After Hours go to Emergency Room of your choice: O’Connor Hospital (408) 947-2666,El Camino Hospital (650) 940-7055, Regional Medical Center (408) 259-5000, Washington Medical Center (510) 791-3430

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Milpitas315 S. Abbott Ave.Milpitas, CA 95035Ph: (408) 790-2900Fax: (408) 790-2912

www.allianceoccmed.com

Monday - Friday 7AM - 7PM

Work-Related Injuries & Physicals

Santa Clara2737 Walsh Ave.Santa Clara, CA 95051Ph: (408) 228-8400Fax: (408) 228-8401

San Jose1901 Monterey Rd., Ste 10San Jose, CA 95112Ph: (408)) 477-8080Fax: (408) 477-8081

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Alliance Occupational Medicine

Date 11/24/09 Alliance Occupational Medicine-ML Page 1315 South Abbott Avenue

Milpitas, CA 95035

(408) 790-2900, Fax: (408) 790-2912

Work Status Summary

Company: Altera Corp

101 Innovation Drive

San Jose, CA 95134

Attention: Vikki Norton

Telephone: (408) 544-6788

Fax: (408) 544-8303

vnorton@altera.comProvider: Azar, Dan R. MD MPH (Milpitas)

Visit Date: 11/24/09 Time In: 2:13PM Out: 3:01PM

Employee: Sarah Ellis707 Continental Cir #123

Mountain View, CA 94040

Department:

Ident: xxx-xx-9306 DOB: 5/31/68

Job Title: Staff Program Mgr

(408) 839-6068Phone:

Purpose: 1 First Medical Visit (WC)

Insurance Information

St Paul Travelers MN Contact: Jane Cunningham

P.O. Box 64907

St. Paul, MN 55164-0907 Fax: 877-288-2793

Ext:800-842-3073Telephone:

Presenting Problem

Date of Injury: 11/20/09 Case Number: 2009-00009 Claim Number:A5K6382

picking up box, extreme (8 out of 10) pain in lower left of spine back. Pain in lower back thru Friday,

Sat Pain shoots thru left quad. Mon, pain shots thru left quad and left leg felt heavy. Rx from my

primary- 800-600mg Ibuprofen x3 daily (started last night)

Diagnosis

847.2 Sprain / Strain Lumbar Spine (Lower Back)

Current Work Restrictions

Acute Injury / Illness Starting: 11/24/09 Continuing

Rehab Next Appt If Not Better Starting: 11/24/09 Continuing

Recordable Starting: 11/24/09 Continuing

Estimate 4-6 Weeks Until P&S Starting: 11/24/09 Continuing

Work Status

Work Status: Released for Full Duty As Of: 11/24/09

2 Medical ReCheck (WC) Braren, Maria NP (Milpitas)Follow-up Appointments: 12/01/09 at 8:30AM

SAMPLE WORK STATUS REPORT

SAMPLE WORK STATUS REPORT

St Paul l l l l l l l l l l l l l l l Tr

P.O. Boxoxoxoxoxoxoxoxoxox 6

St. Paululul, , , , , , , , MN

Date of Injury:

DOCTOR'S FIRST REPORT OF OCCUPATIONAL INJURY OR ILLNESSSTATE OF CALIFORNIA

Within 5 days of initial examination, for every occupational injury or illness, send two copies of this report to the employer's workers' compensation insuranc e carrier or the insured employer. Failure to

file a timely doctor's report may result in assessment of a civil penalty. In the case of diagnosed or suspected pesticide poisoning, send a copy of this repor t to the Division of Labor Statistics and Research,

P.O. Box 420603, San Francisco, CA 94142-0603, and notify your local health officer by telephone within 24 hours.

1. INSURER NAME AND ADDRESS

2. EMPLOYER NAME

3. Address No. and Street City Zip

4. Nature of business (e.g., food manufacturing, building construction, retailer of women's clothes)

5. PATIENT NAME (first name, middle initial, last name) 6. Sex 7. Date of

Birth

PLEASE DO NOT

USE THIS

COLUMN

8. Address: No. and Street City Zip 9. Telephone Number

10. Occupation (Specific Job Title) 11. Social Security Number

12. Injured at: No. and Street City County

13. Date and hour of injury

or onset of illness

14. Date last worked

15. Date and hour of first

examination or treatment

16. Have you (or your office) previously

treated patient?

Patient please complete this portion, if able to do so . Otherwise, doctor please complete immediately. Inability or failure of a patient to complete this portion shall not affect his/her right to worker's;

compensation under the California Labor Code.17. DESCRIBE HOW THE ACCIDENT OR EXPOSURE HAPPENED . (Give specific object, machinery or chemical. Use reverse side if more space is required.)

18. SUBJECTIVE COMPLAINTS (Describe fully. Use reverse side if more space is required.)

19. OBJECTIVE FINDINGS (Use reverse side if more space is required.)A. Physical Examination

B. X-ray and laboratory results (State if none or pending.)

20. DIAGNOSIS (If occupational illness, specify etiologic agent and duration of exposure) Chemical or toxic compounds involved?

