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U n e m p l o y m e n t I n s u r a n c e B e n e f i t D e t e r m i n a t i o n Georgia Department of Labor

148 Andrew Young International Blvd. NE Atlanta, Georgia 3 0 3 0 3 - 1 7 5 1 ,

DARNETT A M NICHOL S 1030 REUION PLAC E ATLANT A GA 30331

***-**-672 4

Weekly Benefit Amount $322 Date iVIaileci 08/27/10 Potential Number of Weeks 17 Appeal Rights Expire 09/13/10 Maximum Benefit Amount $5474

Your claim year begins on 08-26-10 and ends on 08-25-11. Your claim is based on wages paid from 04-01-09 to 03-31-10. Examine the wages carefully to be sure that they are reported correctly.

Unless a written appeal is filed, this determination becomes final 15 days after the date it is mailed to you. (If the 15th day falls on a Saturday, Sunday or state holiday, the next work day will be considered the 15th day for purposes of filin g an appeal.) An appeal may be filed in person or mailed to the career center where the claim was filed.

E m p l o y er A P R - J UN 09 J U L - S EP 09 O C T - D EC 09 J A N - M A R 10 To tal

FULTON COUNTY GOVERNME $ 6 2 5 6 . 62 $ 2 6 9 2 . 52 $ 7 2 9 9 . 39 $ 6 2 5 6 . 62 $ 2 2 5 0 5 . 15

$ 6 2 5 6 . 62 $ 2 6 9 2 . 52 $ 7 2 9 9 . 39 $ 6 2 5 6 . 62 $ 2 2 5 0 5 . 15

See back of this form for explanation of this monetary wage determination and other factors that affect your eligibilit y for benefits.

Your loca l Georgi a Departmen t of Labo r Career Center has resource s availabl e at no charg e to assis t in you r employmen t search , includin g compute r access , workshops , career guidance , trainin g options , and othe r relate d supportiv e services . D O L - 4 1 ih ( r -11 /07)

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C W B .

***_**_g'72 4

08/26/10

08/22/10

GEORGIA DEPARTMEN T OF JLABOR CLAIMS EXAMINER'S DETERMINATION

CAREER CENTER 3500 ^ SOUTH METRO 2636-14 ML K JR. DRIV E ATLANTA , GEORGIA 30311 FAX # (404) 505-4898

D O L - 4 4 2 B U R - 0 8 / 0 9 ) NM2006

7000

CLAIMANT EMPLOYER

DARNETT A M NICHOL S FULTO N COUNTY GOVERNMENT 1030 REUION PLACE C/O JON-JAY ASSOCIATES, INC . ATLANT A GA 303 31 P . O. BOX 6170

PEABODY MA 01961

_ ' - ^^^^ ^ DETERMINATIO N Benefits are aTTowed as of 0 8 / 2 2 / 1 0.

Section 3 4 - 8 - 1 9 (2) (A) of the Employment Security Law says that you cannot be paid unemployment benefits if you were f i re d from your most recent employer for not fol*|pwin g your employer's rules or orders. In addition, you may not be paid unemployment benefits if you were f i re d for fa i l in g to perform the duties for which you were hired, i f that fa i lur e was withi n your control . You also cannot be paid benefits i f you were suspended for any of these same reasons. The law says that your employer has to show that discharge or suspension was for a reason that would not allow you to be paid unemployment benefits. If you cannot be paid unemployment benefits under thi s section of the law, you may quali f y at a later time. To do this, you must f in d other work and earn wages covered under unemployment law. The covered wages must be at least ten times the weekly amount of your claim. If you then become unemployed through benef i ts.

no faul t of your own, you may reapply for unemployment

You were l et go by your employer because ther e ar e unemployed b e n e f i t s.

due to a l a ck of work , You can was no work to do. You be p a id unemployment

NOTICE t(D EMPLOYER:

NOTE: This determination will become final unless you fil e an appeal on or before 0 9 / 2 9 / 1 0. if you fil e an appeal you must continue to report on your claim as instructed, or you will not be paid if you win your appeal. Refer to the Claimant Handbook booklet or contact an office of the Georgia Department of Labor for more details.

Georgia Department of Labor Claims Examiner

0 9 / 1 3 / 10

Date of Interview

0 9 / H / 1 0

Mail Date

G E O R G I A D E P A R T M E N T OF L A B O R - A P P E A L S T R I B U N A L S u i t e 2 0 1 , 1 6 3 0 P h o e n i x B l v d . , C o l l e g e P a r k , GA 3 0 3 4 9 - 5 5 0 6

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D A R N E T T A M N I C H O L S

E m p l o y e r F U L T O N C O U N T Y G O V E R N M E N T

D A R N E T T A M N I C H O L S 1 0 3 0 R E U N I O N P L A C E A T L A N T A GA 3 0 3 3 1

A P P E A R A N C E S : T h i s w a s a t e l e p h o n e h e a r i n g i n w h i c h t h e c l a i m a n t , V i n c e n t H a r r i s , h e a r i n g r e p r e s e n t a t i v e f o r t h e e m p l o y e r , a n d A n n H a i m e s , r e g i o n a l d i r e c t o r o f l i b r a r y s e r v i c e s f o r t h e e m p l o y e r , p a r t i c i p a t e d .

O . C . G . A . P R O V I S I O N S AND I S S U E S I N V O L V E D : OCGA S e c t i o n 3 4 - 8 - 1 9 5 C a ) C 3 ) C A ) C i ) - W h e t h e r t h e c l a i m a n t r e q u e s t e d a n d w a s o n a l e a v e o f a b s e n c e .

O C G A S e c t i o n 3 4 - 8 - 1 5 7 C b ) - W h e t h e r t h e e m p l o y e r s u p p l i e d w r i t t e n s e p a r a t i o n i n f o r m a t i o n t o t h e D e p a r t m e n t o f L a b o r i n a t i m e l y m a n n e r .

F I N D I N G S OF F A C T : T h e c l a i m a n t w o r k e d f o r t h e n a m e d e m p l o y e r f r o m J u n e 1 9 9 6 t o M a r c h 3 0 , 2 0 1 0 , a s a l i b r a r y a s s i s t a n t s e n i o r . T h e c l a i m a n t w a s n o t s e p a r a t e d f r o m e m p l o y m e n t a s o f M a r c h 3 0 , 2 0 1 0 . R a t h e r , t h e c l a i m a n t w a s u n d e r a d o c t o r ' s c a r e a n d w a s u n a b l e t o p e r f o r m h e r j o b d u t i e s . T h e c l a i m a n t w a s o n a p p r o v e d l e a v e f o r a m e d i c a l i s s u e . T h e c l a i m a n t ' s a p p r o v e d l e a v e e n d e d o n J u n e 1 , 2 0 1 0 . T h e c l a i m a n t t h e n w a s o n u n a p p r o v e d l e a v e w i t h o u t p a y b e c a u s e t h e c l a i m a n t h a d n o t r e q u e s t e d a n e x t e n s i o n o f h e r l e a v e a n d h a d n o t s o u g h t a n a c c o m m o d a t i o n t o b e a b l e t o r e t u r n t o w o r k w i t h h e r r e s t r i c t i o n s . T h e e m p l o y e r r e c e i v e d a d o c t o r ' s n o t e f r o m t h e c l a i m a n t ' s d o c t o r s t a t i n g t h e n e e d f o r a r e a s o n a b l e a c c o m m o d s t i o n . T h e c l a i m a n t w a s g i v e n r e f e r r a l i n f o r m a t i o n t o t h e e m p l o y e r ' s r e a s o n a b l e a c c o m m o d a t i o n s p e c i a l i s t a n d t h e a p p r o p r i a t e f o r m s t o be f i l l e d o u t .

