ~ 00:_'" 0:_ oV_UEDlNG o_R.OW o_flOW: PSH: TNAOa lllSPCllIT10It TNAOa WTIIMHTlOII C SPUNT1I C IClI C StVIU OP"""'" C 01>Q; oOiSCKl""'" \llTAL SIGNS R: It:, LOSS OF CONSCIOUSNESS CYES AJFfNAY CNASAI. CORAL CET TUBE oOTlElt OXYGEN CMASK CNASAI. L?oll. MAST CAPPUEO CINF1.ATED SOLlIT1ON SfTE GAUGf IV THERAPY SPUNI' $cxooARo ( TlME BEGUN: MEOICATlOIlS ADMINISTERED IN ROUTE TRIAGE NURSE SlGNATlJRE: ASSESSMENT COMPlETEO BY: \...-J' ,,=,a... , ~ J rp/; //90 :t:1ll1l tJ' r9;:, >J AIr ~; .....-- ,.. .... J I ., 7 DATE: - 2/.sr JnME: 'Zl:ll 0 POLYCLINIC MEDICAL CENTER DIVISION OF PATIENT CARE SERVICES EMERGENCY DEPARTMENT ADMISSION DATA BASE " NURSES fIAOCINSS NOIIS .Q~L .n ~/' 7;O~ ~ '. C!!tfJJ ...... 1_ If A ...... ~ ~<-.. .........<,.: A_, -.~f,. ~/J r".II>& . ~ (i;F7fJ"~ J /l t'Jh ',/. ~ ~' '~Ij ~/KJ.< - ,& ...., ~ /: ~h A,u /A. /./lA ,'.- ~J ,; ./.... ~ t:.' vI'", :7'L.-A""JA..I1 ,.....: ~.0k. __ .A ~ 'J -'~, I... A/A ;!; n~ ~~~../ ~......., - J J./ /('.'/iJ2t ...../- _.J U R M ,Jc:. , 1::J.r) 1/ /J ':i t1!:J. 'tC ~,n" "'- Z. ..J d": A J ~ 'h.AJY1f. .A fA J""~ II' J. ~ ~ /; ~ ~ 4r,dA~ ~..." ~ r ~., ,"h.... ~ "'ll................v.. . i ... ~ t:7 '" c::. t:",. . ~'~ IOl'dL . ~ . ...... 'r,:;;t....n. "". :..+JSt ~ '" J.., A .... ., 77~ ~ " J><-t- - )dA ./1::r--/.L~ -A '. MI_ ?/I J~.......7A ~"'" ,7' _~AI .;,,"" """" ~ ,-, . n . ,~ /:. 7 <';' ...n-.A ..-/ II '41..0- /Z /)" IL.J ":T ,'- d A , ..... -m LJ.,Q..t1 d ,.\- J/....-L ---..5; " 4i- tr.,;,..J~. .',.#.,. "IA~' ~ 'I.M'.IO.A_ -~ , DtSl'OS/TlOH o DISCHARGED TO: D1SCHARGEO IN TliE CARE Of, 0 SELF INSTRUCT10HS GIVEH~' S ONO (REASOHl: ,,""', IV SOUIT1ONS~ lIOOE: OAIIBWTORY 0 :::AMBUWICE OCARRlED OOTl!ER: ~ CATli sm: SOlUT1ON lIlT 0 ADMmeO TO MEDICAL CENTER ~ I~ ~ l> - ADMISSIONS CA!-LEO: BEO ASSIGNMEHT: . . " =:;=~~sg~ELCHAIR cs:~Oc::<T:~LE: . ..,:; . <, DISCHARGE NURSES SlGNATlJRE: . POLYCLINIC MEDICAL CENTER ,- .r . INTAKE DATEITlMf ORAL " I DA TE/l1IlE OTliER I t71l.2b ., , OUTPUT URiNE EMESIS J/ ,,~ ~ DA1VTlIIE PUPILS AIL NEIlRO CH(C1(S RA LA AL LL OTliER INT DATEITIIoIE IXlNSULTS NOTlFlED Plf(SICIAN/SERVICE T1IIE SEEN /"'\-1-' rJ.kv tlJ,,~ -,~ ~ I?...n ~ r<; , .. (:}"/ 7.l) T INT ~J '"bn 1AL- lA IlE01CAT1OHS DAmTlIIE DRIIG AIIOUHT IRoun;I sm: INT Q.I~ n....../ _ e...... for, \ .R."1 , :r"' r :Zq82&~t : '<~~-33~' ~17-~~7-6961 \.'~::~'" . 1"lH:' . ::~lllb I. ! DIVISION OF PATIENT CARE SERVICES EMERGENCY DEPARTMENT \C ; l"':; '! ::1'~1;:5 H!.::'I;~R Pl 17063 III 0&115/83 .PHRIClC F - r ~ PAGEl_Of _ A OATE: o SPOUSE 0 PAREHT TlIoIE: o GUARO"'" NURSING PROGRESS NOTES v ~ - r- . , .r , . r PAGE I ~OF _ DATEITWoIE INTAIlE ORAL '" , R NURSU PAQGRESS HOltS I I J A'. ,/_ r,-{ L) 'J...~ ..... AA :'~d I. . .eM.. .u J ~ JJ_ ch. ~~~ .'1: )~; ~ ~. . "" /l -:. -'-' ,/:.JL ,'<"1- ,. -" :.. 10.. JJ,~, ') 'UJ..<h.A ~... ._,,~ )"t!.f!. ..A... .A~, ./U. Jo..",J., Jl ....- ~ ,I~J; / R,. J IdlU /!;;~;z. A. ~;o.L . A. /./. '-" ~. ; oJ' .L!:' (t.... ", I:L bI. ~I, ... '-vf "'-A. . ~~ ".1 . 4.Wo. ~-p bl. A, c . I .1' -1-..' ~...c.:,,~ 1.....~ I/J.L "!"A. LCr .~- ,/l.. EI,: /J.._-J..,,' _' ,co, IP-.t..~" JL /17J~ -:G~ W:;I , dlJ ..... "" ,....,.. O..J ~ 0. A cLA. "",^... l- n. LL..')o....L n.. ~A ..LI. lS'l. ~ 1-\0. J..+.c.vwu....... LV . (\\.ll) nC\."l'\d. ,,.,....! CO h..'....,l, c:: ..o\.I~ ",. , ,.n I - A nn- tf'YVN4.v1I~1"l4 Il!, 4o/ltvl ~d ...." . .,ri A..N'U'" A' /ht i)~".. -I\..w..,., 1." t.A4.d I ~~ h,ul\.C ~.L 'j.., ~,~~~ ~_,/~;I. ~ ~ "r7..L ./l.J., ~A . II.... " ~..., ~ A'.' "'" 'l'."""'~ . ..L.~ AA.l ~ .YA.f/ /uM-'I...fJ-,e:....... II ~j, lSPOsmoJl ,V,L ,/ _ 2"ii.SCHARGED TO: ....d DATE: '/:?f h5 T'Ue.OOS DISCHAAGED IN THE CAllE Of: I~LF 0 SPOuSE . D p,G,EHT D GUARDIA.\ D OTHER: INSTRUCTlDHS Gl1IEN: DVES OHO (REASON): I/ODE; DAMBUl.ATOAY DWHEELCHAlR CAMBUWlCE DCARAlED DDTHER: FlATE INT D ADIIITTED 10 IIEDICAl. CENTEA ADIIISSlONS CAUED' BED ASSlGNIIEHT: BED READV: REPORT CAUEO: a.. ~ 0 n ACLSPROTOCOl.: DVES CNO ~ TO ",,,r 71 ~~_c.~;JytRJ IIODE DAMBUl.ATORV DWHEELC~IRET~ER ~R 1 DISCHAllGENURSESSlGNATURE /}~k. .-. J l!' . ~ . . ' .f'.' S ~ I i ~ . ' J POLYCLINIC MEDICAL CENTER A ~. . It q II XC! ; ,. ,,;~y..,' "c~~:" tq&q-Lqq-LIL Lqtt-tZ-.. .SqZ9&Z' j el OUTPUT URINE EIIE~S OTHER DATf/TlIIE ., 1(7~ .... I~Y , - OATE/f1IlE PUPILS RIL NEURO CHECKS FIA LA RL LL OTHER INT 1/?~/2. ZZ2C :uw Zz I ,;J.~ '-It/- I. DATE/llME NOT1F1ED CONSULTS PHYSlCtAN/SEIMCE nilE SEEN INT IIEIlICAT10NS ~ DATE/I1IoIE llRUO AMOUNT ROUTE SITE INT {'OS '221. f-'anl'1Mll't\i\.a..... q _.D 'If/I, ~ f),.., '''''A. ,<1J,. A-oYJ~ ~ f1~:-.J " 1.<. 1//1 ~ a W SOLlITIONS DATE/I1IoIE ....,IUI: CATH SITE SOLIIT1OII . J :lJllIlY ~. te/il/~O 111 tqOLl 'd DIVISION OF PATIENT CARE SERVICES EMERGENCY DEPARTMENT NURSING PROGRESS NOTES v PA 1706J JIT 06/15/83 F .PATRICIC REQUEST FOR CONSULTATION AND TREATMENT (UnleSS Otherwise Indicated) v r I r r " , NOTE: "you dufr. 10 If.n,'.r p.li,nt 10 .nolh" phy,fci.n', '''VIC'. "cord Ih, Ifln,'" nOI, on Ih. Order .nd prog"" RlCord. . r, '\ REQUEST FOR CONSULTATION AND TREATMENT (unlen olherwlse Indicated) \.!) ConlullaUon Rlqu.lt.d By Dr, ConsullltlOn R.quesl.d 10' 0, Oil' RlqulSl.d R.ason lor R.qu.lt ,v€()P.<:ISU~ _ CONSULTATION ONLY - ~o illld By: It ~/. ~ ~ W~ ~A ~ ~ .t.J:;f- ,;.. ~ ~ -+ v~ :tb- I.v_ ~ J.:- ~,~ ~ ~ ~r, ~~r~"'-~ ~- ~r~~.4rW ~V.~..t. ~(_..~_~--D-~ ~~~ ~~ A>.-..~*_~.e-t., ~~~ ~ ~~~~-j '~~j~A~~ L:rw~""~"G ~~,~~ eo--e...~,rA~stIMr""" lii~~~_~.. ~ t-ve-;):;:J- j;:. ~ ~ ~ ~ ~ c ~ ~~ ~ r c-....l W~~ ~ ~ p~ ~ \,l ~ :t;:. A-OL ~, ~ p~' I~ . . P....,;-L ~ --. ~~ j~ ~~ ~'''-''-L-~. ' ~'-' 1- -i:;r LI ~ .,J'.: '::l )( . . 4."1:! ~~ R,N. Oil. Tim. _ M.l/PM 2:.Jt),' .,~ . II' and Tim.) ~1'L'~~ (ConsuUant'. Signa . ~T,. J298%SSC :~~-Z3-3367 717-667-6961 w;~:~" . lHA~Cl POLYCLINIC MEDICAL CENTER OF HARRISBURG ., , CONSULTATION RECORD ~: ~ 30H IIIL~OT OI/ZI/95 ALLE:lCER 110 .- , , . .r ,/ t ,- NOrt!: "you d"l,e 10 I"n,'e, p,lieill 10 ,nolh" physlcl,n', lII,vlce, "co,d Ih, trans'" no I' on Ih, O,d" ,nd "'0(1'''' Reco,d. ~"'\ REQUEST FOR CONSULTATION AND TREATMENT (unle., otherwise indicaledl \!;I Con,unttlon AtqUllltd 8y Dr. ConsullItlon R.quest.d lor Dr. Otll R.qU..lld fII...on lor A.qu..t _ CONSULTATION ONLY Notill.d By: R.N.. 0.1. Tim. _ AM/PM .~ C-.S~ ~',"^1J -)~ ~ ~t <r'- ~ ~,~~~~~~~, ~ /l-. ~- ~~~.:*"v'~'~;!:i}r-,'VJ:J..---J w.J.t - v. . ~~.Lw-~~~~~~ ~~~~~-4r-~'; U Pe(F ~ .'~ J)-r ~ ,,'. -. . ~ . ~ ,-.- r:r:-.- ~'-r.Q.. C;, O-~. Cl-t-~~w~, ~r;~~ ~~fi:~e~~-~ ~ ~~~~t;'vj.-J-~~-~. ~~ ~ .1ioo I'l . ' 2., ;',.J "J ~ . (Oil' Ind Time) I-L. (Consultlnl'. 51 ~T~ ~ JZ~a26~4 ~:~.l!-3J~7 717-667-6961 ~:L~C~ . A~AHOl ;>: 'l 90% 11!l ~ ! ..~a r 01/Z1/95 HlC'~:C'~ POLYCLINIC MEDICAL CENTER OF HARRISBURG CONSULTATION RECORD PI 170&3 lIT 06/15/83 .PITRIt:r F REOUEST FOR CONSULTATION AND TREATMENT (Unless Otherwise Indicated) ~' x ci :II llIl: ~ ~ Cl ~ ~ 8 '" .&J 11 ~ t! ~ : ~~ 5,... . ~~ ~~~ .~ :Bi:a ~~i~l~ ~lil",i:5t;!; .......:>-'I"'z C!i . is::S Iii: COol ~~ i~~i : !E~~: g ~ Dll eo= 9 5: ..j ~ Cl Dll ~ .&J ] .. eo= ~ e eel; ;; O..........,lICIN :0< NCCOllClOl -- ~ ~ "''''''' ","'- .., _& '" ."':: a e! S..ll ....!:;:;&~ l:eo=eo=f:....c. > c..acyt!..= c . 'B... ~:;;:c ur-~ ., c", .:-~!:~~ -~:l1c!!'" . ". ~'. . ., I -'j 111111111111011__1111111111 ... . .. II z ~ :E . Dll Dll S it! ~ ~ , --.-,- :~"-' - _.~. ..;'-'--' .~U) -. -- ... .... :!I ...- ~ . Dll ~ ...... ., .', - ...... .... - '. . '. . .~. .. . - .. .... - -.. --_.- ~.__. .. _ . - ..N': - .~';'..' "..:.;-:, =~::::~~ ...,~~~~~,:~.~~:~' ," -'~.:~- . . ..... .-.. - -.... --. - ',-.._. : .--.:... --.--'-. .....- -...- .-- !Ii -.---. . . -----..--. _._~ _.. ._._u..._..___._ ..___.___ ._____ .____._, __. .,_ ~ - _ ., __. .eo=.__.__ _~_,._.__.. llIo_.__ _.__~_ ,__... ,_ .. :: -.-.= .:.-.::.=~-= -~.== ...~---- - --_.._~-- _....~~..... -.- 1= .. ... -.. --_. ----- --_. -- - -- .. -..-. .----.. .-- '__0"_" ._____ _______ __.....__ _.. .. :I! ~ j - j - > c-: c: L: -1 'C -.-J' , C" - c J I x '" - z '" .J ...l C .J ~ .J Z j. ... ... I . ; ... ~ I; Ill: .... !. . Z o III -- ~~ Iii;! In '" W13 !Zw !Z- >=~ ~~ ;~~!I ::>w~ < 0"': "'w... <. III ~.!!lc!u Q_Z-- -"'... 0:."''''- ow CU o ..J w ....<...... .X::1Il . 0:"'% ::~o:i 'a ". ~ ... c o " c ::> _.___,._ ..,7"- " u__.__( ..... . ~ :.:::'.' ':".'= -_.- , . -- .------. .----- .--'- m~_____~_ '" Q ..J - :~_... : >- ._ .0. S> 'a. "--- .. .; .. .,.....- ... .... '" S> NZ:..." on cnLII..rI " III , " N04'41CDCD .....-.--. ~ II\NNCDCJ'ICD . --- ." C uon , '" ',;'a ~:g on c " 0 0 . 0 .. . . .. "'''' .. > .. .. c . .. . x 0 en .. .. ~ . z ...'" .. ~ " .. ,; coo...... ).,.. .. - 01 'a- X " C ""D: ,,- It 0 IIo:ra::t-. x: 1Il..J >...00... c ~ ~ 8 .,; ~. :::.;~ U~.lS:" onOO"N N-ofo..> - >, ,- ) / .( I. AmOt\da.. W;"\s'crl'l ""IIIN' ()II LtG......" .11"O..~..~I.'t.$O.. 'ulhall" Ih, PalychnlC M.dICI! C.nl" la Tllnsr" ~...~ . .~ mQdJcaO ~ II .1~.IVIfrfQ'.CI"I'l' .haurs on SIClHATUIOI """ wor"us RI!ASON FOR TRANSFER .i- M'dlc.1 _ Su,glc.1 _ PSyChlllllc ~ P.II.nr. IIquest . PIII.nr. r.mlly nalllled ar I,.nsl., ~ _Na p~~ _ A leg.lly 'espanslbl, pe,son ,c,,"g an Ihe pllien!'s beh.II IIqullt .Nlm.' ~ F.mlly PhYSlclan/Specllhll requ.st . PhysIcian's Name. Rel.llanshlp 1.40/00 _Olner LEAVING Palyclinlc Medlc.1 C.nler II PhYSlclln .rranglng Itlnsler fY1~,..