21. Are your findings and diagnosis consistent with patient's account of injury or onset of illness?

22. Is there any other current condition that will impede or delay patient's recovery?

23. TREATMENT RENDERED (Use reverse side if more space is required.)

24. If further treatment required, specify treatment plan/estimated duration.

25. If hospitalized as inpatient, give hospital name and location.

26. WORK STATUS - Is patient able to perform usual

work?

Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation

for the purpose of obtaining or denying worker's compensation benefits or payments is guilty of a felony.

Form 5021 (Rev. 4)

1992

Doctor's name and degree (please type)

Address

IRS Number

Telephone Number

Mo. Day Yr.

Mo. Day Yr. Hour Mo. Day Yr.

Case No.

Industry

County

Mo. Day Yr. Hour

Occupation

Return Date/Code

ICD-9 Code:

If "no", please explain.

If "yes", please explain.

Specify restrictions:

Modified work

If "no", date when patient can return to:

Regular work

Hospitalization

Disease

Hazard

Age

Date admitted Estimated stay

2009-00009

St Paul Travelers MN P.O. Box 64907, St. Paul, MN 55164-0907

Altera Corp

101 Innovation Drive, San Jose, CA 95134

programmable chips

Sarah Ellis 05/31/1968

707 Continental Cir #123, Mountain View, CA 94040

000-00-9306

(408)839-6068

Female

Staff Program Mgr

101 Innovation Drive San Jose Santa Clara

07:00AM11/20/2009

02:13PM11/24/2009 No

picking up box, extreme (8 out of 10) pain in lower left of spine back. Pain in lower back thru Friday, Sat Pain shoots thru left quad. Mon, pain shots thru left quad

and left leg felt heavy. Rx from my primary- 800-600mg Ibuprofen x3 daily (started last night)

SEE ADDENDUM

SEE ADDENDUM

none

847.2No847.2 = Sprain / Strain Lumbar Spine (Lower Back)

Yes

No

SEE ADDENDUM

see 23

Yes

Rehab Next Appt If Not Better; Acute Injury / Illness; Recordable; Estimate 4-6 Weeks Until P&S11/24/2009

408-790-2900315 S. Abbott Ave., Milpitas, CA 95035

5164-0907St Paul Travelers MN P.O. Box 64907, St. Paul, MN 55164-09075164-0907

SAMPLE DOCTOR'S FIRST REPORT

Doctor's Signature CA License Number A51723Ramesh, Jaishri MD(Milpitas) 77-0572487

Page 1DOCTOR'S FIRST REPORT OF OCCUPATIONAL INJURY OR ILLNESS - ADDENDUM

11/24/200911/20/2009 Treatment: 2009-00009Sarah Ellis DOI:

18. Subjective Complaints:

ADDENDUM TO DOCTOR'S FIRST REPORT:

Translator: none

Current Meds: None relevant to injury.

Drug Allergies: NKDA

Denies history of Ulcer or NSAID-related gastritis / GI upset.

Denies being pregnant or breastfeeding.

Employee states while at work 4 days ago had the sudden onset of left sided low back pain radiating to left thigh after lifting

a box weighing approximately 50 lbs (containing 2 monitors). The EE went home to rest and applied heat. She returned

later that day for a meeting. Over the weekend her symptoms persisted but did not worsen. Yesterday she went to her

personal MD at PAMF and was advised to use Ibuprofen 800, apply ice and file a WC claim with her employer (which she

did this morning).

Currently the EE reports only slight low back pain; she has momentary intense radiating anterior thigh pain which is

somewhat electrical in nature, and less intense aching or heaviness of the thigh.

Denies lower leg pain or sensory changes, bowel or bladder changes, or saddle paresthesias.

PAST MEDICAL HISTORY / REVIEW OF SYSTEMS:

Except as described above, patient denies prior injury to back or back pain in past.

Except as described above denies pre-DOI symptoms, restrictions or limitations.

Except as described above denies recent medical or chiropractic treatment for current condition.

Except as described above denies hobbies, sports or nonindustrial activity as cause or contributor to injury.

19-A. Objective Findings:

BP: 120/82

THORACO-LUMBRO-SACRAL SPINE:

normal examination except decrease in ROM due to pain and minimal tenderness along left PSIS

Normal gait, no foot drop

Normal curvature and posture

No edema, no discoloration, no scar, no open wound

Range of motion @ thoraco-lumbar-sacral spine (estimated):

Flexion at the waist: 80/90

Thoracic Spine Rotation Right: 30/30

Thoracic Spine Rotation Left: 30/30

Lumbar Extension: 5/20

Lumbar Lateral Flexion Right: 30/30

Lumbar Lateral Flexion Left: 30/30

Parathoracic and paralumbar muscles nontender

Sciatic notches nontender

Lower extremities demonstrate full strength and sensation

No palpable spasm

Deep tendon reflexes intact bilaterally at knees and ankles

Midline thoraco-lumbar-sacral spine nontender

Seated straight leg raise bilaterally negative

Additional Assessment:

847.2 Sprain Lumbar Spine (Lower Back)

Page 2DOCTOR'S FIRST REPORT OF OCCUPATIONAL INJURY OR ILLNESS - ADDENDUM

11/24/200911/20/2009 Treatment: 2009-00009Sarah Ellis DOI:

23. Treatment Rendered / 24. Treatment Plan:

ADDENDUM TO DOCTOR'S FIRST REPORT:

35 minutes spent face to face with over 50% spent on patient counseling.