T h o s e f o r m s w e r e n o t c o m p l e t e d a n d r e t u r n e d t o t h e e m p l o y e r . T h e c l a i m a n t f i l e d h e r c l a i m f o r u n e m p l o y m e n t b e n e f i t s o n A u g u s t 2 6 , 2 0 1 0 . T h e c l a i m a n t w a s s t i l l o n u n a p p r o v e d l e a v e a t t h a t t i m e a n d h a d n o t c o m p l e t e d t h e n e c e s s a r y s t e p s t o h a v e h e r l e a v e e x t e n d e d o r t o b e g r a n t e d a r e a s o n a b l e a c c o m m o d a t i o n .

T h e e m p l o y e r r e s p o n d e d t o t h e n o t i c e o f c l a i m f i l i n g b y f a x b e f o r e t h e d e a d l i n e g i v e n . T h e r e f o r e , t h e e m p l o y e r t i m e l y s u b m i t t e d w r i t t e n s e p a r a t i o n i n f o r m a t i o n t o t h e D e p a r t m e n t o f L a b o r .

See r e v e r s e s i d e

GEORGIA DOL OFFIC E 4

2636-1 4 MARTI N LUTHER KIN G JR . DRIV E

ATLANTA G A 30311-103 5

FAX: (404)505-489 8

Re: DARNETTA NICHOL S Account : 120068-0 2

SS: 260-39-672 4 Employer : FULTON COUNTY GEORGIA

Dear S t a t e R e p r e s e n t a t i v e :

T h i s i s i n r e f e r e n c e t o f o r m DOL-442B2 , C l a i m s Examiner ' s D e t e r m i n a t i o n , d a t e d Septembe r 14 ,

201 0 which , a l l o w s b e n e f i t s t o t h e abov e i n d i v i d u a l . We w i s h t o a p p e a l t h e d e t e r m i n a t i o n base d

on t h e f o l l o w i n g .

The c l a i m a n t i s c u r r e n t l y o n a n app rove d l e a v e o f absence . We w i s h t o q u e s t i o n t h e i r

e l i g i b i l i t y base d o n t h e i r u n a v a i l a b i l i t y f o r work .

Be a d v i s e d , TAL X U C eXpres s i s a d u l y a u t h o r i z e d agen t empowere d t o a c t o n b e h a l f o f t h e abov e

emp loye r . An y co r respondenc e r e l a t e d t o t h i s i n d i v i d u a l s h o u l d b e m a i l e d t o : P.O . Bo x 283 , S t .

L o u i s , MO 63166-0283 .

F o r a d d i t i o n a l i n f o r m a t i o n , p l e a s e c o n t a c t me a t (978 ) 326-622 5 o r yo u ca n r e a c h me v i a e m a i l

a t lmurphy@talx .co m o r f a x (800 ) 844-5167 .

Than k yo u f o r you r t im e an d c o n s i d e r a t i o n .

S i n c e r e l y ,

L i n d a Murph y

UI C

P, PM, MS

Septembe r 03 , 201 0

GEORGIA DOL OFFIC E PRCT

148 ANDREW rOONG INTERNATIONAL BLVD . N E

P.O. BOX 74005 2

ATLANTA GA 30374-005 2

FAX: (404)656-248 2

Re: DARNETTA NICHOL S Accoun t : 120 0 68-0 2

SS: 260-39-672 4 Employer : FULTON COUNTY GEORGIA

F a c t F i n d i n g Date ; 9/7/201 0

Dear S t a t e R e p r e s e n t a t i v e ;

T h i s i s i n respons e t o f o r m DOL-1199FF , N o t i c e o f C l a i m F i l i n g an d Reques t f o r S e p a r a t i o n

I n f o r m a t i o n , d a t e d Augus t 27 , 201 0 w i t h a n e f f e c t i v e da t e o f Augus t 27 , 2010 . I n v ie w o f t h e

f o l l o w i n g , we r e q u e s t r e l i e f o f b e n e f i t cha rge s and/o r a d e t e r m i n a t i o n o n t h e c l a i m a n t ' s

e l i g i b i l i t y .

F i r s t Day : No t A v a i l a b l e L a s t Day : 03/30/201 0

The c l a i m a n t i s c u r r e n t l y o n a n a p p r o v e d l e a v e o f absence . We w i s h t o q u e s t i o n t h e i r

e l i g i b i l i t y b a s e d o n t h e i r u n a v a i l a b i l i t y f o r work .

Work i s a v a i l a b l e , t h e y a r e w a i t i n g f o r documen ta t i on . Se e a t t a c h e d

Be a d v i s e d , TAL X U C aXpres s i s a d u l y a u t h o r i z e d agen t empowere d t o a c t o n b e h a l f o f t h e abov e

e r t p l o y e r . Th e d e t e r m i n a t i o n , o r an y r e l a t e d c o r r e s p o n d e n c e , s h o u l d b e m a i l e d t o : P.O . Bo x 283 ,

S t . L o u i s , MO 63166-0283 .

F o r a d d i t i o n a l i n f o r m a t i o n , p l e a s e c o n t a c t ou r S t a t e Agenc y Respons e Cen te r a t (800 ) 829-151 0

o r me a t (978 ) 326-622 5 o r yo u ca n r e a c h me v i a e m a i l a t lmurphy@talx.co m o r f a x (800 ) 844 -

5167 .

S i n c e r e l y ,

L i n d a Murph y

UIC

ATTACHMENT

I, PM, NCV

K a i s e r P e r m a n e n t e

C A S C A D E I N T E R N A L M E D I C I N E 1175 C a s c a d e Pkwy. A t l an ta G A 30311

Encoun te r Date : 6/23/2010

Pat ient : Darnet ta Nichols Hea l th R e c o r d Number : 0436325

V E R I F I C A T I O N O F T R E A T M E N T

Darnet ta M Nicho ls w a s seen at our medica l off ices on 06/23/2010.

S p e c i a l instructions: No bending, no stooping, no lifting of more than 10 pounds for an addi t ional 2 w e e k s .

Please note : A cop y of thi s informatio n wil l be maintaine d in our medica l record. If validatio n of thi s verificatio n is requested , a cop y of thi s form wil l be forwarde d to the requestin g party .

I author ize re lease of this med ica l information.

Da te /T ime Provider Signsiture / M l

N a m e Date

W i t n e s s Date

Y o u r Heal th C a r e T e a m , Authent ica ted and electronical ly s igned by: M a r y J Mos ley , M D

g 4

a j f l i i t l i atlanta-fulton public librar y system

Take your dreams off the shelf'

Confidential Sent regular and certified mail

'September 2, 2010

Darnetta Nichols 1030 Reunion Place Atlanta, GA 30331

Dear Ms. Nichols:

CO

m

I

o

o

-a rn

CO o

As discussed, I am writin g this letter in reference to your current leave status. Your last day worked was March 30, 2010. You provided medical documentation to support your Family and Medical Leave (FMLA ) absence through June 1, 2010. As you know, you are eligible for 12 weeks of FMLA during this calendar year.