~e,.;z.. Physiclln acc.pHng transfer (! ~ I~ haulS an DATI MD.DO Phane ~a-4l.J1,I.D 1.40/00 Phan. TRANSPORTED BY: .!...Ambulance Q'lQJr\d ~ N.m. al Ambul.nce: \-I.a.c..4.h..A.u \ Repan Given la Crew _ Ves _ Na _ Crisis N.me al Casewa,ker: _ Other N.me & Rel.lianshlp, DISPOSITION OF BELONGINGS: 0 Transferred with p.lient 0 GIven ta Family Tim. al DepanuII: Farm Campleled by: If accampanled by PMC 5"" person: Candltian an a",v.l, C SI.bl. :: GUllded :: Clllical Tim. al Arrival: Transler Nurse: ReceiVIng Nurse Authallzatian lar relelse af Medicallnla,matlan Signed ~ Yes, _ Na Medicallnfarm'lian sent WIth p'ali.n'J L Ves _ Na t. .. ~2~82&-:~ I." ...."-..367 717-"&7-{,~". . ..." ,,"lii:l POLYCLINIC MEDICAL CENTER PATIENT TRANSFER SHEET .' .. ~ .... . ; :f: . ,~ ! Pl 17063 11~ 0&115/&3 F ,PATRICX .. 10 .: . J" oii2,i~s A\.l E '.:: E it ...-- -..--- _.~ ) "'~ (. '...'0.)1 r- - PROG~SS RECOIL - (- . I DATil TlMl: i 1-\ ~,).:('. ~ ~ a:: ~~ - L3\: Xs , \ QIt..o.\-m\.. ~t.x:~;:\'3' :>e.tu>\... 'l:" ~ -.0 \ '" ~O~. 0>" <A. -- '~, ~ ( I~IZA ""-v;; , -:;:e~~ 3 0'\. \M~' <>1T'-'(JJ:o~ . . 1 " . . \ t . . .' A'ROGRESS RECORO SHOULD CONTA'N ADIIISSlON NOn. OfF,SERVICE TRANSFER NOn.'RE AND POSTOPERATIVE NOTE. PERTINENT TREATMENT. AND CONDmOIl ON DISCHARGE. E r 1 t H982654 ~~'.23-33b7 717-667-6961 ! Wll:~i ,A/WIOA , , R: ~ SIH lib HIL~:lr 01/21/95 HLE:I::ER . -I : Polyclinic Medical Center PRDORESI RECORD P.l 17063 II T 0"11 5/83 ,PATRICK , ! PATlH/T InENTl FICATION .......~ ( ~AIIi TIME \ 1...,\ ~\~- \""""": r:\ ~~ - ~C) ~ ~18"'\I~ \ ~ i:\D - -W'l"'~' ,- ~a.<< ~~'\"' (i4 ~A\.. \.nl2,~ ~f.~"1 ~ }.),~\'^~ oc:...,..,t , ~~\.. ~S II '\. \'3. t J .ft~ \ 4.:> , IO~ ,'- /.,..'"\ f ~t.C" " 2. \ \ '1..'?, '\). r " . . . . . I , ... . ~4-1 ICO I ~~ I '4. "2.. I ~ ~ or; I flu ~~~/400 \0:> 10 I ff:f - So . . , I , , {'" "'~... . ~ ~ ~~ "iO I~MC. \ i f\\"'- ,....~ ;: {h. \\ {:aIM~'" (~\ \ ~o ,\ , I \ 1~' ~ A-oo____~ ~eW ./ I ~ . , r=r::- 'l~ .... ~ ~ ~A. /' , . , . , "J . ., . I. .., CONSENT TO ADMINISTRATION OF BLOOD AND BLOOD COMPONENTS (or lhe lulhOriZed representllive Icllng on blhlll of hlreby Icllnowledgl thlt Dr. hu Informed ml Ihll I blood or blood compenlntlren.fullon II or mlY bl medically Indicated In my CUI. Thl phYllciln hu dncrlbld 10 mlthl pellnllllly dlngeroul rilkllnd COnHqulnCH oflcelpllng thl blood or blood compenlnttrenlfullon. u will U Ihl rilkJ Ind conllClUlllClS of refullng 10 acelPlthl blood or blood componlnt Idmlnlllretlon. I acknowlldge thai I ha.e authorized and consented 10 receipl 01 I bloocllrlnsluslon or blood compenentadmlnistlltlon II medically Indicated. PaUenrl 61gNllure Delt Ind TI.... wttn..... Signetu,. Plllentll a Minor: ~~lt~/'--- a I vl3 10'110 Pllllnt I unlbllto consent because the medical condillon II Iufllclenlly gre.eto werranl the use of blood or blood compo",n" without oblalnlng Informed consenL ~n" Slgnalure . "... ... ~:O-2]-~3b~ 717-bb7-b96l w I ~S:l" ~ . AHlllCA R: 2 BOX lib KILqOT PA 170b3 01/21/95 II f Ob/15/B3 F ALLENCER ,PATRICK I I .1 POLYCLINIC MEDICAL CENTER Hartllburg. Pennlyl.lnla ~ -, \ CO ~ LN _.... ....~....-... -. ~--.. x -- . ., . .. . Dill I~ 11 1',.1 I I I I Time ~,'\) I I I I V.NT.lInTINal V.nhlIIOt S"''X Modi 1('1_.1 p'HlUre Supporl tY ..., Rill . ~ ~ '" (.J VT (j l.U FI02 '. oJ PEEP/CPAP < PIP - Flow I/r MAX TIITI'll> l~ PIUIt 'll> 0 III III a: a: SeII:E RIIIO - :) :) .. .. Sensitivity - 7~ w ~ w ~ ~ l:l ~ l:l SERVOlWortuna Pressure ," iii iii PATI_NT DATA Sponllneous VT - VT With P.S.V. - Total RR '1,) - TOIII VE , ACluall:E Ratio - LUNG M_CHANlCS MAP PAP ~CI I Pt.I.au Pressura ...... Cat /.) Aulo PEEP 1I~ ALARM' oj .. Hloh Preu A1armlLlmil /l() a: a: :) :) Low Insp. PrtlS - W i w !( z L_ PEEP/CPAP ... ~ 0 ~ 0 iii iii HlDh VE Ill, low VE 6 Alanna Ch.clctd V WaItt La'ItI Tublno Drained n . Heal.. T.mp. . Proximal T.mp. '" , , , Humidln" . ~,.... -.; Analvz" Sloped (IN) .- ~ Reldv Uohl On ~ A 1 y-" " 0 0,..- -4 uu I . ~~ Inllia'l ()() NI III ~ - , w- ~IIl !( Z .. " .. ~ '.! :-: ~ v . ., '. ( .. . DAT!/TIIolE PERTINENT INFDRIolATlON NAIolE V..1., _it :'" bJ no,," 1lJ'n ",- -,III_,4. ~ L/o~ l(.P .. I.:::' V.J.::> tl,. j .A . A Q_ - ': ~ r._ ~\ ~.UJ \),YJ .L L.. IiX-. \ /\A , . J ,.. fhJJ A'A ~,j"~ . .. _ M ({,f?- ) l/ 0 , - . , '. . . : ~ H9IU~ · POLYCLINIC MEDICAL CENTER ".:;-3367 1'1-",,'.(,O;fd RESPIRATORY SERVICES , .' ." . HU';& ,; : c II & I "" ] CHARTING FORM '. '. PI , C'~,.: iii ., ; . . . . i IIf 7~ . 'ITrtlCl y . . IT . ~ DEPARTMENT OF RADIOLOGY ~~lInlc alOIN Tl<IRDST I~~.........u.. HARRISBURQ PA 11110 SOCIAL SECURITY NO, DATE ~f3j33367M 01/23/9S cIVI510NOFC.T. IMAGING WILSON. AMANDA , STREET RD 2 BOX 116 CITY STATE ZIP MILROV PA 17063 AGE LOCATION 11 V ER PHYSICIAN ~~~g~~bD~r:SOCIATES 704S0-0/74160-0/70001-5/7000e-3 TERMINOLOGY. CT SCAN OF BRAIN / CERVIAL SPINE 1 ABDOMEN DATE OF SERVICE: 01/21/95 HISTORVI l1-VEAR-OLD FEMALE IN MOTOR VEHICLE ACCIDENT. CT BRAIN DIAONOSISI FRACTURE THROUGH THE FRONTAL SINUS WITH SMALL COLLECTIONS OF AIR WITHIN THE BRAIN. INCLUDING THE INTERHEMISPHERIC FISSURE, BOTH SVLVIAN FISSURES. AND WITHIN THE SULCI OVER THE CONVEXITY. LOW ATTENUATION RIGHT FRONTAL LOBE. POSSIBLY FRONTAL LOBE CONTUSION, BUT INFARCT NOT EXCLUDED. PROBABLE FRACTURES THROUGH THE ETHMOID AND MAXILLARV SINUSES. COMMENT! 5 MM TRANSAXIAL SECTIONS WERE TAKEN THROUGH THE POSTERIOR FOSSA WITH 10 MM TRANSAXIAL SECTIONS THROUGH THE BRAIN ABOVE THE TENTORIUM. THERE IS A COLLECTION OF AIR OVER THE LEFT FRONTAL BONE JUST ABOVE THE ORBIT AND OVER THE LEFT FRONTAL SINUS. THERE IS ALSO AIR ANTERIOR TO THE LEFT GLOBE. WHICH IS EXTRACONAL. THERE IS A SMALL AMOUNT OF AIR ANTERIOR TO ,THE RIGHT GLOBE UNDER THE EVELID. WHICH IS NOT NECESSARILV ABNORMAL\ A FRACTURE OF THE FRONTAL BONE IS PRESENT WHICH INVOLVES THE LEFT FRONTAL SINUS. THERE IS ALSO AIR WITHI~ THE BRAIN WITH SMALL COLLECTIONS WITHIN THE INTERHEMISPHERIC FISSURE. SYLVIAN FISSURES.\AND WITHIN THE SULCI OVER THE CONVEXITIES. THIS INDICATES A FRACTURE INVOLVING BOTH THE INNER AND OUTER TABLES THROUGH THE FRONTAL SINUS. IN ADDITION. THERE IS MUCOPERIOSTEAL THICKENING WITHIN BOTH ETHMOID SINUSES AND THERE ARE AIR-FLUID LEVELS WITHIN BOTH MAXILLARY SINUSES. GREATER ON THE RIGHT THAN THE LEFT. CONTINUED NEXT PAGE DIVISION OF C.T. IMAGING IR-?77~""1 .IAN ?~. 199!,,; \11\\ l( r.nN~ll1 TATlnN I=lFPnPT nFPAI=lT:l.'F~IT OF RAD'nu)(W ~1~ipN. AMANDA ~Hv 2 BOX 116 MILROV ~(JIO LOCATION 11 V ER PHYSICIAN EMERGENCY ASSOCIATES ?flOCEDURE CODES, 70450-0/74160-0/70001-5/7000a-3 TERMINOLOGY: CT SCAN OF BRAIN 1 CERVIAL SPINE 1 ABDOMEN DATE OF SERVICE: ( ~ DEPARTMENT OF RADIOLOGY ~rllnlc HOI~ THIAoar I~~_.,......' HARRISBURQ.,. '7'10 SOCIAL SECURITY NO DATE a00233367M Ol/23/9S OIVISIONOFC. T. IMAGING NAME STATE ZIP PA 17063 01121/95 CONTINUED - CT BRAIN - PAGE 2 OF 3 I DO NOT DEFINITELV IDENTIFV FRACTURES THROUGH THE ETHMOID OR MAXILLARV SINUSES. BUT I SUSPECT THAT THEV ARE PRESENT. I WOULD NOTE THAT SCANNING WAS NOT PERFORMED TO EVALUATE THESE REGIONS BUT WAS DONE TO EVALUATE THE BRAIN. THERE IS A LARGE AREA OF LOW ATTENUATION SEEN WITHIN THE RIGHT FRONTAL LOBE. I DO NOT DEFINITELV IDENTIFV ANV HEMORRHAGE IN THIS REGION. THIS MAV REPRESENT A PARENCHVMAL CONTUSION. BUT THE POSSIBILITY OF INFARCT WOULD NOT BE ENTIRELV EXCLUDED I HOWEVER. GIVEN THE HISTORY. CONTUSION WOULD BE MORE LIKELV. THE VENTRICLES. SULCI. AND CISTERNS ARE WITHIN THE RANGE OF NORMAL IN SIZE AND THERE IS NO SHIFT OF THE MIDLINE OR HERNIATION. NO OTHER ABNORMALITV OF THE BRAIN IS SEEN. CT SCAN OF UPPER CERVICAL SPINE DIAGNOSISI NO FRACTURE AT THE Cl-2 LEVEL. COMMENTI AN ORAL AIRWAY AS WELL AS A NASOGASTRIC TUBE AND ENDOTRACHEAL TUBE ARE PRESENT. THIN SECTIONS ARE TAKEN THROUGH C1 AND C2. THE ' ODONTOID PROCESS IS UNREMARKABLE. THE RING OF C1 IS INTACT. AS IS THE RING OF C2.' NO FRACTURES ARE IDENTIFIED. NO DEFINITE SOFT TISSUE SWELLING IS SEEN. BUT THE AIRWAV DOES NOT CONTAIN AIR AND MAV BE COMPRESSED BV EDEMA OR FILLED WITH MUCUS OR OTHER MATERIAL. CONTINUED NEXT PAGE DIVISION OF C.T. IMAGING ~-~77'36 t ) 'nN 2'. 1'~9~ 11 . 11 ~ (':aNSUL TATlON REPORT DEPARTMENT OF R.6.DIOLOGY . I . , ' (~ nnl..rllnk llOIN fHIADSf I~ .1!:....., ....... HARRISBURG PA 17110 SOCIAL SECURITY NO DArE ~29t3336711 01/23/95 DIVISIONOFC. T. II1AOING ~lk~.pN. AMANDA RD 2 BOX 116 ::ITY STATE ZIP MILROY PA 17063 AGE LOCATION DEPARTMENT OF RADIOLOGY 11 Y ER PHYSICIAN ~~~gj~~bDf~SOCIATES ?fRt~~L8{14160-0/70001-5/7000a-3 ~ITE%~~~RV9~;BRAIN 1 CERVIAL SPINE I ABDOI1EN 01/21/95 CONTINUED - CT ABDOMEN - PAGE 3 OF 3 CT ABDOMEN DIAGNOSISI SPLENOMEGALY. COMMENT! 10 MM TRANSAXIAL SECTIONS WERE TAKEN THROUGH THE ABDOMEN AT 10 MM INCREMENTS TO THE BOTTOM OF THE KIDNEYS AND THEN SCANNING IS CONTINUED THROUGH THE LOWER ABDOMEN AND PELVIS AT 13 MM INCREMENTS. THE SPLEEN IS MILDLY ENLARGED. NO OTHER ABNORMALITY OF THE SPLEEN IS SEEN. THE LIVER AND PANCREAS ARE UNREMARKABLE. THE KIDNEYS ARE NORMAL IN APPEARANCE. THERE IS NO FREE FLUID WITHIN THE ABDOMEN AND NO FREE INTRAPERITONEAL AIR IS IDENTIFIED. NO ABNORMALITY OF THE BOWEL IS SEEN. A FOLEY CATHETER IS PRESENT WITHIN THE BLADDER AND THERE IS NO EXTRAVASATION OF CONTRAST FROM THE BLADDER. THERE IS A SMALL DENSITY IN THE RIGHT LOWER LOBE OF THE LUNG ADJACENT TO THE DOME OF THE LIVER WHICH COULD REPRESENT A SMALL PARENCHYMAL SCAR. . OI\rvD' o. D. M. BROCKMtl'L..E, M.D. (87) DMS/.JEEr . DIVISION OF C.T. IMAGINO I R-?77':'1AA I ,IAN ?~. Iq9~ 1II11 ~n~J~' II T !\TlrH,1 ~!:pnPT nl=D A RT~' P.IT ()I= q A 1]1('\1. O~V Ij . . ......lI.I.....W_.Ul '_"J.'