DISCUSSION/DIFFERENTIAL DIAGNOSES:

Acute strain of low back with referred pain - possible piriformis syndrome but not consistent with herniated disc or frank

lumbar radiculopathy.

Treat conservatively; patient declines my offer of physical therapy at this time; home exercise sheets reviewed with patient

and dispensed.

CAUSATION:

Mechanism of injury and physical examination are consistent with a work-related injury.

At this point, no issues of causation or apportionment identified.

PATIENT EDUCATION:

Diagnosis, treatment options and prognosis explained to employee.

Work recommendations reviewed and given self-care instructions.

Importance of compliance with restrictions and treatment emphasized.

Questions regarding treatment answered.

PATIENT CONSENTS TO THE FOLLOWING TREATMENT:

Dispense Ibuprofen 800mg 1 tablet 2-3/day with food or milk, #40; discontinue if GI upset or melena/hematochezia arise.

Dispense Cyclobenzaprine (Flexeril) 10mg 1-2 tab at bedtime if needed for spasm dispense #20; cautioned about sedation.

Continue ice/heat as needed for comfort.

If improved less then expected at next visit: start Physical Rehab.

If improved at next visit monitor until MMI, and D/C then or sooner if appropriate.

RECORDABLE, INDUSTRIAL INJURY

No Permanent Disability Expected

WORK STATUS:

Full duty

FOLLOW-UP:

Recheck 1 Week

Patient warned to follow up sooner (no appointment needed) if condition worsens or interferes with ability to work as

prescribed above.

As requested, designated employer representative contacted by telephone to coordinate medical and disability management.

I declare under penalty of perjury that this report is true and correct to the best of my knowledge and that I have not violated

Labor Code 139.3

Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be

subject to fines and confinement in state prison.

________________________________________________

Medical Director

Alliance Occupational Medicine

Jaishri Ramesh M.D. CA Lic # A51723

Dictated 11/24/2009 but not reviewed until signed / Transcribed byJR

315 S. Abbott Ave. Milpitas ♦ Ph: (408) 790-2900 ♦ Fax: (408) 790-2912

2737 Walsh Ave. Santa Clara ♦ Ph: (408) 228-8400 ♦ Fax: (408) 228-0456 315 S. Abbott Ave. Milpitas ♦ Ph: (408) 790-2900 ♦ Fax: (408) 790-2912

1901 Monterey Rd. Ste 10 San Jose, CA. 95112 ♦ Ph: (408) 477-8080 ♦ Fax: (408) 477-8081

Marlowe Magallanes MD License # A102136 has been treating injuries since

2008. Dr. Magallanes received his medical degree from the University of the

Philipines and is Board Certified in Internal Medicine. He completed his

postdoctoral training at Overlook Hospital in New Jersey, the primary academic

and clinical affiliate of Mount Sinai School of Medicine and The Mount Sinai

Hospital. Dr. Magallanes is also fluent in Tagalog and happily married with 3

sons. He is also NCRME certified for DOT physicals # 6968979761

Jaishri Ramesh MD License # A51723 has been working in occupational medicine

since 1995. She received her Medical degree from Bangalore Medical College. She

completed her internship in Internal Medicine at St Vincent Hospital in Portland

Oregon and residency in Internal Medicine at Kaiser in Santa Clara, CA. She

became board certified in Internal Medicine in 1994. Dr. Ramesh is fluent in

English, Kannada, Marathi, Hindi, and Tamil. Dr. Ramesh is also a Certified

Medical Review Officer and the lead physician in our Santa Clara facility. Dr.

Ramesh is also NCRME certified for DOT physicals # 6408767753.

Tom Zdimal, P.A. License #PA10590 has been practicing as a Physician’s

Assistant in Occupational Medicine in this area since the late nineteen eighties. Tom

graduated from the George Washington University Medical School Physician’s

Assistant program. Tom served as a Preventative Medicine Specialist in the United

States Air Force. Tom’s professionalism, knowledge, demeanor, and

communication skills make him invaluable in the occupational health arena. He is

also NCRME certified for DOT physicals # 7211965891.

.