On June 1, 2010, you gave your supervisor a note from your doctor that stated you were cleared to return to work with the following limitations for 6 weeks: "No bending, no stooping, no liftin g of more than 10 pounds". Your supervisor Informed you that you could not return to work until you could fulfil l the physical requirements of your job. Librar y Assistant Senior, which is a "medium work" job. "Medium work" jobs require employees to occasionally exert up to 50 pounds of force, frequently exert up to 20 pounds of force, and/or constantly exert up to 10 pounds of force to move objects. :(See attached Librar y Assistant Senior job description.) As of July 12, 2010, the six week period, that was specified in the doctor's note, expired.

You are currently out on unapproved leave because you have not submitted the necessary paperwork to request any time off since June 1, 2010. This matter needs to be rectified immediately. Our expectation is that you will return to work at the Southwest Branch Librar y on or before September 9, 2010. When you return, you will need to bring a note from your doctor certifying that you are able to perform the work that is required to be done in the Librar y Assistant Senior job description. Additionally , we also need medical documentation to support your entire period of absence beginning June 1, 2010. I have attached an Exceptional Circumstance Leave Request Form. This form needs to be completed by you and submitted to your supervisor along with medical documentation that supports your leave request.

To the extent that you are seeking work accommodations, the Office of Equal Employment Opportunit y and Disability Affair s is available to work with employees who may require disability related accommodations, if you feel the Office of Disability Affair s can be of assistance to you, please feel free to contact Wayne Stokes, Disability Affair s Program Coordinator, at (404) 612-7391.

If you fail to return to work as specified above or otherwise fail comply with this request, we will assume that you have abandoned your position at the Atlanta-Fulton Public Librar y System.

Sincerely, ^ , .

'Anne T. Haimes ^ . Branch Group Manager

cc: Sylvia Culver Aldridge, Human Resource Manager Andrea Akiti , Branch Manager

Central Library I One Margaret Mitchell Square I Atlanta, GA 30303 I p/ione 404 730-1972 I /n.v 404 730-1990 I www.afplweb.com

a i f i l f i l i atlanta-fulton public librar y system

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P E R S O N A L A N D C O N F I D E N T I A L - S e n t v i a cer t i f i ed a n d r e g u l a r m a i l -

February 25 , 2011

Darnetta N icho ls 1030 R e u n i o n P l a c e At lanta, G A 30331

Dear M s . N icho ls :

T h e Ful ton County Civi l Serv ice Act and Personne l Regulat ions provide that an Appoint ing Authori ty may d ismiss , s u s p e n d without pay, demote or otherwise discipl ine a permanent c lassi f ied employee for c a u s e upon furnishing written notice to the employee setting forth in detai l the reasons for such act ion and providing the Fulton County Personne l Board with a copy of the written notice.

In a c c o r d a n c e with the above authority and based on the information currently avai lable to me, this is to notify you that I a m consider ing d ismiss ing you for cause as spec i f ied below. Before I make my dec is ion , I will g ive you an opportunity to give me your s ide of the story or otherwise respond to me orally or in writing. I have reserved 3:00 p.m., March 3, 2011 , to meet with you . T h e meet ing will be held in the smal l con fe rence room on the 6"^ floor of the Centra l Library, if you fall to meet with me or otherwise respond, your d ismissa l will be effective at the c lose of bus iness on March 4 , 2011.

I a m cons ider ing this action for the following reasons:

o Y o u have violated the following Personne l Regulat ions as il lustrated below. o 1800 - 2 Art ic le 1. Absen tee i sm and Tard iness . A . Chron ic absen tee ism, def ined as

habitual, sus ta ined, conf i rmed, or cont inued u n e x c u s e d a b s e n c e , o 1800 - 2 Art ic le 1. Absen tee ism and Tard iness . C . U n e x c u s e d or unauthorized a b s e n c e

on any schedu led workday or during working hours, o 1800 - 2 Art icle 1. Absen tee ism and Tard iness . D. Abandonmen t of posit ion for five (5) or

more consecut ive workdays (or shift equivalent). • Y o u have been absent from work without approval s ince June 1, 2010. • Y o u have fai led to submit the appropriate documentat ion to request approva l for

this a b s e n c e . o 1800 - 2 Art icle 11. Insubordination. B. Fai lure to carry out orders, failure or e x c e s s i v e

delay In carrying out work ass ignments or speci f ic instruct ions of superv isors. • Y o u have failed to comply with requests for information and documentat ion to

support your absence from June 1^' 2010 to present. Speci f ical ly:

• Y o u have failed to respond to our repeated attempts to work with you to

Central Library One IVlargaret Mitchell Square Atlanta, GA 30303 p/ione 404 730-1972 /a.i 404 730-1990 www.afplweb.com

determine if you are interested in being considered for a leave of absence and continued employment. You have failed to follow through with providing the information regarding your absence requested by the Fulton County Office of Disability Affairs .

if it is my decision to dismiss you and you feel that the decision is based on personal, political, or religious reasons or that it is not otherwise justified, PR-900-1 gives you the right to appeal to the Fulton County Personnel Board by answering the charges in writin g and requesting a hearing. Any such request must be received by the Fulton County Personnel Board within ten working days after you are notified of my decision. An appeal form is attached.

in addition, if it is my decision to dism.iss you and yoy feel that your reputation may be damaged or that you otherwise-may be stigmatized by the decision, the aforementioned appeal shall also serve as a name-clearing hearing.

Respectfully,

John F. Szabo Director

Attachment

cc: Personnel Board Paris Brown Sylvia Culver Aldridg e Anne Haimes

N i c h o l s , D a r n e t ta

From: Edmondson, Teffeny

Sent: Thursday, March 18, 2010 5.07 P M

To; Nichols, Darnetta

Subject : Letter

Type this exactly like this.

Mrs. Haimes,

Ms^ Zamora walks out the building at * 2 ^ ^ m te iS^^^^^ t ' ' ""^f^ ""'^

Darnetta Nichols

3/20/2010

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^^^— ^ REQUEST F O ^ L E ^ E / "

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I HEREBY REQUEST A LEAVE OF ABSENCE FROM MY OFFICIAL DUTIES AS fSlLOWS

BEGINNING

ENDING

TOTAL WORKING , HOURS OFF

I REQUEST THAT THIS ABSENCE BE ALLOCATED TO:

VACATIO N LEAV E

MILITAR Y LEAV E

OTHER LEAV E

* SICK LEAV E

INJURY LEAV E

(Attach orders)

FAMIL Y LEAV E

COURT LEAV E

(Attach subpoena)

COMPENSATORY LEAV E

OFFICA L LEAV E (Attach

authorizaton)

(Specify)

1 hereby certify that I was unable to perform my duties diuing this period of sick leave because I was sick or had to obtain professional medical care.

I hereby certify that I was imable to perform my duties during this period of time due to a catastrophic injury as defined in PR 1200-5, revised March 1991.