~ In', ~v"I"I. ,... GENERAL RELEASE FOR AND IN CONSIDERA nON OF lhe payment to us of the sum of Nine Thousand Five Hundred and 00/100 Dollars (59.500.00). and olher good and valuable consideration. we, being of lawful agc. have released and discharged. and by lhese presenls do for ourselves. our heirs. executors. adminislrators and assigns. release. acquil and forever discharge DAVID J. GANTT, DAVID E. GANTT and ALLSTATE INSURANCE COMPANY and any and all olher persons. finns and corporalions. of and from any and all past. presenl and future aClions. causes of action. claims. demands, damages. COsls, 1055 of services. expenses. compensalion, third party actions. suils at law or in equily, including claims or suits for conlribution and/or indemnity. ofwhalever way growing oul of any and all personal injuries, and property damage resulling or 10 resull from lhe automobile accidenllhal occurred on oraboul Janulll}' 21, 1995. on Roule 114 West in Silver Spring Township. Cumberland County. Pennsylvania. We hereby declare and represenl thallhe injuries sustained may be pennanent and progressive and that recovery lherefrom is uncertain and indelinite. and in making this Release and agreement. it is underslood and agreed thaI we rely wholly upon our own judgmenl, belief and knowledge oflhe nalure. extent and duralion of said injuries. We understand lhat lhis settlement is thc compromise of a doubtful and dispuled claim, and that lhe payment is not 10 be construed as an admission of liability on lhe part oflhe persons, linns and corporations hereby released by whom Iiabilily is expressly denied. It is underslood and agreed lhal this Release is executed in connection wilh the selllemenl of the claims of the undersigned as sel forth in a Civil Action enlered 10 No. in lhe (SEAL) . . Court of Common Pleas of Cumberland counly. Pennsylvania. which action is 10 be marked as discontinued. setded and withdrawn. IN WITNESS WHEREOF. we have hereunto set our hands and seals this _ dlY of . 199-, intending to be legally bound hereby. WITNESS: Daniel p, Wilson Individually and as Pareol and Natural Guardian of Amanda Wilson. A Minor (SEAL) Sharon M. Wilson Individually and as Parent and NaMal Guardian of Amanda Wilson. A Minor (SEAL) . . COMMONWEALTH OF PENNSYLVANIA COUNTY OF SS: On this _ day of . 199_. before me personally appeared Daniel P. Wilson. known to me to be the person whose name is subscribed to lhe foregoing Release and acknowledged lhal he execuled the same for lhe purposes lherein contained. IN WITNESS WHEREOF. I have hereunlo sel my hand and official seal. NOlary Public . . COMMONWEALTH OF PENNSYLVANIA COUNTY OF SS: On this _ day of . 199-, before me personally appeared Sharon M. Wilson. known 10 me 10 be lhe person whose name is subscribed 10 the foregoing Release and acknowledged thaI she executed lhe same for the purposes therein contained. IN WITNESS WHEREOF. I ha\'e hereunto set my hand and official seal. NOlary Public (SEAL) _2 ....... .~ " . . ~""'\lQolo.""",,,ILClf.lllol~"'X"'" ~1""'.A_I~'" . . ~~-::-i<,;;; \i 'i,';'.tT.';:'~;\-" .~.-~,{",j(~~'( ;'" exhibit 0 ~ 1011 . ~~.._~_~lo"",,'d . . @ PENNS~LVA~IA TUITION ACCOUNT PROoa!. Commonweolth of Pennsylvania '1, Catherine Boker Knoll, Treasurer "\1' f \ STATEMENT OF ACCOUNT STATEMENT FROMI 01-01-95 TO. 06-30-95 PAGE DAN I EL P WI LSON R D 2 BDX \16 1\1 LRDY PA 17063 BBNEFICIARYI AI\ANDA R WILSDN ,~", ACCOUNT NOI 0000027979 START DATEI 09-01-2001 t' If ..:'. .', SCHOOLI STATE RELATED UNIVERSITY CODBI 12999 ': " STATUS. RESIDENT I. , TAP CREDIT RATEI 233.00 UNIT RATEIl1l20lh of I credit) l' .65 ~. DATE ACTnnTY TOTAL PREVIDUS ACTIVITY, THIS PERIOD'S ACTIVITYI 01-19-95 PAYI\ENT TOTAL THIS PERIDDI AMOUNT 200.00 RATE CRBDITS o 200.00 233.00 o o '. 1~,17 Itt 17 'f.: 200.00 f, .'f' i;L.. '" \~ , " TOTAL PAYI\ENTS & CREDITS TD DATEI ~OO.OO I ...._.1.. .1.. ."fIlI ..".""" COMMONWEALTH OF PENNSVLVANIA GOVERNOR'S OFFICE HARRISBURG Good advice and good intenlions don'l create an effeclive college fund. lhough, Sound inveSlmenls do. Dear Fellow Pennsylvanians: One thing lhal worries parents more lhan IOOay'scost of higher education is tomorrow's price lag, Indeed, lhe handbooks on parenting and personal finance are filled with good advice aboulthe need 10 sel aside regularly for fUlure college and universily expenses, The Tuilion Accounl Program offers a way for parenls and grandparen15, from virtually all income levels. 10 purchase lu- ilion credi15 IOOay for use in lhe fUlUre al a hosl of Pennsylvania colleges and universilies, I can think of no more prudent and scnsible investmenlthan higher educalion for our children. lhe leadcrs of the 21 st century. And thaI's why I'm pleased to have signed legislalion supported by both parlies in the General Assembly creating the Tuilion Account Program in the office of Stale Treasurer Catherine Baker Knoll. ()~:? Robert p, Casey Governor COMMONWEALTH OF I'ENNSVLVANIA HARRISBURG Dear Fellow Pennsylvanians: Today is not a momenlloo soon 10 stan planning for the educational fulure of our children. Higher educalion is imponanl in helping our youth acquire the knowledge they need to meet the challenges of our changing socielY, Wilh lhis in mind. we are delighted 10 announce lhe Tuition Accounl Program, We recognize lhat Pennsylvaoians are very concerned about lhe cosl of providing lheir children with the opponunity of a higher education, The Tuilion Accounl Program is a pan of the solulion to Ihe growing problem of meeting lhis expense in an affordable manner, This program provides lhe f1exibilily of prepaying tuition by purchasing luition credils now to be used al a later date, II is designed so people from all income levels can panicipate, II is intended 10 help make lhe hopes and dreams of more Pennsylvania children an accessible realilY, Our youlh are our future. We depend on their success. II is our honor 10 orfer you a realistic plan 10 help them receive the education lhey need to reach their full potenlial. ~L Roben C, Jubel Slate Senator (!~ Catherine Baker Knoll Slale Treasurer reparing or colleg · The Tuition Account Program is designed to provide for the advance purchase of college tuition credits in order to assist families of all income levels planning for the future educational expense of their children. · Tuition rates for colleges in Pennsylvania and across America have been rising at a rate al most Iwice that of national inflation and will continue to increase considerably in the future, To better prepare for this expense, smart parents and grandparents need to begin planning as soon as possible, Establishing a pre-paid tuition plan can keep your family one step ahead, · The pre-payment of college tuition is an essential investment in your child's future, You can assure that sufficient Tuition Credits will be available when your child is ready for college. Increasing Tuition Coslln Pennsylvania 11000 11000 17((lO $6000 "000 $<000 1>000 $>000 IUICIO 10 I"' 19lH '''' 1997 "'" · This Program guarantees that credits purchased today will retain their value for the Pennsylvania community college, state college or university you have selected. he Progra . Individuals can purchase 'fuition Credits in any amount, and as often as they wish, without any further obligation to purchase additional 'fuition Credits. 'fuition Credit prices will be set annually, based on an actuarial assessment that will include current tuition rates, projected tuition inflation and the earnings of the Fund. · The Pennsylvania Tuition Account Program is a plan that allows you to "lock-in" tomorrow's tuition costs today for your children. It helps make a child's continuing education affordable. . The Tuition Account Program provides an edge against inflation by paying for future tuition today. . You can participate in the Program by purchasing Tuition Account Program Credits, A "'fuition Credit" is equal toone-twenty-fourth (1/24) of the annual tuition at member colleges and universities for full-time undergraduate students, For community colleges one credit hour is equal to one Tuition Credit. . .. - --. --.. --:-. · The Tuition Account Program will allow for the partial payment of Tuition Credits to assist in personal budgeting. These partial payments are called "Thition Units." Twenty (20) Tuition Units equal one (I) Tuition Credit. For example, if a college Tuition Credit costs $100, you would be able to purchase a Tuition Unit for $5. Tuition Units make paying for college easy and affordable. The minimum payment is one (1) Tuition Unit. . You may purchase Tuition Credits or Tuition Units as frequently as you choose. Your payments may be weekly, biweekly, monthly, annually or vary as you like. This is NOT a mortgage type contract. · Tuition Credit prices will be set annually based on current tuition prices, expected tuition inflation and the expected earnings of the Fund. An actuarial study will be conducted annually to determine the soundness of the Fund. · Tuition Credits can be purchased for a specific school, or at a standard rate. Tuition Credits may be purchased at either the resident or non-resident rate, Community colleges will also have a third Tuition Credit price for in-state but out-of- district students. · When schools change their tuition, the price of the Tuition Credits will change. Additional purchases by an individual will be made at the new rates. · The Program allows you to use your Tuition Credits anytime after they mature. Tuition Credits mature four (4) years after the date of purchase, ~ he Program's exibili . The Tuition Account Program is structured to offer you a wide range of choices and is flexible enough to work with virtually an budgets. In these uncertain economic times, it is comforting to