Christine Nga Le, P.A. License #PA16365 has been practicing as a Physician’s

Assistant in Occupational Medicine in this area since 2005. Christine graduated

from Massachusetts College of Pharmacy and Allied Health Sciences Physician’s

Assistant program. She speaks English, Vietnamese and some Spanish. She is also

NCRME certified for DOT physicals # 5638677379

315 S. Abbott Ave. Milpitas ♦ Ph: (408) 790-2900 ♦ Fax: (408) 790-2912

2737 Walsh Ave. Santa Clara ♦ Ph: (408) 228-8400 ♦ Fax: (408) 228-0456 315 S. Abbott Ave. Milpitas ♦ Ph: (408) 790-2900 ♦ Fax: (408) 790-2912

1901 Monterey Rd. Ste 10 San Jose, CA. 95112 ♦ Ph: (408) 477-8080 ♦ Fax: (408) 477-8081

Edward Cooper, M.D. License #G32478 has worked in occupational

medicine and urgent care since 1976. Dr. Cooper graduated from Oklahoma

State University School of Medicine and completed his internship at

Washington Hospital Center in Washington D.C. He is also certified in

completing INS examinations and NCRME Certified for DOT Physicals #

4167314950

Maria Braren, N.P. License #12680 has been working in occupational

medicine since 2003. She graduated from San Jose State University with a

Masters of Science in Nursing. Maria completed her undergraduate training at

Southern Connecticut State University. Maria is Board certified as a Family

Nurse Practitioner. She is also NCRME Certified for DOT Physicals #

774036268

Sapna Sheth Rajput, D.O. License #20A9578 has been working in

occupational medicine since 2009. She received her Bachelors of Science in

Genetics from the University of California at Davis. She graduated from the

Chicago College of Osteopathic Medicine in May 2004. She completed her

residency in Family Medicine through the San Jose-O’Connor Hospital Family

Medicine Residency Program which is affiliated with Stanford University

School of Medicine. She is Board Certified in Family Practice. Dr. Sheth

Rajput is proficient in Intermediate Gujarati. She is also NCRME Certified for

DOT Physicals # 9535372382

315 S. Abbott Ave. Milpitas ♦ Ph: (408) 790-2900 ♦ Fax: (408) 790-2912

2737 Walsh Ave. Santa Clara ♦ Ph: (408) 228-8400 ♦ Fax: (408) 228-0456 315 S. Abbott Ave. Milpitas ♦ Ph: (408) 790-2900 ♦ Fax: (408) 790-2912

1901 Monterey Rd. Ste 10 San Jose, CA. 95112 ♦ Ph: (408) 477-8080 ♦ Fax: (408) 477-8081

Lynda Lee Kay M.D., License # A52407 has been practicing Occupational

Medicine since 2005. She graduated from the Institute of Medicine in Burma. Dr.

Kay completed a Family Practice Residency from the University of Louisville,

KY. Dr. Kay is a member of the Santa Clara County Medical Association and the

United States Burmese Medical Association. Dr. Kay speaks Burmese and

Chinese as well.

Henry Poon, MD License #687335 has worked in occupational medicine since

2004. He received his medical degree from Tufts University School of Medicine.

He earned his Masters Degree in Public Health and Masters in Business

Administration from the University of North Carolina at Chapel Hill. Dr. Poon

completed a residency in occupational medicine from Emory University where he

was chief resident. Dr. Poon is Board Certified in Occupational Medicine, a

Certified Medical Review Officer, and a Certified Medical Examiner on the

National Registry. Dr. Poon is fluent in English and Chinese.

Satish K. Sharma M.D., License # A45180 has been practicing Occupational

Medicine since 1988. He graduated from L.L. RM Medical College. He completed

his Residencies in Family Practice and Internal Medicine from Meharry/Hubbard

Medical College & Hospital in Nashville, TN. He completed his Residency in

Neurology and Fellow in Electrophysiology from the University of California at

Davis. He is Board Certified in Internal Medicine and Board Eligible in

Neurology. He is also a National Registry Certified Medical Examiner for driver

exams. He is fluent in English, Hindi and Punjabi.

315 S. Abbott Ave. Milpitas ♦ Ph: (408) 790-2900 ♦ Fax: (408) 790-2912

2737 Walsh Ave. Santa Clara ♦ Ph: (408) 228-8400 ♦ Fax: (408) 228-0456 315 S. Abbott Ave. Milpitas ♦ Ph: (408) 790-2900 ♦ Fax: (408) 790-2912

1901 Monterey Rd. Ste 10 San Jose, CA. 95112 ♦ Ph: (408) 477-8080 ♦ Fax: (408) 477-8081

James Petros, M.D. License #A90732 is dual board-certified in Physical Medicine

& Rehabilitation (Physiatry) and Internal Medicine. Dr. Petros specializes in pain

management. He provides consultation and multi-faceted care to patients whose

pain does not respond to conservative measures. He performs EMGs and

interventional procedures, such as epidurals. Dr. Petros completed his B.S. in

Biology at Santa Clara University, graduating magna cum laude. He then attended

Tulane Medical School, obtaining his M.D. with high honors. Dr. Petros completed

his Internal Medicine residency at CPMC/UCSF and his Physiatry residency at

Stanford. He was voted as one of America's Top Physicians by the Consumer

Research Council in 2009. Dr. Petros is fluent in Aramaic, Farsi, and French. He is

a Qualified Medical Evaluator for the State of California.