• EMERGENCY LEAV E

/ hereby certify that I was unable to perform my duties during this period of eniergency leave because the illness or death of the following member of my immediate family necessitated my personal attendance:

(Relationship)

/ UNDERSTAND THAT A PHYSICIAN'S CERTIFICATE MAY BE RE-JIRED FOR ANY ABSENCES IN THESE CATEGORIES UPON THE {QUEST OF THE APPOipfflNG AUTHQ^TY CONCERNED

AGENCY: 650 ORG: (<pSHf) PAY PERIOD STARTING:

LAST NAME

•.MJ4MJ^ FIRST NAME: PdrnfA SOCIAL SECURITY NUMBER:

7 MIDDLE INITIAL

PAY PERIOD ENDING:

SIGNATURE:

i ' E ^

APPROVAL SIGNATURE: (UlTON COUNTY

TIME TIME TIME TIME HRS LEA\'B COMP 1 TIME

b-

HOLIDAY LEAVE COMP TIME HOURS INJURY IVC

IN OUT IN OUT KEG SICK EMEKG FMLA FMLA C USED HOL V HOLE LWOP MIL E I.S EI.O EXTRA

INJURY IVC

WEDNESDAY

THURSDA Y t 3 ^ _w——

FRIDAY

SATURDAY

SUNDAY ^{•i—

•

MONDAY n CD

TUESDAY ••

TOTAL ADJUSTMENT

S

SUBTOTAL

WEDNESDAY

THURSDA Y In FRIDAY 7

SATURDAY

SUNDAY

MONDAY

TUESDAY 11 TOTAL ADJUSTMENT

S •

SUBTOTAL _. „„--. ^ .- . - -J - -

GRAND TOTAL 1 . t ' \ Comments/Other leave \ \ i 1

(Le. Court, Official,

Blood, etc) .MAY 1 2 ZD 10

F U L T O N C O U N T Y R E P O R T O F P E R S O N N E L A C T I O N

F O R M - 8

FUITOHCOUHTV

Date of Request: 05/14/2010

Employee ID: 0000015937

Name: NICHOLS, DARNEl

U

PAM.

Personnel Action:

Description: LEAV E OF ABSENCE W/O PAY

Personnel Action Reason: FAM

Description: FAMIL Y LEAVE

Start Date: 3/30/2010

Perm/Temp: P

Pay Class Code: EXCA

Employment Status: I

Civil Service Status: LWOP

Payroll Number: OFFPR

Appt ID:

Grig. Appt Date: 6/12/1996

Effective Date: 4/28/2010

End Date: Time Class Code:

6/22/2010 FULL

Titl e Code: 202352 Position No.: 0002448 Grade: A13

Description: LIBRAR Y ASSISTANT SENIOR

Description: LIBRAR Y ASSISTANT, SENIOR

Leave Progression Start Date: 2/12/1997

Agency Code: 650 Description: Librar y Organization: 6540 Description: Librar y - Southwest Regional

^^^^^^1 Pay Type Rate Code ^ P e °c e n r Effective Date

REGLR A $27,112.0000 .4/28/2010

Authorit y for Action: PR 1200-11

Comments:

Approved:

PERSONNEL DIRECTOR

Document Reference: ESMT-650-05141000000000007363-1

FORM 8 (03/09/2008) awillingham

_ • F U L T O N C O U N T Y K.-^-W R E P O R T O F P E R S O N N E L A C T I O N

FORM-8

FULTON GOUHTV

Date of Request: 06/24/2010

Employee ID: 0000015937

Name: NICHOLS, DARNETTA M.

Personnel Action: U

Description: LEAV E OF ABSENCE W/O PAY

Personnel Action Reason: ILL

Description: ILLNESS

Start Date: 6/23/2010 Employment Status: I

Civil Service Status: LWOP

Payroll Number: OFFPR

Titl e Code: 202352

Position No.: 0002448

Grade: A13

Appt ID:

Grig. Appt Date: 6/12/1996

Effective Date: 6/23/2010

End Date: 12/22/2010

Time Class Code: FULL Perm/Temp: P Pay Class Code: EXCA

Description: LIBRAR Y ASSISTANT SENIOR

Description: LIBRAR Y ASSISTANT, SENIOR

Leave Progression Start Date: 2/12/1997

Agency Code: 650 Description: Librar y Organization: 6540 Description: Librar y - Southwest Regional

Rate Code

REGLR A $27,112.0000 6/23/2010

Authorit y for Action: PR 1200-11

Comments:

Approved:

PERSONNEL DIRECTOR

Document Reference:

FORM 8 (03/09/2006)

ESMT-650-06241000000000009043-1

awillingham

F U L T O N C O U N T Y R E P O R T O F P E R S O N N E L A C T I O N

FORWI-8

fULTOHCOUNTV

Date of Request: 04/16/2010

Employee ID: 0000015937

Name: NICHOLS, DARNETTA M.

Personnel Action: UP

Description: LEAVE OF ABSENCE W/PAY

Personnel Action Reason: FAM

Description: FAMIL Y LEAVE

Start Date: 3/30/2010 Employment Status: A

Civil Service Status: P

Payroll Number: B100

Perm/Temp: P

Pay Class Code: EXCA

Appt ID:

Orig. Appt Date:

Effective Date:

6/12/1996

3/30/2010

End Date: 6/22/2010

Time Class Code: FULL

Titl e Code: Position No. Grade:

202352 0002448

A13

Description: LIBRAR Y ASSISTANT SENIOR

Description: LIBRAR Y ASSISTANT, SENIOR

Leave Progression Start Date: 2/12/1997

Agency Code: 650 Description: Librar y Organization: 6540 Description: Librar y - Southwest Regional

^ ^ ^ ^ ^ ^ H Pay Type Rate Code ^Pereen ^ Effectiv e Date

1 R E G L R A $27,112.0000 3/30/2010

Authorit y for Action: PR 1200-11

Comments:

Approved:

PERSONNEL DIRECTOR

Document Reference: ESMT-650-04161000000000006246-1

FORM 8 (03/09/2008) awillingham

f E S MT Page 2 of 3

- Applicant Information -

Applicant ID: H Split Job Notice ID : F

Job Notice ID:

^Probation Dates

Probation Start Dt: {06/23/2010

Probation End Dt; 12/22/2010

f Progression Dates

Pay Progression Start:

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'm

'rClassification Attribute s

*Payroll Number: jOFFPR a *Title : 202352 B

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Civil Service Status : | l w o p @ Assignment Type:

Civil Service Class Desc : [ l e a v e w o P A Y

Time Class : J f u l l H

Time Class Desc: jFUL L TIM E

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' For Form 8 Action Report

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Form 8 Remarks :

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Name Prefix:

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Middle Name:

112/31/9999

m 'Original Appointment Date:

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Last Name: jNICHOL S

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- Assignment Information

'Personnel Action Code:

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'Percent Full-time:

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Union Affiliatio n :

Union Affiliatio n Desc:

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Employee ID: 0000015937

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Appointment ID: Q

Alternate ID:

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*From :

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04/28/2010

12/31/9999

'Original Appointment Date: 06/12/1996

First Name: DARNETTA

Middle Name: iM

Last Name: jNICHOL S

Name Suffix:

•Assignmen t Information ——

'Personnel Action Code

Personnel Action Desc

Personnel Action Reason

Personnel Action Reason Desc:

'Employment Status :