know that you have paid for the tuition expense when your children are ready to continue their education, This Program allows students to apply to any licensed or accredited school in the United States, . You may pre-purchase a student's entire tuition requirement in a lump sum, or purchase Tuition Units or Tuition Credits over an extended period through payroll deduction or periodic payments. . Another example of the Programs flexibility is open enrollment. You may enroll in the program at any time, . This is the only program of its kind in the country, People can participate by paying only a few dollars at a time, Squirrel away money for their future. nroll in the Progra · At the time of application. the Purchaser OR the Beneficiary must be a resident of Pennsylvania, · Read the Pennsylvania Thition Account Master Agreement thoroughly for all terms and conditions. · Complete the application and return it with the application fee and proof of residency* in the self-addressed envelope enclosed. · DO NOT SEND ANY ADDITIONAL MONEY AT THIS TIME. · Once approved. you will recei ve an acceptance leller and then you may begin to make purchases, · Beneficiaries will still need to satisfy the requirements for admission, continued attendance and graduation from the college or university they select. .See the application . Your account is backed by the full faith and credit of the Tuition Account Program Fund. Your Tuition Credits are guaranteed to be available for your Beneficiary when he or she is ready to use them. provided they have been in the Fund a minimum of four (4) years, . The Tuition Account Program's financial statements are audited annually, In addition, an actuarial audit is prepared each year by the Fund's actuarial firm, Investments and balance sheets are reviewed quarterly. Tuition Credit prices are adjusted annually to ensure the solvency ofthe Fund. These business practices provide safeguards for the financial stability of the Fund. The Tuition Account Program is an essential state service; however, the pre-paid Program is not backed by the full faith and credit of the Commonwealth of Pennsylvania, . The Tuition Account Program's credits are exempt from Pennsylvania state and local taxes, · The Program has been designed to minimize federal income tax consequences, The Treasury Department has requested a determination from the Internal Revenue Service regarding the taxability of the Program, Unless the Internal Revenue Service rules otherwise, any increase in the value of the credits may be subject to federal income taxation, The Beneficiary or the Purchaser may incur a tax liability when the credits are used, and the Purchaser may incur a tax liability in the event of a refund. Every tax situation is unique. Purchasers and Beneficiaries are encouraged to seek guidance from their tax advisors, uestions & Answe~ --- Q: Can the Beneficiary attend any other college 01" university? A: The Beneficiary can apply the value of the account to any accredited or licensed post-secondary school in the United States of America, Q: Is there an advantage to selecting a specific school's tuition rate over the standard rate for that category of schools? A: If you know which school the Beneficiary would like to attend. then the answer is yes! The advantage would be in knowing that you have selected the appropriate tuition rate, Q: Can the Beneficiary use Thltlon Credits at a private school? A: When you purchase Tuition Credits and then decide to attend a private school. the value of your account will be paid to that school. You will be responsible for paying any differences between the account value and the school's tuition expense, Since most private colleges are more expensive than state colleges and universities. extra credits should be purchased to offset the difference. Q: How many Thltlon Credits should I purchase for an Associate's Degree program at my local community college? A: Most community colleges calculate tuition costs based on the number of total credit hours for the courses selected, At these schools, one Tuition Credit will equal one credit hour, Most Associatels Degree programs require a minimum of sixty (60) academic credits. Therefore. at least sixty (60) Tuition Credits should be purchased, You must detennine the specific credit requirement for your Beneficiary by contacting the college he or she plans to attend, Q: How many ThUlon Credits should I purchase for a Bachelor's Degree program? A: A Tuition Credit is one-twenty-fourth (1/24) of the annual tuition at a Purticipaling Institution, Twelve (12) Tuition Credits equal the tuition for one semester and twenty-four (24) Tuititon Credits equal the tuitio!l for one year, Since most Bachelorls Degree programs require four academic years, the total purchase should be at least ninety-silt (96) Thition Credits, However, where a Participating Institution calculates tuition on the basis of cost per credit hour. a Tuition Credit will equal a credit for one academic hour. This Program is designed to pre-purchase credits at the full-time undergraduate rate, If the Beneficiary allends school on a part-time basis, the tuition cost may be greater per credit hour, The Program will convert the value of the account to the part-time equivalent. Q: How often will the price of Thitlon Credits change? A: Prices for Tuition Credits will be established annually and will be in effect from September I st through August 31 st. Each year. as colleges announce their tuition rates for the following academic year, an actuarial study will be completed to determine the new annual prices, We fully expect college tuiiion prices to increase annually and that the Tuition Credit prices will also increase, Q: Can the Beneficiary attend schools other than colleges? ", I.: A: Tuition Account Program credits can be used for tuition payments at any state accredited or licensed post-secondary school. This includes trade, business, art. culinary and professional schools, Q: Can I change the Beneficiary? A: Yes, This requires a contract change, Forms to request a Beneficiary change will be provided, Each contract change will be subject to a $ I 0,00 administrative charge, Q: What happens if the Beneficiary decides he or she does not want to continue his or her education and I do not have a substitute Beneficiary? A: If the Beneficiary decides not to go to college. or any other accredited school. then ninety (90) percent of the value of the tuition account or ninety (90) percent of the value of Tuition Credits. whichever is less. will be returned to the purchaser upon req uest. Q: Can the applicant also be the Beneficiary? A: Yes. You can purchase Tuition Credits for your own collegc tuition. but as the applicant, you must be at least 18 years of age. Q: How can a business, service club, civic organization or alumni organization participate In the Program? A: Any legal entity can establish a Tuition Account. A business can participate by enabling its employees to purchase Tuition Credits through payroll deduction I providing an employee benefit through matching funds forTuition Credit purchases. or establishing a scholarship with Tuition Credits, Service clubs, religious groups and civic organizations can also purchase Tuition Credits for scholarships, Q: Is the Program limited to tuition only? A: This Program is designed to cover the single largest expense,..tuition. There are many other expenses associated with attending college, You must learn about these additional expenses directly from the schools, If an account contains more Tuition Credits than needed to complete a degree program, you may apply to the Department to use the credits for a Master's Degree or other advanced degree programs. or for room, board and other educational expenses after application of a conversion factor determined by the Department. Q: Can I decide how many Thition Credits can be used In any given semester? A: You may use the Tuition Credits in any manner you choose as long as the four(4) year maturity requirement has been fulfilled, Q: Does the value ofThition Credits affect student aid eligibility? A: For Pennsylvania state student aid - no, For any Federal student aid. yes, Conlact your school's Financial Aid Office for specific details, Q: What If I can't afford to purchase all of the Thition Credits for a four year degree? A: Credits may be purchased.at any time in any quantity that is convenient and affordable, The only requirement is that the minimum purchase is one Tuilion Unit. Q: Can I terminate my conlract and receive a refund? A: You may terminate an account and be entitled to a refund, The amount of the refund will depend on the reason for the termination of the account. Full details about the refunds are in Article VI of the Master Agreement. Q: May two or more people jointly purchase a 'fultlon Account contract? A: There can be only one Purchaser per contract. However, someone other than the Purchaser may contribute towards the purchase of Tuition Units orTuition Credits for the Beneficiary, Q: Who controls the 'fultion Account? A: The Purchaser of the Tuition Credits controls the account. The Purchaser can change Beneficiaries or terminate the account at anytime, Q: Can a Beneficiary have more than one account? A: Yes. any number of Purchasers can open an account for a specific Beneficiary. The Beneficiary has all the same flexibility in the use of the credits. and each individual Purchaser maintains control of his or her account. Q: What are the state and federal tax consequences for Purchasers and Beneficiaries? A: The Program has been designed to minimize federal income tax consequences, The Treasury Department has requested a determination from the Internal Revenue Service regarding the taxability of the Program, Unless the Internal Revenue Service rules otherwise. any increase in the value of the credits may be subject to federal income taxation. The Beneficiary or the Purchaser may incur a tax liability when the credits are used. and the Purchaser may incur a tax liability in the event of a refund, Every tax situation is unique, Purchasers and Beneficiaries are encouraged to seek guidance from their tax advisers, . ' ~ ~o~ a ~ EI m ~.