Samir Sharma, M.D. License #A72062 is a general orthopedist with an emphasis

on knee, shoulder and hand surgery. Dr. Sharma completed his medical training

and Residency in Orthopedics at Wayne State University. Dr. Sharma also

completed a sports medicine fellowship in Lake Tahoe performing over 400

operative cases. Diplomate American Board of Orthopaedic Surgery, Fellow

American Academy of Orthopaedic Surgeons, Fellowship trained Sports Medicine,

and State of California Qualified Medical Evaluator.

Prasad G. Kilaru, M.D. License #A60104 is a plastic and reconstructive hand

surgeon, who is Board Certified in Plastic Surgery. Dr. Kilaru completed his Surgical

Residency at Baystate Medical Center and his Plastic Surgery Residency at USC/LA

County. He completed a Hand/Microsurgery Fellowship at USC Medical Center. He

completed his MBA program for Executives through the Wharton School of

Business. Dr. Kilaru has been treating traumatic and repetitive industrial injuries of

the hand since 2001. Dr. Kilaru also has expertise in wound care, scar management,

burn treatments and other aspects of plastic and reconstructive surgery in addition to

hand surgery.

315 S. Abbott Ave. Milpitas ♦ Ph: (408) 790-2900 ♦ Fax: (408) 790-2912

2737 Walsh Ave. Santa Clara ♦ Ph: (408) 228-8400 ♦ Fax: (408) 228-0456 315 S. Abbott Ave. Milpitas ♦ Ph: (408) 790-2900 ♦ Fax: (408) 790-2912

1901 Monterey Rd. Ste 10 San Jose, CA. 95112 ♦ Ph: (408) 477-8080 ♦ Fax: (408) 477-8081

Bruno Kovacic - BioFunction® LLC Mr. Kovacic is the founder and managing

member of BioFunction® LLC, a forensic disability consulting company, which

is working in cooperation with Alliance Occupational Medicine to provider work

capacity examinations and functional restoration. Bruno brings more than 25

years of progressive healthcare & occupational medicine experience including:

conducting sophisticated Evidentiary Forensic Disability Examinations for more

than 400 claimants in private, public and government sectors, designing

advanced intra-data validation, behavioral & discomfort factoring software used

to quantify chronic pain, providing written med-legal opinions for ergonomic,

personal injury and workers’ compensation claims in California, the Division of

Workers’ Compensation Appeals Board, the State of Hawaii’s Disability

Compensation Division, and Canada’s ICBC, creating and designing a web-

based medical restriction / job task matching software application to safely

match limited duty employees to modified tasks in the work environment for the

U.S. largest employer, and developing the industries first ergonomic risk sorting

algorithm to quantify frequency, duration and severity of early symptom patterns

associated with cumulative trauma / repetitive motion injuries. Mr, Kovacic is a

peer reviewed published researcher in Evidence-Based Functional Restoration.

Mr. Kovacic also holds credentials as a medically trained Certified Ergonomic

Compliance Director and is one of two Certified ERGOS® Trainers in the U.S.

Jeffrey T. Holmes MD License #G48778 is an Orthopedic Surgeon and has

experience in occupational medicine for more than twenty years. Dr. Holmes

completed his undergraduate and graduate studies at Stanford. He completed

Preclinical studies at the Royal College of Surgeons in Ireland. He is a graduate from

Harvard University Medical School. He completed his Internship and Residency in

Orthopedic Surgery at Stanford University. Dr. Holmes has specialty expertise in

shoulder, knee, and hip issues. He treats a wide variety of industrial and sports

injuries. Dr. Holmes is a State of California Qualified Medical Evaluator as well.

315 S. Abbott Ave. Milpitas ♦ Ph: (408) 790-2900 ♦ Fax: (408) 790-2912

2737 Walsh Ave. Santa Clara ♦ Ph: (408) 228-8400 ♦ Fax: (408) 228-0456 315 S. Abbott Ave. Milpitas ♦ Ph: (408) 790-2900 ♦ Fax: (408) 790-2912

1901 Monterey Rd. Ste 10 San Jose, CA. 95112 ♦ Ph: (408) 477-8080 ♦ Fax: (408) 477-8081

Physical Therapists, Hand Therapists & Physical Therapy Assistants:

Vicki Jaw, D.P.T., License # has been working in physical therapy since

2012. Vicki received her BS degree at the University of Michigan, with

an emphasis in Movement Science and Kinesiology. She received her

Doctor of Physical Therapy degree from the University of Colorado and

has received her clinical training in the areas of Orthopedics, Sports

Medicine and Pediatrics.

Elmma Pena, D.P.T., License # PT39084 has been working in physical

therapy since 2012. Elmma received her BS degree in Kinesiology at Cal

State University in Hayward. She received her Doctor of Physical Therapy

degree from the University of St. Augustine in San Marcos and has

received her clinical training in the areas of Orthopedics and out patient

therapy. She is fluent in Spanish as well.

Lucy Austin PTA License #AT1228 has worked as a physical therapy

assistant in occupational medicine since 1994. Lucy received her Physical

Therapy Assistant degree from DeAnza College. Lucy has received

additional training in kinesiotaping, pilates for rehab, and edema differential

diagnosis and treatment. She is also certified ergonomics assessment

specialist.