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•Applican t Information-

Applicant ID: B Split Job Notice ID: F

Job Notice ID: B

Probation Dates

Probation Start Dt: |03/30/2010

Probation End Dt: |06/22/2010

^Progression Dates

Pay Progression Start;

Benefits Progression Start:

Leave Progression Start: 02/12/1997

'('Classification Attribute s

'Payroll Number: [bIOO B

Payrall Number Desc : jGENERAL 100

'Pay Class : jEXCA B

Pay Class Desc ; | b I W K SALARY

Civil Service Status : |p " B

Civil Sen/ice Class Desc : [PERMANENT

Time Class : jpULL B

Time Class Desc: |FULL TI ME

'Title : [202352 ' B

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'Original Appointment Date:

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06/12/1996

First Name: [ d A R N E T T A

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'Personnel Action Code

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-•Applican t Information

Applicant ID ;j " 3 Split Job Notice ID : T

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' 'Probatio n Dates - / o

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Benefits Progression Start : |

Leave Progression Start: jo2/12/1997

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To: 40-18760992 From: (40473073/r-; m/tK/ll lorza HI rayc la ur ca

I N T E R - O F F I C E M E M O R A N D U M

D A T E :

T O :

F R O M :

J o h n F. S z a b o , Library Di rector

Fulton Coun ty Pe rsonne l Depar tment

May 26, 2 0 1 0 FULTON COUNTY

S U B J E C T : Fami ly Med i ca l Leave d o c u m e n t s for:

Da rne t ta N i c h o l s (2) Employee Nama

O u r records indicate that w e have received a comp le te F a m i l y & Med i ca l L e a v e

P a c k a g e conce rn ing the a b o v e - n a m e d . T h i s p a c k a g e w a s rece ived by the P e r s o n n e l

depar tment o n 05/21/10.

T h i s is to k e e p you informed a s to what Fami ly M e d i c a l d o c u m e n t s that has b e e n submi t ted to P e r s o n n e l , w e will be logging this e m p l o y e e s informat ion into ou r s y s t e m to ind icate that their F a m i l y M e d i c a l L e a v e has been a p p r o v e d by your depar tment .

If you h a v e a n y quest ions or conce rn in regards to this matter p l e a s e contact you r P e r s o n n e l Payro l l Spec ia l i s t or Rache l B raswe l l at (404) 6 1 3 - 0 9 0 6

c c : J e a n e l l e Smi th

Opt-Out: +

10: ^BIB/bUaa/ nun: vHoiiooij i 1/

a l f l f i i l i atlanta-fulton public librar y system

Take your dreams off the shelf.™

TO:

F R O M:

SUBJECT:

RE:

D A T E :

INTER-OFFICE M E M O R A N D U M

Rachel Braswell, Payroll Lead Specialist Department of Persormel

Sylvia Culver Aldridge, Human Resources Manager

Request for Family and Medical Leave

•35 - o

[-0

-o

Dametta Nichols (March 30, 2010 tlirough June 1, 2010 (Leave Wi tho i^ Pay Status)

May 19,2010

This memorandum is in regards to the above-mentioned subject. The following documents are enclosed:

1. Exceptional Circumstance Leave Request Form dated 5/12/10 2. Copy of Employee's Leave Management Screens dated 5/19/10 3. Family and Medical Leave Memorandum dated 4/2/10 4. Notice of Eligibilit y and Rights & Responsibilities dated 5/12/10 5. Designation Notice (Family and Medical Leave) dated 5/12/10 6. Certification of Health Care Provider for Employee's Serious Flealth Condition

4/28/10 7. Libraiy Assistant Senior Class Specification 8. Benefits Office Notification of Employee on Leave Sent to the Fulton County

Finance Department

I f you have any questions, you may contact Jeanelle Y . Smith, C P M, Human Resources Coordinator Senior at (404) 730-1871.

••jy s

Encs

X c : Personnel Files (AFPLS) D. Nichols T. Edmondson (Southwest) A . Akit i A . Haimes

Central Library I One Margaret Mitchefl Square I Atlanta, GA 30303 tphone 404.730.1972 l/oi: 404.730.1990 I www.afpls.org

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1 MAY 1 9 2010

Atlanta-FuIioH Publ ic L ib rary System "- '-

Exceptional Circumstance Leave RequesLform .- .

T O: ' T d - f f e i ^ i y ^ J / ^ 6 > ^ c i s C < ^ DATE : 6 P ' ^ / ^ 0

PROM: ^ P c / t / ' M g ^ ^ ^ r l ^ p f ' ^

I woul d lik e t o tak e leav e from I understan d thi s leav e reques t

w i l l b e considere d fo r approva l base d o n individua l qualifyin g circumstances . M y reaso n fo r requestin g

leav e i s {chgc k appropriat e space(s)} :

•2 Famil y an d Medica l Leav e '- g

o Birt h o r adoptio n o f childre n o r placemen t o f foste r childre n ^ ^

a- 'aer ioo s illnes s o f spouse , child , paren t o r employe e

o Fo r employe e t o participat e i n children' s schoo l activitie s o r t o tar a a pa r ^ j t t o

th e docto r ^

Sic k Leav e (Doctor' s statemen t needed ) y ip^

Othe r (Explain ) ^ j

I hav e a sufficien t amoun t o f pai d leav e t o cove r _ _ _ _ day s o f ray requeste d leave .

1 d o no t hav e a sufticien t amoun t o f pai d leav e t o cove r m y requeste d leave .

Addi t iona l Information :

AgencvAJnit: Soui^uJ^^i-

Approved a Not Approved a

Approved o Not Approved •

Approved fcT^ Not Approved p

Approved d Not Approved a

Approved a--" Not Approved •

Comments:

Immediate Supervisor. Signature:

Branch/Unit Manager Signature: _

Group Manager/Administrator Signature:

Deputy Director Signature;

Director Sii

NOTE: This form is to be used if leave is requested for exceptional circumstances as h'sted above. For infoiTiiatiou regarduig leaves, please refer to the Fulton County Personnel Regulations Handbook PR" 3200 series.

Revised 01/07/03 AFPLS/HRD

Opt-Out: *

If your leave does qualify as FMLA leave yon will have the following responsibilities while oaFMLA. leave (only checked blanks apply):

Contact _ at ij-O^ <$/^-7x^/9 to make arrangements to continue to make yovir share of tlie premium payments on your health bisurance to maintain health benefits while you are on leave. You have a miniimim 30-day for, indicate lopgerpeiiod. if aoplicablel grace period in which to make premium payments. If payment is not made timely, your group health insurance may be cancelled, provided we notiiy you in writing at least 15 days before the date that youi' health coverage will lapse, or, at our option, we may pay yottr share of the premimns during FMLA leave, and recover these payments from you upon your return to work.

You will be required to use your available paid •'^iclc . vacation, and/or (.^^ other leave during yom- FMLA absence. This means that you will receive your paid leave and the leave win also be considered protected FMLA leave and counted against your FMLA leave entitlement

Due to yovu' status withhi the company, you are considered a "key employee" as defined in (he FMLA. As a "key employee," restoration to employment may be denied following FMLA leave on tbe grounds that such restoration wiB cause stibstantial and giievous economic injury [o us. We have/ have not detemilned that restoring you to employmeiit at the conclusion of FMLA leave wUl cause substantial and grievous economic harm to us.