~ ~ II m ~ ~ m ~ ~ ~H fa ~ II II ~ Pi e ~ 1!I0 ~~ ~ ~ ~.. II 16 T tate public colleges & universities THE STATE SYSTEM OF HIGHER EDUCATION D BLOOMSBURG UNIVERSITY OF PENNSYLVANIA III KUTZTOWN UNIVERSITY OF PENNSYLVANIA o CALIFORNIA UNIVERSITY OF PENNSYLVANIA III LOCK HAVEN UNIVERSITY OF PENNSYLVANIA o CHEYNEY UNIVERSITY OF PENNSYLVANIA mil CLEARFIELD CAMPUS D CLARION UNIVERSITY OF PENNSYLVANIA DlI MANSFIELD UNIVERSITY OF PENNSYLVANIA m VENANGO CAMPUS m MILLERSVILLE UNIVERSITY OF PENNSYLVANIA o EAST STROUDSBURG UNIVERSITY OF PA m SHIPPENSBURG UNIVERSITY OF PENNSYLVANIA II EDINBORO UNIVERSITY OF PENNSYLVANIA m SLIPPERY ROCK UNIVERSITY OF PENNSYLVANIA D INDIANA UNIVERSITY OF PENNSYLVANIA m WEST CHESTER UNIVERSITY OF PENNSYLVANIA DlI ARMSTRONG CAMPUS 1m PUNXSUTAWNEY CAMPUS ALINCOLN UNIVERSITY STATE.RELATED UNIVERSITIES A NEW KENSINGTON CAMPUS A OGONTZ CAMPUS .All. SCHUYLKILL CAMPUS A SHENANGO CAMPUS ..th. WILKES-BARRE CAMPUS A WORTHINGTON.SCRANTON CAMPUS ..&. YORK CAMPUS A PENNSYLVANIA STATE UNIVERSITY ..th. ALLENTOWN CAMPUS A ALTOONA CAMPUS A BEAVER CAMPUS Aa. BERKS CAMPUS A DELAWARE CAMPUS A DUBOIS CAMPUS .All. ERIE BEHREND CAMPUS A FAY EnE CAMPUS A GREAT VALLEY CAMPUS A HARRISBURG CAPITAL CAMPUS A HAlLETON CAMPUS A HERSHEY MEDICAL CENTER CAMPUS .A. McKEESPORT CAMPUS .A MONT ALTO CAMPUS A TEMPLE UNIVERSITY .A AMBLER CAMPUS A UNIVERSITY OF PlnSBURGH 4l.. BRADFORD CAMPUS A GREENS BURG CAMPUS A JOHNSTOWN CAMPUS A TITUSVILLE CAMPUS " ALLEGHENY COUNTY BEAVER COUNTY BUCKS COUNTY BUTLER COUNTY DELAWARE COUNTY ERIE COUNTY HARRISBURG AREA COMMUNITY COLLEGES , LEHIGH COUNTY LUZERNE COUNTY I MONTGOMERY COUNTY NORTHAMPTON COUNTY AREA PHILADELPHIA READING AREA . WESTMORELAND COUNTY 17 THE PENNSYLVANIA TUITION ACCOUNT PROGRAM MASTER AGREEMENT ARTICLE I . INTRODUCTION 1. This Mssler Agreement Is a contracl lor the prepayment 01 educalional services, and describes the terms and conditions 01 the Pennsylvania Tuition Account Program es defined by the Tuition Account Progrem and College Savings Bond Act Dnce you complete an application for a Tuilion Account Paymenl Contract, and your application Is accepted, you will be ISlued an acceplance package. The application, kepi on file on your behall, this Master Agreemenl, and tha acceptance package conslitute the Tulllon Account Payment Contract between you and the Treasury Department. Modiflcallons and additional terms and conditions may be mede to Ihls Masler Agreemenl by Ihe Treasury Department. and will be In~rporated Into lhe Tuition Account Payment Conlrael. 2. Sec1lons301to 317 of the Act, 24 P.S. ~~6901.301-6901.317 and regulations to be prom~lgated at 22 PA Code Chapter 551, as amended from time to time, will epply 10 the Tuition Accounl Payment Conlract and are Incorporated herein by reference. You may receive copies 01 the stalule and regulations Irom the Department upon request. ARTICLE II . DEFINITIONS 1. The lollowlng words and phrases will have the meanings given to them In this section unless the contexl clearty Indicates olherwlse: 'Ar;f' The Tuition Account Program and College Savings Bond Act, Act 011992, April 3, P.L. 28, No. 11,24 P.S. ~6901.1 01, aJ..eg, 'BeneflclarY" A person who meets the eligibility crileria sel forth In Ihe Act, and on whose behall a Purchaser enters Into a Tulllon AccOunt Payment Contracl. 'Deoertmenr The Treasury Department 01 the Commonwealth 01 Pennsylvania. 'DI...blllly" A medical or physical condition of a Beneficiary which In the judgment 01 the Department makes attendance by !he Beneficiary et a Participating Institution or Nonparticipating Inslllutlon Impossible or unreasonably burdensome. 'edueatlonal exoenses' Expenses, other than Tuition, necessary for attendance at either a Participating tnslitutlon or Nonparticipating Institution, Including, bul not limited to, charges for room and board, provided by Ihe Participating Institution or Nonparticipating Institution laboralory feas, compuler fees, book costs, and studenl activity fees. 'Enrollment Period' Any period deslgnaled by the Department during which applications lor enrollment In the Program will be accepled by the Department. 'Famllv Member" A family member Is a spouse. child, slepchild or any descendant or stepdescendant 01 either; a sibling. half sibling, stepsibllng, or any descendant or slepdescendant 01 any of them; and an ancestor or a slepancestor. An adopled person Is considered Ihe child of the adopling person. 'EunlI" The Tuition Payment Fund established by the Act. 'Materiat Mlsreoresentatlon' A lalse stalement made with the intent to deceive by the Purchaser or Beneficiary, either In the applicallon or In written correspondence with the Department regarding the Tuilion Account Payment Contract. relating to a substantial fact, Including but not limited 10. age of the Purchaser. Ihe residency of the Purchaser or Beneflclary, or the reason lor Termination of the Tuition Account Payment Contract. 'Nel Eamlnos Rale 01 the Fund" The percentage relum of the investment 01 Fund essels after adjusling for any taxes and oparatlng expanses. 'Nonoerticloatlno Inslltutlon' Any postsecondary educatlonallnstilutlon accredited or licensed by lhe Pennsylvania Department of Education or similar egency of anolher stale or the U.S. Department 01 Education which Is nol a Participating Instilution In Ihe Program. 'Partlcloeting Institution' Any accrediled, degree.granllng college or university required by the Act to participate In lhe Program as selforth below: (A) Community colleges operaling under Article XIX.A ofthe Ael 01 March 10. 1949, P.L. 30. No. 14. known as the Public School Code 011949; (B) Universities comprising the Slale Syslem 01 Higher Education; (C) The following Stale.related Institullons: (I) Pennsylvania State University; (Ii) University 01 Pittsburgh; (IIi) Temple University; flY) UncoIn University; (v) any InsIiMion which is designated as "Stale-related" by lhe ColM1onweaIth. 'Prooram' The Tuition Account Program established by Ihe Act. 'Purchaser" A person, Including a natural parson who Is at least eighteen (18) years old. corporation, association, partnership orolher legal entity, who meets Ihe eligibility requirements as set forth In Ihe Act and who enlers into a Tuillon Account Payment Conlrael. 'Reslden<;y" Domiciled wilhin Ihe Commonwealth of Pennsylvania for no less than 12 consecutive months prior to and Including lhe dale of application. For a person under the age of one year. he or she must have been bom In the Commonwealth 01 Pennsylvania and have been domiciled In the Commonweaith continuously Irom birth Ihrough the date of application. 'Scholarshlo' Any amount received by a Beneficiary, Including a grant, or fellowship, provided that the amount Is required to be used for Tuition and Educational Expanses, and does not have to be repaid as a loan. 18 'SIAndArd Tullion Lovol' Th. .pproxlm.l. .v.r.ge Tuition lor an .cad.mlc y.ar al (i)lh. Commonw.alth'. communily colleges. (Ii) unlv...llle. In the SI.I. Sysl.m 01 Higher Educallon. or (ill) SI.I.,r.l.t.d Inslitullon., In .ach ca.. .. .slabll.hed by Ih. D.partm.nt. "T.rmlnation ollho Tulllon Accounl PavmAnI Contract" Tho voluntary or Involuntary disconllnuallon 01 a Purchaser from th. Program .nd the volunlary or involuntary dlsconllnualion 01 the Ben.,lclary'. righllo roc.lv. benefits under a Tuijion Accounl Paym.nt Contr.cl. "IuiIillD" Th. tot.1 (II alt I... and charg.s r.qulred for an.ndance at an Instllutlon 01 hlgh.r educalion lor a lult,tlm.. undergraduate .cad.mlc y.ar, .xcluding charg..lor room and board. F..s and charg.. a. u.ed In thl. d.finltlon do notlnelude co.ls lor (I) aClivllles or lunellons unr.laled to cou... or program wolll (I.... atud.ntacllvlty f...), and (II) .peclfic cou... or program fe.. charged by an In.lltulion 01 hlgh.r education, which ar.ln addilion to Ih. olh.r f... and charg.alor .n.nd.ne. (I.... laboratory f.... comput.r I..., and book COSI'), "Tullio" Account" Th. account .stabll.hed by a Tullion Account Paym.nt Conlractlor a .peclllc Beneficiary. "Tullion Account Pavment Conlracr Th. contracl enlered Into by a Purcha.er .nd the Departm.nt to provide for th. advance purcha.. 