315 S. Abbott Ave. Milpitas ♦ Ph: (408) 790-2900 ♦ Fax: (408) 790-2912

2737 Walsh Ave. Santa Clara ♦ Ph: (408) 228-8400 ♦ Fax: (408) 228-0456 315 S. Abbott Ave. Milpitas ♦ Ph: (408) 790-2900 ♦ Fax: (408) 790-2912

1901 Monterey Rd. Ste 10 San Jose, CA. 95112 ♦ Ph: (408) 477-8080 ♦ Fax: (408) 477-8081

Chiropractors (cont.)

James Grubinskas DC License #DC25571 has worked in occupational

medicine since the late nineties. He received his Doctor of Chiropractic

Degree from the Palmer College of Chiropractic in San Jose. Dr.

Grubinskas focuses on home exercise programs and works under the

direction of our primary treating providers to expedite recovery from work

related injuries. Dr. Grubinskas is also a Certified Ergonomics Assessment

Specialist

Richard Chau DC, QME License #DC21183 has worked in occupational

medicine since 1991. Richard attended the University of Miami

studying Biology. He received his doctor of chiropractic degree from Life

West Chiropractic College in Hayward. Richard is a Certified Ergonomics

Assessment Specialist and a Qualified Medical Evaluator. Richard

is trilingual, fluent in Spanish and Cantonese Chinese.

Miral Patel License #PT41286 has worked in occupational medicine since

2013 and has been working in physical therapy since 2009. Miral received

her Bachelor of Physiotherapy at SNDT University in Mumbai, India. Miral

received additional training in orthopedic and neurological treatment during

her clinical rotations. She’s taken courses in Sports Medicine, Soft Tissue

Mobilization, Essential Taping Techniques, and Low Backache Syndrome.

Miral is fluent in English, Hindi, and Gujarati.

First Aid/Non-Recordable

FIRST AID VS MEDICAL TREATMENT

Employers may elect to pay directly for claims that are deemed “first-aid” or “non-recordable. We follow the CAL-OSHA recommendations per Standard 1904.7 effective January 1, 2002 for designation of “first aid” or “non-recordable” as outlined below.

• Use of nonprescription medication at nonprescription strength • Administration of tetanus vaccine • Cleaning, flushing or soaking wounds on the surface of the skin • Using wound coverings such as bandage (s), Band-Aids or gauze pads,

or using butterfly bandages or Steri-Strips • Using hot or cold therapy • Using any non-rigid means of support (such as elastic bandages, wraps,

non-rigid back belts) • Using temporary immobilization devices while transporting an

accident victim • Drilling of a fingernail or toenail to relieve pressure, or draining fluid

from a blister • Using eye patches • Removal of foreign body from the eye using only irrigation or cotton

swab • Removal splinter or foreign material from areas other than eye by

irrigation, tweezers, cotton swabs or other simple means • Using massage • Using finger guards • Drinking fluids for relief of heat stress • Negative x-ray diagnosis (use of diagnostic procedures such as x-rays

or blood tests for diagnostic purposes only)

Medical Treatment/Recordable • Use of prescription medication or non-prescription medication in prescription strength • Restriction of work or motion beyond the day of the injury • Injury requiring transfer to another job • Injury causing days away from work • Administration of other (non-tetanus) vaccines such as Hepatitis B vaccine or rabies vaccine • Use of wound closing devices such as sutures (stitches) or staples • Using devices with rigid stays or other systems designed to immobilize parts of the body • Physical therapy or chiropractic treatment • Loss of consciousness • Significant injury or illness diagnosed by a licensed health care professional such as: cancer, chronic irreversible

disease, fractured or cracked bone, punctured eardrum, or progressive disease. • Positive x-ray diagnosis • Hearing loss of more than 10 decibels • Death

2737 Walsh Ave. Santa Clara, CA. 95051 | phone 408.228.8400 | fax 408.228.0456 315 S. Abbott Ave. Milpitas, CA. 95035 | phone 408.790.2900 | fax 408.790.2912

DMV TIPS FOR COMMERCIAL DRIVERS REGULATIONS REGARDING CERTAIN MEDICAL

CONDITIONS MAY AFFECT YOUR LICENSE ONLY NATIONAL REGISTRY CERTIFIED

MEDICAL EXAMINERS CAN ASSESS YOUR MEDICAL CAPACITY TO DRIVE AS OF 5/21/14

1 High Blood Pressure (Hypertension): Qualified for 1

year if you are currently on medication or had been treated in the past. BP needs to be below 139/89 on the exam date to be qualified.

2 Diabetes: Qualified for 1 year. You might need a clearance letter from your doctor to confirm that your blood sugar level is well controlled with no complication or hypoglycemic episodes. INSULIN treatment is an automatic disqualification for commercial drivers. You may be disqualified if your blood sugar is not well controlled.

3 Obesity: At risk for obstructive sleep apnea (OSA) if you have the following conditions: BMI 35 and above, neck size >17 cm (male) / >15.5 cm (female), small airway, Hypertension, Diabetes, Hypothyroidism, age 42 and above, experienced a single-vehicle crash...etc. You will need to do a sleep study.