While on leave you will be required to furnish us with periodic reports of your status and intent to return to work every . (Indicate interval of periodic reports. as appropriate for the particular leave situationl. «

-• H If the circumstances of your leave change, and you are able f u return to work earlier than tlie date indibffted on the reverse side of this form, you will- • be requii ed to notiiy us at least tvvo workdays prior to tlie date you intend to report for worlu . If your leave does qualily as FMLA leave you will have the following rights while on FMLA leave:

Youjjjye aiightundertheFMLAforup to ]2weeks ofunpaidleaveina 12-monthperiod calculated as: , | MAY 1 9 2010

the calendar year (January - December).

a iixed leave year based on

the 12-month period measured forward from the date of your first FMLA leave usage. a "rolling" 12-nionthpeiiod measured bacltward fiom the date of any FMLA leave usage.' j.

You have a right imder the FMLA for up to 26 weeks of unpaid leave in a smgle 12-month period to care for a covei'ed servicemembet with a serious injury or illness. This single 12-raonth period commenced on Yoiar health benefits must be maintained during any period of luipaid leave under the same conditions as if you continvied to work You must be reinstated to the same or an equivalent job with the same pay, beneiits, and terms and conditions of employment on your return &om FMLA-proteeted leave. (If yotff leave extends beyond the endof yourFMIA entitlement, you do not have rctuin rights under FMLA.) If you do not return to work following FMLA leave for a reason otfier than: 1) tbe continuation, recurrence, or onset of a serious health condition which would entitie yon to FMLA leave; 2) the continuation, reouirencc, or onset of a covered serviceiueniber's serious injury or iltoess which would entitle you to FMLA leave; or 3) other circumstances beyond your control, you may be requli-ed to reimburse us for our share of health insurance premiums paifl on your behalf during yom' FMLA leave. If we have not informed you above that you must use accrued paid leave while taking your unpaid FlVlLA leave entitlement, you have the right to have

. siclc, vacation, and/or other leave run concuiTentl y with your unpaid leave entitlement, provided you meet any appUcable requirements of tbe leave policy. Applicable conditions related to the substitution of paid leave are referenced or set foith belo-w. If you do not meet the requirements for taking paid leave, you remain entitled to take unpaid FMLA leave.

For a copy of conditions applicable to sick/vacation/other leave usage pleas e refer to available at .

Applicable conditions for use of paid leave: -n

3:;

•X-+

Once we obtain the information from you as specified above, we wil inform you, witMn 5 business days, whether your leave wilLhe desi ated as ffMLA leave and count towards your FMLA leave entitlement if you have any questions, please do not hesitate to contact: TT ^

PAPERWORK REDUCTION ACT NOTICE ANB Pt!BUC BLmDEN STATEMENT It is mandatory for employeis to provide employees with notice of their eligibility for FMLA pwtecdon and their rights and responsibilities. 29 U.S.C. § 2617:29 C.F.R. § 825.300(b), (c). It is mandatoiy for employeis to retain a copy of tliis disclosure in theii-records for thi«e years. 29 U.S.C. § 2616; 29 C.F.R. § 825.500. Peiotis arenotrequiedto respond to this coUecdon of infoimation unless it displays a cuiTently valid OMB control number. The Depattment of Labor estimates that it will take an average of 10 minutes for lespondents to complete this collection of information, including tte time for reviewing i3ish-uctions,searehjiig existing data souires, gathering and maintaining the data needed, and completnig and reviewing the collection of infonnation. If you have any comments regarding this burden estimate or any other aspect of this collection infoiTuation, including suggestions fnr reducing this bm-den, send tliem to the Administrator, Wage and Hoiu-Division, U.S. Depaitment of Labor, Room S-3502,200 Constitution Ave.. NW, Washmgton, DC 20210. BO NOT SENB THE COlMPLETED FORIM TO THE WAGE AND HOUR DIVISION. Page 2 " ' Form WFM 81 Revised lanuaiy 2009

Opt-Out:

TO: ' 048/601392 nuia; siu-iuoiji 1/

Notice of Eligibilit y and Rights & U.S. Departmen t of Labor I V i l l i Responsibilitie s ^SZ'^^^:^^''''''^' ^WUHO (Family and Medical Leave Act) u„s,\\5>s.m,jHm.fDivaor,

OMB Control Number: 121S-0181 Expires: 12/31GD11

In general, to be eligible an employee must have worked for an employer for at least 12 months, have worked at least 1,250 bovu-s in the 12 months preceding the leave, and work at a site with at least 50 employees within 75 miles. While use of this form by employers is optional, a frilly completed Form WH-381 provides employees with the infonnation required by 29 C.F.R. § 825.300(h), which must be provided within live business days of the employee notifying the employer of the need for F M L A leave. Part B provides employees with information regarding then- rights and responsibihties for taking FMLA leave, as required by 29 C.F.R. § 825.300(b), (c).

[Part A - NOTICE O F ELIGIBILITY1 ^

TO: Va^i^e-fizc M.'-chdIs \ Employee I

FROM: ' T t . - f ^ e ^ ' j BAyt'iv^Js - j f . yw 1 9 2O'i0 Employer Representative |

DATE:

On .ly/ t ' ^ j 0 , you informed us that you needed leave beginning on 3 / 3<^^/ / for

e biith of a child, or placement of a child with you for adoption or foster care;

Your own serious health condition;

Because you are needed to care for your spouse; child; parent due to his/her serious health condition.

Because of a qualifying exigency arising out of the fact that your spouse; son or daughter; , p a r ^ is on active duty or call to active duty status in support of a contingency operation as a member of tie National Guard or j ^ e i v 6 ^

Because you are the spouse; son or daughter; parent; next of kin of a covered s ^ ^ c e m ^ b e r with a

serious injury or illness. ^

This Notice is to inform you that you:

Are eligible for F M L A leave (See Paii B below for Rights and Responsibilities) y ^

Are not ehgible for F M I A leave, because (only one reason need be checked, although you may not be eligible fonSthcr rfgsons):

You have not met the FMLA's 12-month length of service requu-ement As of the first date of requested v e ^ yW will have worked approximately months towards this requirement. You have not met the F M L A ' s 1,250-hom-s-worked requirement. You do not work and/or report to a site witli 50 or more employees within 75-miles.

If you have any questions, contact / .^.jp^cA^ij t^'dMcJ ScS'' or view the F M L A poster located in ^ .

[PART B-RIGHTS A N B RESPONSIBILmES FORTAIONG F M L A L E A V E ]

As explained in Part A , you meet the eligibility requirements for faking F M L A leave and still have F M L A leave available in the applicable 12-nQOnth period. However, in order for us to determine whether your absence qualifies as F M L A leave, you must return the following information to us by . (If a certification is requested, employers must allow at least 15 calendar days fi'om receipt of this notice; additional time may be required in some cumirastances.) If sufficient information is not provided in a timely manner, your leave may be denied.

Sufficieat certification to support yom' request tor FMLA leave. A certification form that sets forth (he infonnation necessaiy to suppott yom-request is/ is not enclosed.

Sufficient doctmientarion to establish the requied relationship between you and your family member.