01 Tuition Credll.lor a Beneficiary anending a Participating Inslltullon, which contraclcon.I.I. of this Ma.ler Agreement, application, acceplance packag., annual prlc. schedule lor Tuition Credits as periodically amend.d, and oth.r relal.d documenls. "Tuition Credll"Wher. a P.rtlclpating Instilution calculale. Tuition on a semesler basis (as opposed to a credit hour besis), a Tuition Credit I. defined au one.lwenty.fourth (1/24) 01 the Tuition lor an academic y.ar at that Participating Inslilution. In such a cas.,lwelve (12) Tullion Credlls will equal one (1) semest.r. and lwenty.four(24) Tuilion Credits will equal one (1) acad.mlc year of Tullion althat Participating Inslilullon. Where a Partlcipallng Inslllullon calculales Tuition on Ihe basis 01 cosl per credit hour only (es opposed to a semesler basis). a Tuition Credit Is defined as on. (1) academic credd hour, For example, II a Partlclpaling Inslilution charges by the credil hour and requires lilteen (15) credit hours. Ihen Illteen (15) Tuition Credils persemeslerwlll b. needed to pay lor the credit hours. In such a case,thirly (30) Tuition Credits will equal one (1) academic year of Tuition at thai Participating Institution. This delinillon Is based on Seellon 309(c) of th. Act (relaling to Tulllon Credits under the Tuition Accounl Program). "Tuition Rate" Thetype 01 Tulllon charged, on Ihe basis 01 Residency stalus (I.e. Pennsylvania resident. non. Pennsylvania resldenl. or out.ol-district). "Tuition Unlr Is live percent (5%) of a Tulllon Credit. Twenty (20) Tuition Units equals one (1) Tuition Credit. "Value 01 the Accounl" The sum 01 all payments made pursuant to a Tuition Account Payment Conlractlor the purchasa 01 Tulllon Credits or Tuilion Units plus, In the case 01 each payment, a pro rala share olthe Net Earnings Rate 01 the Fund Irom the dale 01 payment to Ihe time 01 valualion, compounded annually. ARTICLE III- PARTICIPATION IN THE TUITION ACCOUNT PROGRAM 1. In order 10 participate In Ihe Program, either you ("the Purchaser') OR Ihe person you have deslgnaled to recalve the benefils of the Program (1he Beneficiary") must be a resldanl 01 the Commonwealth 01 Pennsylvania allhe time 01 appllcalion lor partlclpallon In the Program. The final delermlnation regarding Residency slatus will be at the sole discretion ollhe Department. 2, In order to partlclpale In the Program. you must deslgnale. at the time 01 application, the Beneficiary. You may name yourself as the Beneficiary. The Beneficiary you name on the application will be the designated Beneficiary, unlil such time that you eleetto nama a subslilute Beneficlary In accordanee with the provisions 01 this Master Agraement. You may designate a B.neficlary as unnamed. provided thallhe designation Is part 01 a Scholarship award beginning on a staled date of enrollment, pursuant to a Scholarship program previously approv.d by the Department. 3. In order 10 participate In the Program, you must designate, on the application, the projec1ed dale of enrollment for the Benellclary who will anend a Partlclpatlng Inslllution or Nonpartlclpallng Instilulion. The projacled date 01 enrollment you designate on the application will be the proposed dale 01 enrollment, unless you request subslilution of Iha proposed dala of enrollmenlln accordance with Ihe provisions of Ihls Master Agreement. The Dapartment will have the right to approve. at lis sola discretion. a substitution of proposed date of enrollment, and reserves the right to limit the number or proposed date of such .ubstltullons. 4. In order 10 partlclpale In the Program, you must designate, on the application, the Tuition level lor which you wi'l purchase Tulllon CredltslTultion Unlls. You may purchase Tuition CreditslTultion Units at a Standard Tuillon Level, as listed on an annual price schadule lor either (I) Pennsylvania community colleges: (II) unlversllies In the Slale System of Higher Education; or (iii) Slate.related Instilullons. If you choose not to purchase Tuition CredilslTultlon Units at a Slandard Tuition Level. you may purchase Tulllon CredilsfTultion Unils at the Tuition on the annual price schedule for a specific Participating Inslllution. The ennual price schedule will specify the cost 01 Tuition CreditslTultion Units at the respeellve Slandard Tuition Levels. and at specific Participating Institutions. In each case lor resident and non. resident sludents. You lurthor undersland lhallhe Departmenl may annually change Slandard Tulllon Levels. the Tuition lor a specific Partlclpaling Institullon, and Ihe purchase prices 01 Tuition CreditsfTultlon Units. The Tulllon level you designate on the application will be the Tullion level al which your purchase 01 Tuition CredltsfTulllon Units will be calculaled. You may substitule the deslgnaled Tullion level, In accordance with the provisions 01 this Master Agreement: however. Tuition CreditslTuillon Units purchased up 10 the time the Department Is notified of your subslitutlon 01 Tuition levels will be converted to Tuition CredilsfTulllon Unlls at the subsliluled Tuition level. In accordance with the provisions of this Masler Agreement. 19 ARTICLE IV. PAYMENT METHODS 1. You may purchase Tulllon CredilslTullion Unils by (I) a lump sum payment lor an amount 01 Tuilion CreditslTuilion Unils you specify on Ihe appllcallon; (Ii) personal check accompanied by accounl coupons provided 10 you by the Depa~menl; (Iii) dlrec1transfer Irom your bank account; or (iv) payroll deduclion. You select your melhod 01 peymenl on the Applicelion; however. you mey change payment melhods al any lime upon wrlUen request 10 the Depa~menl. 2. You will be charged e $20.00 lee lor any paymenls relurned uncollecled lor insufflcienl lunds. ARTICLE V . REDEMPTION OF TUITION CREDITS 1, You understand that e period 01 lour years must elapse Irom the dale 01 each purchase 01 e Tulllon Credit to the time when auch Tulllon Credit mey be redeemed el a Partlcipallng Inslllution or Nonparticipating Inslilullon. 2. The Beneficiary must enroll In a Partlclpallng Instllutlon or Nonpa~iclpallng Inslilutlon within a five.year period Irom the flrsl day 01 Ihe month specified on the appllcallon as the proJecled date 01 enrollment. You may extend this period lor an additional flve'year period provided you nollfy the Department In wrillng prior 10 the end 01 the Inlllal five'year period. and If determined by the Departmenlto be necessary, you pay an assessment 10 ensure the actuariallOundness 01 the Tulllon Account or the Program. The lallure 01 the Beneficiary to enroll wllhln Ihe specified five.year period, plus any epproved five. year extension, will be deemed a decision by the Beneficiary 001 to allend a Partlclpallng Inslilullon or Nonpartlclpallng Inslilulion. and will resullln (I) a Termlnallon 01 the Tuilion Account and (II) the Issuance 01 a relund In accordance wllh the prOvisions 01 the Masler Agreemenl. Any lime spent by a Beneficiary as an aclive duljl member 01 the United Slates Armed Services will not be Included In Ihe five.year period specified In Ihls Paragraph. 3. The Beneficiary must redeem all Tuillon Credils within a ten.year period beginning on Ihe first day 01 Ihe monlh of enrollmenl. Failure ot'lhe Beneficiary to redeem all Tullion Credits within the specified len.year period will be deemed a decision by the Beneficiary not to aUend a Partlclpallng Instilullon or Nonparticipating Inslilullon and will result In (I) a Termlnalion 01 the Tullion Account. and (Ii) the Issuance of a refund In accordance wllh the provisions 01 the Master Agreement. Any lime spent by a Beneficiary as an aellve duljl member 01 the Unlled Slales Armed Services will be added to the ten'year period specified In this Paragraph. 4. To redeem a Beneficiary's Tulllon Credlls at a Participating Instllulion, you or Ihe Beneficiary must request, In wrillng from the Department, a certified slalement of accumulated Tulllon Credits. Such request must Include (I) Ihe specific Partlcipallng Inslilution to be aUended by the Beneficiary; (Ii) the amounl, if any, 01 any Scholarship for the academic year againsl which the Beneliclary seeks 10 apply his or her Tuition Credlls; (Iii) the Tullion Account Payment Contracl number; and (Iv) the Tulllon Aale Ihalthe Beneliclary will be charged by Ihe specllic Particlpaling Inslilullon. You undersland that Ihe Depa~menl will conve~ previously purchased Tulllon Credits. In accordance with A~icle V, Paragraph 8 01 this Masler Agreement, If Ihe specilic Pa~lclpallng Inslilullon and/or the Tullion Aale Indica led on the request lor the ce~ified stalemenl 01 accumulaledTuitlon Credlls Is different Irom that specified In your applicalion. For example, If you purchase Tullion Credits( Tullion Unlls at a Tuition Aale lor residents. and subsequenUy Ihe Beneficiary auends a Pa~lcipallng Inslilullon as a non. resident. the Depa~menl will conve~ your Tullion Credits 10 Ihe non.resldent Tuition Aate. 5. You or Ihe Beneficiary must forward the ce~ified stalemenl 01 accumulaled Tulllon Credits 10 the specific Partlclpallng Inslilution which the Beneficiary will alland. The specific Pa~lclpallng Inslitullon will relurn Ihe certified slatement 01 accumulated Tulllon Credits 10 the Departmenl, logelher wilh a slalemenl, signed by an appropriate official 01 the specific Partlcipallng Instilullon. ce~ilylng thai the Beneficiary has been accepled for enrollment lor the current academic year. A Pa~lcipallng Instilullon aUended by a Beneficiary will acceptlhal Beneficiary's Tuition Credits. 6. Upon receipt of alllhe documentallon required by A~lcle V, Paragraph 5. the Depa~ment will pay dlreclly to Ihe specific Participallng Inslllullon the lesser of (i) the actual Tullion lorthe number of Tuition Credilspurchased for that academic year, or (II) the purchase price 01 Ihe Tulllon Credits plus a pro rala share 01 Ihe average annual Net Earnings Aale of the Fund compounded from the year of purchese 10 Ihe year In which such Tulllon Credlls are to be used. "the amount In Paragraph 6(11) Is the lesser amount. the difference between Paragraph 6(1) and 6(11) will be a Tullion Shortfall. The Department will add from the Fund the amounl 01 the Tullion Shortfall 10 the paymenl made dlrecUy to the specific Partlclpallng fnsliluUon. 