4 Obstructive Sleep Apnea: Qualified for 1 year. You need to show proof that you use your CPAP machine regularly. Have your doctor print out usage data from your CPAP machine. To be qualified your compliance data must show at least 4 hours per day of use on 70% of days.

5 Asthma/ Lung Disease/Smokers over the age 35: requires a spirometry to measure lungs function.

6 Heart Disease: Qualified for 1 year. You may need a clearance note from your cardiologist stating your current heart condition/function, applicable test reports, and your ability to operate CMV.

7. Heart Surgery: Depending on the type of surgery you may be temporarily disqualified for a short period before you can be qualified to drive again. You will need a clearance letter from your cardiologist stating your heart condition/ function, and your ability to safely operate CMV.

8 Stroke: Disqualified at least 1 year. Need clearance from neurologist.

9 Hearing Impairment: You may need hearing aid if you do not meet DOT requirement. You must have no more than 40 decibels hearing loss on the better ear. You will be temporarily disqualified for further testing by your ear specialist (audiologist).

10 Vision Impairment: You may need glasses if you do not meet DOT requirement for both eyes. Your vision should be less than or equal to 20/40 in each eye. If you do not meet requirement, you will be temporarily disqualified until corrective lens provided.

11 Work Restriction: for any medical conditions will be disqualified as DOT requires drivers to have a full physical and mental capacity to be a commercial driver and be able to do strenuous work.

12 Mental Disorder: You may need clearance from your psychiatrist to comment on your current mental condition and whether it affect your judgment, attention, concentration, and ability to operate safe CMV.

13 Dementia: Disqualified 14 Dizziness and Vertigo: You may be

disqualified for a short period and requires a clearance from your doctor stating that you are symptom free for at least 2 months.

Santa Clara Clinic 2737 Walsh Ave. Santa Clara, CA. 95051 Phone: (408) 228-8400 Fax: (408) 228-8401

Milpitas Clinic 315 S. Abbott Ave. Milpitas, CA. 95035 Phone: (408) 790-2900 Fax: (408) 790-2912

San Jose Clinic 1901 Monterey Rd. Ste 10 San Jose, CA. 95112 Phone: (408) 477-8080 Fax (408) 477-8081

Information Technology Solu-

For More Information: (408) 332-5410 tfiack@allianceoccmed.com

Humans come in many shapes and sizes, as do respirators. This results in a wide variability of physical dimensions and features of both people and respirators. The ability of a respi-rator to form a satisfactory seal or barrier be-tween the wearer and the contaminated envi-ronment may be significantly affected by these variables. If the respirator-user math “fit” is not checked, an unsatisfactory seal may unknow-ingly exist. This could allow excessive leak-age of airborne contaminants into the wearer’s breathing zone, even though user is wearing a respirator correctly selected for the application. A fit test is used to assess whether a specific type, model, and size of respirator can ade-quately fit a specific individual.

There are two basic types of fit tests: 1. qualitative (QLFT) and 2. quantitative (QNFT). The qualita-tive test is a pass/fail test relying on the subject’s voluntary or involuntary response to a challenge agent:; i.e. smell or irritation. The Alliance staff encourages the use of the more sophisticated quantitative fit test. The quantitative fit test is an objective test that measures the particulates in the surrounding air vs. what a person is breathing in through the respirator. The instrumentation is typically capable of measuring fit factors of 10,000 or higher. Our staff will perform a quantitative fit test of the individual workers and their personal respirator. We can perform this testing at our con-venient Santa Clara Clinic or at your site. This service is combined with the Pulmonary Func-tion Test and Physical/Medical Review.

Fi t Test A l l Masks Inc lud ing: • Half Mask APR • Ful l Mask APR • PAPR • SCBA • N95

Serving the Following Indus-tries: • Aerospace & Defense • Agriculture • Automotive • Biotechnology • Chemicals • Construction • Electric Power • Emergency Responders • Energy • Firefighters • Health Care • Law Enforcement • Manufacturing • Mining & Drilling • Nuclear Power • Oil & Gas • Pharmaceuticals • Transportation & Logistics

Alliance Now Offers Quantitative Fit Testing with the State of the Art PortaCount Plus

E RGO N OM I CS P R OG R A M M A N -AG E ME N T We will help you build a sustainable ergonomics process that is supported by the infrastructure and values of your organization, along with developing an action plan that will accelerate your success. E RGO N OM I CS T R AI N I NG From basic ergonomics awareness training to engineering workshops, our hands-on approach ensures each class is custom matched to your needs W O R KP L A CE AS S ES S ME N TS From mini individual workstation as-sessments to full ergonomic evaluations our qualified staff will identify issues and offer specific solutions with an empha-sis on individual responsibility, behav-iors, postures, and techniques.