Otlter information needed:

No additional infwmation i-eques!ed Pngcl CONTINUED OM NKX-TPAGIS Foim WH-381 Revised Januaiy 2009

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D e s i g n a t i o n N o t i c e U . S . D e p a r t m e n t o f L a b o r

( F a m i l y a n d M e d i c a l L e a v e A c t ) wage and Hour oMsion

OMB Control fu lbel-: 1213-0181 Exnires: 12/31/2(111

Leave covered under the Family and Medical Leave Act (EMLA) must be designated ns EMLA-protccted and the employer must infoiin tlie employee of tlie amount of leave Uiat will be counted against the employee's IMLA leave entitlem ent In order to determme -whether leave is covered trader the FMLA, the employer may request tliat the ]e.ive be supported by a cci-tification. If tte ccrtificntion is incomplete or insufficient, tlife"employer must stale in jyriting.'B'fl.at additional mforniation is necessary lo inalce the certification complete and snffideiit. WhUe use of this form by employes is optionai, a fully completed Form 'WH-382 provides an easy method of pro-viding employees with the wrifteo information required by 29 C.FJl. §§ 82S.30B(c), 8|553«ly-OTd 823:305*); "™™=

Date: S f l ' ^ f - ' f X } | MAY 1 9 2010 I

We have re-viewed your request for leave under the FMLA and any supporting documentation that you hav y>^g}{l^ed!.;r'-:-;-: r,:^r :g Li&ll '"!'! ) We received your most recent infoimatioa on 6 / l ^ J a^O I O and decided -.• -^^t v-^iSp-^' \

Your FMLA leave request is approved. Al l leave taken for this reason ivil l be designatetE as FMLA leave. -j a

The FMLA requh'es that you notiiy ns as soon as practicable if dates of scheduled leave change or are extended, or were initially unknown. Based on the information you have provided tn date, we are providing the following information about the amount of time that wil l be counted against your leave entitlement:

Provided there is no de-viation fi-om youi- anticipated leave schedule, the following number of hours, days, or weeks wil l be counted against your leave entitlement:

Because the leave you wil l need wil l be unscheduled, it is not possible to provide the hours, days, or weeks that will be counted against your FMLA entitlement at tliis time. You have the right to request this mforniation once in a 30-day period (if leave was taken in the 3 0-day period).

Please be ad-vised (check if apphcafcle): ^ You have requested to use paid leave during your FMLA leave. Any paid leave takea for this reason wil l csgpt ag^st your EMLA leave entiUement. ^

We are requiring you to siibstitute or use paid leave during yom-FMLA leave. ^

_You wil l be required to present a fitness-for-duty certificate to be restored to employment. If such ceitificatiohls not timely received, yoiu- retui-n to work may be delayed until certification is provided. A list of the essential functions of-^ur pSition

is is not attached. If attached, the fitness-for-duty certiiication must address your ability to perform t h^ ftuii&ns.

Additional iiiformation Is needed to detei-mine if your FMLA leave request cau be ap ^ f

Hie certification you have provided is not complete and sufficient to determine whether the FMLA applies to yovu- leave request. You must provide the following infomiatioa no later than , tmless it is not

(Provide at least seven calendar- days) practicable rmder the pai-ticulai- circumstances despite your diligent good faith efforts, or yom- leave may be denied,

CSpcoify information needed to malce the certification complete and suiBcient)

We are exercising our right to have you obtain a second or third opinion medical certification at om: e;{pense, and we wil l provide further detail s at a later time.

Your FMLA Leave request is Not Approved. , The FMLA does not apply to yoiu' leave request. . You have exhausted your FMLA leave entitlement in the applicable 12-month period.

PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT It is mandatory for employers to iufomi employees in writing whether leave minested mider the FMLA has been deteimined to be covered under the FMLA. 29 U.S.C. § 2617; 29 C.P.R. §§ 825.300(d), (e). his mandatoiy for employere to retain a copy of this d is closiu'eui their records for three years. 29 U.S.C. §2616; 29 C.P.R. § 823.500. Pereons ai-e not requhcd to respond to this collection of infonnation unless it displays a cmrently valid OMB control mnnber. The Deparhnent of Labor estimates that it wiB take an average of 10 - 30 minutes for respondents to complete this collection of information, including the lime for reviewing instnjctinns, seai cliing existing data sources, gatbeiiog and maintaining the data needed, and completing andreviewing the collection of infonnation. If you have any coinmenls regai'ding this biu'den estimate or any other aspect of this collection infoimation, including suggestions for reducing this burden, send them to the Adminish-atnr, Wage and Hour Division, U.S. Deparhnent of Labor, Room S-3502,200 Constitution Ave., NW, Washington, DC 20210. CO NOT SEND THE COMPLETED FORM TO THE WAGE AND HOUR DIVISION.

Foim WH-382 Januaiy 2009

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04/12/2010 09:19 FAX 7702203760 KAISERPERMANEHTE ^ CU ROL SELF SERV i l002/005

To I 4843355291 Froi: <HOW) 03/31/19 83!K Pfl 7 Of 18

Cerllflcatlon of Health Care Provider for Employes's Serious Health Condition (Family and Medical Leave Act)

U . S . Depar tmen t o f L a b o r

Wafi* and Hour Dlvisioti

OMBQjnttotKimbc R 1215-018 1 m\m- IMlrtfll l

INSTRUCTIONS ta the EMPLOYER: Tte Family end Mcdieel LiSttve) Act (FMLA) provides that nn ompbyor may require an wnployeo s«eMii£ FMLAprotecdoUs becauEe of a used fer leave due to a seriovia health condititjn to submit» aiodical cettificatloii lasucd by the eniployoe's health osr* provider, Pleaie oomplete Section I bo&te Biving this arm to your employee. Your leaponsc is voluntaiy. While ym a» not required to tibc this fotm, you msy not aak tho Btnplqyao to provide mm lafeniutlon than (Ilowad 'umter flic FMLA roguiBtions, 29 C J J l . 825J0&<fi23 J08. Effltiloyfira must generally mgintsin iwords and documeiits i«laiiae to medical certifications^ recertifications. ot KwdicBl histories of acplc^yecs created ibr FMLA pufj>osea u confidential mediaU ttaxOa m n^etbt ja3«sA«cofda fitml 4e usual jwisonnel files hikJ in accocdancw with 29 C J'.R. § 1630.14(oXl)i iftte Americana wflh rKsabflitiea Att applies.

Bmployor DMno niid eoiitaot;

Employee's job titlw ^ . Reg^lac work gchedulK,

Bmpbyee's assential job fiuiciionB: _

MAY 1 9 20i0

Check i f job description is attachod;

HVSTRUCTIONS to fte EWD?LO"KEE: Please complete Scctioa n before giving this fenn to y' tir medical piovldor. Tha FMLA ptmxa m cmployar to roquiro thst you Suljinit 8 timely, complo (a, and sufficient medical cerrificadon to siipport a request fbrHiDLA leavo due to your own serious health condition. If requested by yf»^ employer, your tospotm is required to obtaiA er rcsic flic banefit of FMLA proieetioHH. 29 If .S.C. §f 2613, ^ 2614(c)C3), Failwe to provide a complete and Saffioieot medical eortificatiDi i may result in a detfiel cf your FlS^iA request 20 C.FJR. § 825313. Youreitiployer must givoi you at least IS cHlendar days to rttum ttds form. 25 C . ^ . §S25.305(b). A

Yownsjne;

a : c a.