7, "the Accounl 01 a Beneficiary conlalns more Tullion Credils than the Beneficiary needs 10 complete the Beneficiary's baccalaureale degree. the Beneficiary may apply to the Depa~ment to use the Tulllon Credlls lor a Masle(s or other post. baccalaureale degree program or for Educallonal Expenses alter applicallon of a conversion laclor delermlned by the Depa~ment; provided however that Tulllon Credlls may be used for Educallonal Expenses only wllh Ihe approval 01 the Depa~menl. 8. At the requesl of you or Ihe Beneficiary. Ihe Depa~menl will convert Tuition CredilslTultlon Units purchased at a Standard Tullion Level to the Tulllon at a specific Pa~icipallng Inslilullon by multiplying the number 01 Tullion CredllslTuillon Unils purchased each year by Ihe ratio 01 that academic yea(s Slandard Tulllon Level divided by the Tuition for Ihe same academic year althe deslgnaled Pa~lclpallng Inslilullon. Upon Ihe request of you or the Beneficiary, the Department, following Ihe same procedure. will convert Tullion CredllslTulllon Unlls purchased al the Tullion 01 a specific Pa~lcipallng Instllullon to the Tullion at another specific Pa~icipallng Inslilution. The sum of Tuition Credils generaled from such conversions will be the tolal Tuition Credlls applicable 10 a specific Pa~lclpallng Inslllullon. 20 9. In order to apply Tulllon Cradllllor Tuition ala Nonparticipating Institution. you or your BenaflClary muslsend the Departmenl documentalion (I.e. an Invoice lor Tuition) thaI shows Ihe Benellciary's acceptance lor enrollmenl by Ihe NonpartlClpaling Institullon. Upon recelpl 01 such cIoCumentation, the Department will pay 10 tha Nonparticipating Instltullon Ihe lasser 01 (I) Iha actuel Tulllon lor Iha number 01 Tulllon CrecMs purchasod allhe Slandard Tulllon Level. or althe Tullion level lor a specillc Partlc;pating Inslltutlon, es designated In the Tulllon Accounl Paymenl Conlract; (Ii) the Value olthe Account; or (ill) the amount 01 the Invoice. ARTICLE VI. TERMINATION AND REFUND 1. You may terminate tha Tullion Accounl Payment Contract and receive a refund 01 the Value 01 the Accounl only In Ihe event 01 anyone JI Ihe following circumstances: (I) Ihe dealh 01 Ihe Beneficiary; (II) the Disability 01 lhe BenefICiary; or (Iii) Ihe lallure 01 the Beneficiary. who has made a good laith anempl, to gain admlaslon to a Participating or Nonpartlcipaling Inslilutlon wl!hln !he lime limits lit by Ihe Department The Beneficiary may be deemed by Ihe Department to have made a good lal!h anemplto gain edmlaslon al a Participating or Nonparticipating Institulion upon Ihe submission 01 (I) a Itatement Irom Ihe Beneficiary lhal flltlthe Partlclpaling andlor Nonpartlcipaling Institutions thatlhe Beneficiary epplied 10 lor the PUrpoll 01 admlaslon, and iI!he Beneficiary did not maka any luch applications, a delaUed explanation 01 Ihe reason lor not doing so; or (Ii) lenera or olher wrinen documenlation lrom Partlcipaling and/or Nonparticlpaling Instllulionslhal rejecled Ihe appliCation for enroliment; or (Iii) olhar documenlatlon as Is salisfactory 10 Ihe Department. Lenera of documentalion which reject admissIon applicalions as Incomplele, unlimety filed, or other reaSOM not based on the meril or qualiflcalions 01 the Beneliclary will not qualify as a good fal!h effort to gain admission by the Baneflclary. 2. lithe Beneficiary Is awarded a Scholarship lor anendance at a Participating or Nonparticipating Inslilution, the terms 01 which cover all or part of the benefits Included In the Tullion Account Payment Contract, you may terminate the Tuition Account Paymenl Contract and/or receive a refund Irom the Department with respect to the benefits covered In Ihe amount 01: (I) !he Tullion lor the number 01 Tulllon CredllslTuition Units purchased at the Standard Tuilion Level, or at the Tuition level lor a spaclflc Particlpaling tnslltulien. as designated In !he Tullion Account Payment Contract; or (ii) an amount equsllo Ihe Value 01 !he Account, whIchever Is less. The refund under thIs Paragraph for anyone academic year will not exceed Ihe amounl 01 !he ScholarshIp lor Ihat year. In order to receive a refund whara a Beneficiary Is awarded a Scholarship, you must submll wrinen nolice 01 !he Scholarship award. the amount of such Scholarship. and a request lor ralund. The wrinen request must also contain the Purchase(s nama. the Baneflclary's name, Iha Tulllon Accounl Payment Contract number. evidence 01 the Scholarahlp award and amount 01 the Scholarship. 3. lithe Beneficiary designated by you In the Tuition Account Payment Conlract decides not to anend a Particlpaling Institution or Nonpartlcipaling Inslitutlon. you may Terminate the Tuition Accounl Payment Contract and racelve a relund, or you may designate a substitute Beneficiary In accordance wllh Iha provisions ollhls Mastar Agreement. II you elect to Termlnale the Tuition Account. the Department will pay a relund to you. Ihe lasser 01: (i) Nlnaty parcent (90%) 01 Ihe Tulllen lor the number 01 Tulllon Credlls purchased allhe Slandard Tuition Level or at !he Tuition leval lor a specific Partlclpaling Instltulion, as designated In Iha Tulllon Account Paymenl Contract, as periodlcaliy amended; or (II) Ninety parcent (90%) 01 tha Value of the Account. Failure 01 a Benaflclary to enroll or redaem the balance 01 Tullion Credits within the time pariods providad for In Ihls Masler Agreemenl, will be deemed by the Dapartmant (I) as a decision by Iha Baneflciary not 10 anend a Partlcipaling Institulion or Nonpartlcipaling Institulion, and (II) an election byyou to Terminate the Tuition Accounl and receive a refund, as sal forth In lhls Paragraph. 4. At any time, you may terminate at will the TuItion Account Payment Contract and receive a refund 01 monies paid. II you so elect to termInate the Tuition Account Payment Contract, !he Department will pay a relund to you, Iha lesser of: (I) NInety parcent (90%) 01 Iha TuItion for the number 01 Tuition Credits purchased at the Slandard Tuition Level or attha Tuition lavel for a spaclllc Partlclpaling Inslilulion. as designated In the Tullion Account paymenl Conlract. as pariodically amended; or (II) Ninety parcenl (90%) of the Valua 01 Ihe Accounl; or (III) The sum 01 all payments mada by you. or on your behall. for the Ihe purchase of Tuition Credits or Tuition Unlls. 5. In order to lermlnale!he Tuilion Account Payment Contract and recelva a refund under this Article. you must provide a wrinen request 10 Ihe Department specilylng your name, the Beneficiary's name, Iha Tullion Accounl Paymenl Contract number, !he reason for termlnalion, and supporting cIoCumentallon as may ba required by ,he Department, and paymant of the lea specified In Article VIII 01 Ihls Master Agraement. 6. lithe Department delermlnes !hal you or !he Beneficiary have made any Material Mlsrapresentation on the applicalion or In your communications with the Dapartment regarding Iha Tuition Accounl Program. the Tuition Account Paymenl Conlract may be termlnaled by tha Dapartment IIlhe Tuition Account paymanl Conlract Is SO tarmlnated, you wili be enlitled to a ralund In accordance with Ihe provisions 01 Paragraph 4 of Article Viol Ihls Masler Agreement 7. All relunds will be made payable 10 the order ollhe Purchaser only. ARTICLE VII . SUBSTITUTION, ASSIGNMENT AND TRANSFER 1, You may transfer Ihe benefits and rights 01 !ha Tuition Account Program to an eligible substilute Beneficiary, II: (I) you axecute a statement verifying Ihatthe parson who Is 10 be subsUMed Is your Family Membar or a Family Member of the original Benaficlary; and (i1) II you ara a nonresident 01 Pennsylllanla,lha subslitule Benerrciary meets Iha applicable Residency requirements. 21 2. You m.y .Iso tr.nsl.r own.rshlp 01. Tuition Account P.ym.nt Contr.cllo .noth.r .lIglbl. Purch....r provld~ such Purchas.r Is your F.mlly M.mber, th.lr.nsf.r Is .ccompllsh.d wllhout consld.ration, .nd 1I1h. B.n.,icl.ry Is. nonr.sld.nt of P.nnsylv.nl., such Purch.s.r meetsth. .ppllc.bl. R.sld.ncy r.quir.m.nts. All r.qu..tslor substitution of . Purch.s.r mustlnclud.: (I) the Tuition Account P.ym.nl Contr.ct numb.r; (II) Ih. n.m., .ddr..., soclalsacurity number, and talaphon. number ollha Purchasar 10 whom you will b.transferring ownerlhlp of tha Tuition Accounl Paymant Contract; (Iii) tha raason for tha Iransfar 01 ownarshlp; and (Iv) Ih. signaturas of yoursell and tha Purchasar to whom ownarship of Iha contract IS 10 ba Iransferrad. 3. Elc.pt as apeciflcally provided In Ihla Mastar Agreemenl. you may not assign or Iranller Ih. Tuition Account paymant Conlr.ct, nor of any Interast, rights, or benefits In It. ARTICLE VIII . FEES 1. You will be chargad a tan dollar ($ 1 0.00) lea under anyof th.following clrcumltances: (a) where you or th. Beneficiary se.k to chang.lh. Standard Tuition level or sp.ciflc Participating tnstitutlon. as deslgnaled In Ihe Tulllon Account Paym.nt Contract; (b) wh.r. you or th. Benallclary seek to t.rmlnal. a Tuillon Account Paymenl Conlract; (c) whera you seek to substlM. the Ben.flclary; (d) where you seek to Iransferth. Tuition Account Payment Contract to a subslllule Purchaser; and (.) whar. you or the B.neflciary seak to convert previously purchased Tuition CreditslTultlon Units 10 a Standard Tuition l,v.I. speciflc Partlclpatlng fnstltutlon olher Ihan as spe.:ified In Ihe Tuition Accounl Paymenl Contracl. 