Why is Ergonomics important for your bottom line? The lack of Ergonomics in the workplace leads to these costs: • How much you spend on your employees long term health and

safety. • How much you spend on boosting employees’ and company mo-

rale. • Turnover • Absenteeism • Productivity • Product quality (how much do mistakes cost?) • Compensation Claims

W W W.AL L IANC EOCCM ED .COM 2737 Walsh Ave. Santa Clara, CA. 95051 Ph: (408) 228-8400 Fax: (408) 228-0456

315 S. Abbott Ave. Milpitas, CA. 95035 Ph: (408) 790-2900 Fax: (408) 790-2912

S E R V I C E S A V A I L A B L E

Effective ergonomics programs assure high productivity, avoidance of illness and injury risks, and increase satisfaction among your workforce. Our certified ergonomists combine practical industry experience with the skills of professional services delivery. We are experts in workplace im-provement. Big project or small, we bring tangible benefits to you and your company at every step. Whether you need to deploy a global ergo-nomics initiative or a single risk assessment, we partner with you to achieve your goals. We listen well, work hard, and evaluate ourselves based upon your success.

Ergonomics is the science of fitting workplace conditions and job demands to the capabilities of the working population.

Complete this form to set up an account at NO CHARGE and no obligations!!

315 South Abbott Avenue, Milpitas CA 95035Telephone: 408-790-2900 Fax: 408-790-29122737 Walsh Avenue Santa Clara CA 95051Telephone: 408-228-8400 Fax: 408-228-8401http://www.allianceoccmed.com

New

Update

Company Name

Date

Address City State Zip

Contact Person

Direct Telephone # Fax

Business SIC CODEE-Mail Address

Would your company like to be billed directly for first aid injuries orshould all bills be sent to your workers’ compensation carrier? Bill company for first aid Bill carrier

WORKERS’ COMPENSATION INSURANCE CARRIER INFORMATION

NoYes Evaluate case by case

Yes NoNoYes

Yes NoSelf Insured? WC Insurance Carrier (not broker)

Claims Address:

Policy # Effective Date To

FaxPhone

EMPLOYER INJURY CARE INSTRUCTIONSDoes your company require a post-injury drug test?

PRIMARY:

ALTERNATE:

FaxDirect #

Does your company accommodate Modified Work restrictions?

FIRST REPORT - Who should we call, e-mail or fax work statuses and fax first reports to? Same as above OR

Email

Direct #

Please note if an employee is exposed to a chemical at your site we request a copy of the applicable Material Safety Date Sheet to accompany thepatient or to be faxed to the clinic.

B. EMPLOYER INJURY CARE INSTRUCTIONS (skip to section C if not needed)What type of physical examinations do you require? Post-offer DMV Respirator

Fitness for DutyAudiogram TravelBack Evals Chem Surv Other

Hep B

PRIMARY:

ALTERNATE:

Fax

Direct #

Who should we call, fax or e-mail physical examination results to? Same as above OR

Email

Direct #

Please continue on next page! Page 1

A. CLIENT INFORMATION

Industry # of local empoyees

Carrier contact (if applicable)? Phone

Email Fax PhonePreferred communication method: (our providers always call after 1st visit)

Other Instructions

other addressMAIL TO: ORSame as above

SUBSTANCE ABUSE PROGRAM (skip to section C if not needed)Do you have a drug and/or alcohol testing program?Who is the contact for you drug and/or alcohol testing program?

Do you need

If you need non-DOT, do you need aWill you use our testing laboratory & Medical Review Officer?

If using own lab, will

We look forward to working with you. Is there anyother information we ought to know about yourcompany or comments that you would like to make tohelp us to serve you and your employees better?

AGREEMENT:Fees for physical exams and medical treatment are due and payable 30 days from the date of billing. Amounts due formedical treatment not paid within sixty (60) days of receipt of billing will be subject to a late payment charge of 10% andbear interest at the annual rate of 7% from the date of receipt in accordance with Section 4603.2 of the California LaborCode. Amounts due for physical exams not paid within thirty (30) days of billing will be subject to a late paymentcharge of 1% per month from the date of billing.

Client signature: Date:

Please fax completed form to (408) 228-8401 or mail to Alliance Occupational Medicine @ 2737 Walsh Ave Santa Clara,CA 95051 or e-mail to info@allianceoccmed.com

If you have questions, please call Rena Flovin at (408) 228-0455

Page 2

NoYes

keep COC's at clinic?employees bring COC's (chain of custodies) or will we

Yes NoNoYes

Same as above OR

Email

PRIMARY:

ALTERNATE:

Fax

Direct #

Direct #

other drug test?5-Panel Instant Drug Test orDOT (Dept of Transportation) or Non-DOT drug tests?

Laboratory Name (if use own lab)

Laboratory Account #

FaxPhone

Address

MRO Name (if using own MRO)

C. How did you hear about us? insurance another employer internet search

walk-in

AOM representative

insurance broker other

BILLING INSTRUCTIONS - who should receive bills and at what address for non wc bills?Same as primary contact and primary employer address for wc injuries OR not applicable OR as following

First Aid Bills go to: Name:

Address

Address

Physical billis go to: Name:

Address

Drug screen go to: Name:

injury prevention programs ergonomic eval

physicals flu shots

work capacity eval drug & alcohol screening

vision/hearing tests travel vaccinations

respirator

quarterly seminars

hepatitis BAre you interested in learning more about our services? (which ones)