2, You will be charged a one dollar ($ 1.00) lee undar any of tha following circumslances: (a) whara you sa.k 10 change Inlormatlon r.gardlng Ihe Purchaser, othar than a transfar of tha Tulllon Accounl Payment Contract 10 a substllul. Purchaser; (b) where you saek to change Information regerdlng Ihe Beneficiary. olher than deslgnallon of a substituta Banaflclary; (c) where you laak to changa the payment melhod by which you will purchase Tuition CreditslTuitlon Units; and (d) where you seek 10 receive a certilied statement of eccumuleted Tuition Credils. olher than the certified statamanl of accumulated Tulllon Cradits provided to you by tha Department on an annual basis. 3. You will pay all lees Imposed undar this Artlcla VIII by check or money order made payable to the 'Tultlon Account Program." ARTICLE IX . MISCELLANEOUS PROVISIONS 1. All notices, changas, options and elactlons made under the contrect must be In writing, signed by you, and racelved by tha Dapartment at the address listed In the acceptance packaga. Tha Dapartmantls nol rasponsible lor lhe accuracy 01 such documentation. If acceptabla to the Department, notlcas, changes, options and elections ralatlng to Iha Beneficiary will lake effec1 as 01 the dale the notice Is received by the Department, unless the Department agrees olherwlse. 2, NOlhlng In Ihe Contrac1 will be construed as a promise or guaranlee by Ihe Departmenl or the Commonwealth of Pennsylvania that a Beneficiary (I) will be admilled 10 an Inslilulion 01 higher educalion, (Ii) will be allowed to continue to allend a Participating Inslilutlon or Nonpartlclpallng Institution aher having been admllled, (Iii) will graduate from a Participating Inslilullon or Nonparticipating Institution. 3. Alllactual datermlnatlons regarding a Purchase~s or Beneficiary's Residency. a Beneficiary's good lalth allemplto gain admission Into a Participating Inslilutlon or Nonparticipating Inslilutlon, Disability, and any olher lactual determinations regarding Ihe Tuition Account Payment Contract will be allhe sole discration ollhe Department. 4, The Department has requesled a detarmlnatlon of the tax status 01 the Fund. paymenls, and benems oflhe Program under the Internal Revenua Coda, Until such time as a final determination Is racalved, you understand that tha Internal Revenue Servica may determlna earnings or benems from the Program are talable to you or to tha qualilled Benaflclary, You understand that all tal situations ara differanl and that you may contacl your tal advisor or olhar tal counsalor, In addition, the Intamal Ravanua Sarvice may datermlne Ihatlhe Fund Is lalable. 5. Tha Tuition Accounl Payment Contract will be construed In accordance wllh Iha laws ollha Commonwealth 01 Pannsylvanla. 6. In tha avantlhat any clausa or portion olthe Tuition Accounl Paymant Contract Is lound 10 ba Invalid orunenforcaabla by a court 01 competent Jurisdlc:ion, that clausa or portion will ba savared Irom tha Tuition Account Payment Contract and tha remalndarollha Tuition Account Paymenl Contract will continue In full force and affact as If such clausa or portion had nevar bean Included. 7. You undarstand thai any claim by you or a Beneficiary agalnsltha Department pursuanlto tha Tulllon Account Paymant Contract will ba mada solely against tha assets 01 the Fund. 22 . ~ ~,. ~ : i : 5 Q' :' - l!! i " ~ c S- ... ::! ("II 9 ;,. = g ; f'4 01 .... ... a ! ~ u .. " ;;:~ , . '" i ! ~ ~ ! i ~i~9~i ~i gi 1il~~el;!~!2~ljli ~,,~ ~~~gg~!!I~:;:! ~"! ~s~~i~~~~!3li:lg~15 on a~~d15iQ~~~~h nUUn~h~iU lD......Ot~=~~:!'t!:e~~eJa ~ " !i ~ i .. ---- . u - , III .... <; . .... ~ = ~ , ~ ~ ~ . 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".~'=-_.."'i II' 10 ~ rp 0 oU?~ K-'i~~ ~ 0'" ~~~It!li ~~i~- i ~ 'i! ~~ ~llJ m;!~1 it 1'1 ':to a Yo' > ... o u !5 c ~ 00 Ul.... ....2 a: a: 01-' a..Ul w- a:o ....I ~8 ot:I: a:u ClUl 5~ oz :I:=> uo UlU Wz ....1_ 0....1 ou. _u. ::;:E POPS - Posltive Student Award November.. 1994 Team 6-1 (Q[jj]G)wc!lw [3g ~fJ U (SJCDlil Has exemplified the five ott i tudes ot focus: Belief in Self Sel f Conti dence Hi gh Expectot ions Goal Setting Self Esteem " , "\.... DANIEL P. WILSON and SHARON M. WILSON. Individually and as Parents and Natural Guardians of AMANDA WILSON A Minor. · IN THE COURT OF COMMON PLEAS .CUMBERLAND COUNTY. PENNSYLVANIA : No.: C;j-~ lJ~o~ OLtK.-(-:J~ . Plaintilfs/Petitioners v, · CIVIL ACTION - LAW . . . DAVIDJ. GANTT, DefendanllRespondent PRAECIPE FOR WRIT OF SUMMONS TO THE PROTHONOTARY: Please issue a Writ of Summons in the above-caplioned action. DO NOT FORWARD THE WRIT. ATfACHED IS AN ACCEPTANCE OF SERVICE FORM SIGNED BY DEFENDANT'S ATfORNEY. ~~ Danie P. Wilson Individually and as Parenl and Natural Guardian of Amanda Wilson. A Minor ~~,G~ Sharon M. Wilson Individually and as Parent and Nalural Guardian of Amanda Wilson. A Minor Dated: /1 //1/ C,5 I / ""''' ,. --..... ,,' -.,-,.~ ..; ....... -,.....-, ;'.. .'. " -,.--...---". ,..t".. .q,._ .: . Commonwealth of Pennsylvania County of Cumberland Daniel P. Wilson and Sharon M. Wilson, individually and as Parents and Natural Guardians of Amanda Wilson, a minor Court of Conunoll Pleas VI. 95-6808 Civil No. _____________________________________ 19____ In ________~_~ y!! __~p_t:~~!:l__:__~~_I!___________ David J. Gantt David J. Gantt: 1:0 _____________________________________________ You are hereby notified that Daniel P. wilson & Sharon M. Wilson ita as ~~E.~!l_t:!l__~__~~~!_!.~~!__~~_l!:!!!~t1!'__~_~__~!!1.!1_'1~_l.!_~g!:l~t1_'__~__!!!.!!I_C!:___ _________________ . , ., Summons - Civil Action - Law the PlallltiffS ha veommenced an acuon III ___________________________u______________u___________ &pinn you which you are required to defend or a default judgment may be entered againat you. (SEAL) I)ate ______!t~~_~~_q~_~__tL________ 19__~5 Lawrence E. Welker :-~~}~::;q;~~;:~~ "';"",..~~'-,,,-,,,,~~,, '''~ __," ,.-,C Y" ,,C--o 0';'''-'<''''''''''4_'''' "J '''''''i'':;'~~ e:: . 0'0 e:: J ke:: 0 III III In .<: r-l en >.r-l '.. ... r-llll~ 'Or-lk e:: III ;l III 1lI;l.j.J'O .S ~ 'Ollie:: r-l e:: ... 2: III ..;! '.. 0> ~ J J > In '.. '0 .j.J I "" r-l'Oe:: -- .j.J U '.. e:: Ill..... e:: e:: ~... 0 III 0 <Xl In Cl '.. 0 . .. o4J U) .j.J <Xl 11<e::e::e:: U I "" o Q) III k .., < I r-l In k '.. 0 I In Q) r-l ill '0 e:: '0 r-l '" '.....11< k'" ..... '.. e::~ III e > > I :a III In ;l III '.. t:l:E IlICl III t:l U I .... -.'- r _, DANIEL p, WILSON and SHARON M. WILSON. Individually and as Parenls and Nalural Guardians of AMANDA WILSON A Minor. PlainlilrslPelitioners v. DA VJD J. GANTT. DefendantlRespondent AND NOW, this 11:~ day of hearing be held on D Umtttl/.). 9 , ....;-,..;: '1iI._.. · IN THE COURT OF COMMON PLEAS .CUMBERLAND COUNTY. PENNSYLVANIA . : No.: yJ-- {;(tr6 (}.-WL1' L J~ · CIVIL ACTION. LAW . . . ORDER () <'/'111 ttv,./ . 19~ it is hereby ordered that a 19 95 al / , -3 () ,:).117 I (}/2 .#Y 0-/ for the Court to consider the Pelilion to Seule the Claim of a Minor. Distribulion: 1) Mr. and Mrs. Daniel P. Wilson RD#2, Box 116 Milroy. PA 17063 2) Deborah A. Cavacini. Esquire CALDWELL & KEARNS 3631 North Front Street Harrisburg, P A 17110 l50m BY THE COURT: ,Ad- / J, _ ~ ~\. /..1./'1I.,s, ...&' '(', . -. .. .,. ~ Lf) ~~ C) e \i ~ 0::: r- ~~ I U.Z ~ u lli~ l.~.1 C) :;; ~ Lf) -j '" 0 DANIEL p, WILSON and SHARON M. WILSON, Individually and as Parents and Natural Guardians of AMANDA WILSON A Minor, · IN THE COURT OF COMMON PLEAS .CUMBERLAND COUNTY, PENNSYLVANIA . · No.: q 5 -~508 . PlainlitTslPelitioners v. · CIVIL ACTION. LAW . . . DAVID J. GANTT, DefendantlRespoodent ORDER AND NOW, this 'L' - day of "':)~ . 199 ~il is hereby Ordered and Decreed lhat the Pelilion 10 SeIde lhe Claim of a Minor is approved. The A1ls1ate Insurance Company is direcled to make paymenl of Nine Thousand Five Hundred and 00/100 Dollars ($9,500.00) \0 the parenls. Daniel P. Wilson and Sharon M. Wilson, on behalf of Amanda Wilson, ,.their minor daughler. This sum shall be deposited on behalf of Amanda Wilson, a minor, as beneficiary, in an accounl previously opened with lhe Penosylvania Tuition Accounl Program. Accounl No. 0??oo27979. The Pelilioners are direcled to sign a Release in favor of David J. Ganu, David E. GanU and lhe Allstate Insurance Company. Upon payment oflhe seUlemenl sums, lhe Pelilioners are direcled 10 disconlinue lhe aclion filed in Cumberland Counly. BY THE COURT: 'A.~. 62m J. ""1':." ~ M ~~ In .. - !~ x <.>7 .J: C- O::>] ~ 3~ N ffi~ c::!-H <<'-' I.LJ r= c 62 -- u.. Ln => 0 a> <.> PRAECIPE TO DISCONTINUE Please mark the above-captioned lawsuit settled and discontinued. BY:~('\~~ ~ ")~ on M. Wilson Individually and as Parent and Natural Guardian of Amanda Wilson, A Minor DANIEL p, WILSON and SHARON M, WILSON, Individually and as Parents and Natural Guardians of AMANDA WILSON, A Minor, PlaintiirslPetitioners v. DAVID 1, GANTT, DefendanllRespondent By: , . Dated: 60661 · IN THE COURT OF COMMON PLEAS · CUMBERLAND COUNTY, PENNSYLVANIA . · No.: Q'5"'BoB . · CIVIL ACTION - LAW . . ~ D 'el . Wilson Indivi ally and as Parent and Natural Guardian of Amanda Wilson, A Minor ::-,j.:'Y'f'Yi: .. ...~;h~';, ~'l)'i ;:..'~,~,. ',' "'0'"'''' . .' '.' ,.....~ ~ ~ ! &f) .. l~ - u~ ::c a.. 9i ~ 0\ N c..:> ~Z \.1.1 rMI~ Q a ~ In 0\ '~: '..:'\:'>.JRi'i:.'.0::]H'.: ::'~.S~~::;;i~:~.t~~2j?(..?"::1?"~:'. <1'