First Middle Last

INStRUCTIONS to the BEAJLTEt CASE JPBOVIBER: Yom patient has requested leave tomJa dja FMLfU AiiBwer.fiilly aad completely, aJUapplioablopartfl. Setr««l qwatioaa seek a laajwoM bb to tlw fewji^o^ <J duration of a condition, tfeatttient, etc. Yotir anawer shouldtw yow best estitnate baaed tipoH yorsrinedical: knowledge, eocpeiricnce, and eKtoninatioa of the patient Be as specific as you can; tcnna suob aa "lifetime," "unknowB," or "indetenninate" may not he sutSciont to detennino FMLA coverago. Limit your responsea to tho conditioa for which the employee is sebkiag leave. Pltaae be sut« to sign ti« &fm on the last psgo.

Provider's name and business address:.

Typo of practice / Medicfil Specialty: _

Tclisphoiie: ( )

(uioor Permanenta-Release of Information

000 DeKalb Technology rarkway

-^^•i &)dg. P-00 SiiitP ?no

CONTJM/ED ON NEXT CAGE

Atlanta, G A 30340 FomiWH.JSD-E Etcviscd JamunyZOOS

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04/12/2010 09:20 FAK 77022037SO KAISERPERHAMENTE CU ROL SELF SERV 1004/005

TO! 4843335291 FrOB: (How) 63/31/10 63:55 PH Pase 9 oP 10

nrated for a single ctsidnuotte period of tune due to Jiis/har medical condition, ^c^inga^^iM*fi!rtrD8tni«ntafldiecov«y7 _ N o

V * boginning and ending dateo for die period of tooapacity;

6, Win the employee need to attend follow-up treatment appp^tmeats or woikpart-time or on a ttdaced schedule bectusc of tbe efllploy^'* medical condition? /L_No _ Yes.

j io tJ«sfiaeats or tie reduced ni3nil>«' of hours of woifc medically necessaiy? _No

Estimate treatment sclxedula, ifanjTiHclu^g the dates of any scjjiliduled appointments and the time requiied for e»ch appoiatnicnt, incIndinfft^Vceaxcjy period:

Estinmte tho part-time or reduced worfc jchedule tho omployeo seeds, i f aoy;

, hour(a) per day; days per week fioin throush ^ „

7. Will the conditijm oatJ3» episodic flate-upj periodicaUy preventing tie employee from purfonnin^'s/heSoli fimetions? y No Yes,

ir the employee to he absent horn work during the flftte-uns?

CO o

Based iipon ifae patient 'a medital history and yo^J^ knowledge of the medical condition, estimate tJie flequefloy of flare-ups and flie duration of related inotipacdty dm the pstient rmy hava ovar ttie next 6 monihs fe.g.. 1 episode every 3 months lasting 1-2 days);

Frefluenoy: times pijr week(s) inonth(s)

Duration:. „ liouig or dfty(s) per episode

•mmm

Fonsl WH-isO-E Bcvial J imiiflO'lOW

( Jt-Out;

j MAY 1 9 20 iO

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04/12/2010 08:19 FAX 7702203760 KAISERPERMANENTE + CU ROL SELF SERV 11 003/005

TO! 4043355291 \ W j ^ : (»™) ^''^'-''^ 83:55 Ptt Page B oF 18

^i^«»kV* • Apprrodoiate date condition cMmmeaced: i T Vut ) V

( \ ) \ ( L m i ^ L t ) -

Frobable domtion of condition:

Mark below as appUcabh: ajf the patient admitted for an overnight stay in a hospital, liospice, or residential medical care feciUty? 5^0 Yes. If so, dates of admission: 3 ! ,

DatoCs) you treated the patJont for condilioni \ _< o

"Will the patieat need to have tteatment visits at least twice per yetir d«a to ftia condMon? fto X } ? " w , g

Was medication, other than oveMhe-counter medication, preeoiibed? .NTo |X Yea. ^ S

Was the parieot referred to other health care provid8i(a) for ovaluaKon or treatment physical therapist)? '~ _ _ N o JL -Yes . If so, state the nature of sechtreatiMectdfljid expected duration of treatnjent:

T h i n m a a a g p m e f ^ V , M e p h P o t o Q l y

2. Is the medical condition pregnancy? ^ _ N o Yes. If so, expected delivery date: i --^ ••^ ' ^ " ^^^

3. Uaotbo iJifomatioji provided by the Bmploytff in Section I to answer ty -< q on-n provjdeftlUtoftheemployee'sessoniialftootionsorajobdescriptlottjBttswerthesequesti^ x y t lu tiie employee's own description of his/her job fractions.

Is the employee unable to pcribnn any cf hia/her job functions due to the condition: Jj ^^i ^'. %

I f so, identify tl»c job fiaactions flic employee is unable to perfoim;

4. Describe other relevant misdical facts, i f any, rdated to the condititEft for which the employee seeks leave (such medical facts may include symptoms, diagnosis, or any regimen of continuing treatment such as the use of BjBcializBd equipment):

ftigeS CONTINUE D ON NEXT PAGE FonnWH-3M).E ReiVJied JiBHi«ty2O0S

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I N T E R - O F F I C E M E I V t o R A N D U M

T O : John F. S z a b o , Library Director

F R O M : Ful ton Coun ty Personne l Depar tment

D A T E : May 26 , 2 0 1 0 FULTON COUNTY S U B J E C T : Fami ly Med i ca l L e a v e d o c u m e n t s for:

Darne t ta N i c h o l s (2) Employee Name

O u r records indicate that w e have received a comple te F a m i l y & M e d i c a l L e a v e P a c k a g e concern ing the a b o v e - n a m e d . Th is p a c k a g e w a s rece ived by the P e r s o n n e l depar tmen t on 05/21/10.

T h i s is to keep you informed a s to what Fami ly M e d i c a l d o c u m e n t s that has b e e n submi t ted to P e r s o n n e l , we will be logging th is emp loyees information into ou r s y s t e m to ind icate that their F a m i l y Med ica l L e a v e has been approved by your depar tment .

If you have any quest ions or conce rn in regards to this matter p l e a s e contac t you r Pe rsonne l Payro l l Spec ia l i s t or Rache l B raswe l l at (404) 613 -0906

c c : Jeane l l e Smi th

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10:4048760992 l-rOB: <,mrMr6/l) m/auw la-.o-i m rayc u. , — ^ c ^ A a v^ u t . ^ Lvx (lyiiK tr u H zj) -ncovmter Date: 04/25^/2010

Telephone Encounter Darnetta M Nichols (MR# 0436325)

Encounter Provider Info Author Note Status Last Update User Last Update Date/Time Md G L Ferryman Signed Md G L Ferryman 4/28/10 07:35 PM

Telephone Encounter FMi_A I N S U R A N C E FORIV!

Encounter Number: 42380826D Ser ious Health Condition: Absence Plus Treatment: (a) A period of incapacity of more than three consecutive calendar days (including any subsequent treatment or period of incapacity relating to the same condition), that also involves (1) Treatment two or more times by health care provider, by a nurse or physican's assistant under direct supervision of a health care provider: or (2) Treatment by a health care provider on at least once occasion which results in a regimen of continuing treatment under the supervision of the health care provider.

P A T I E N T D E M O G R A P H I C S

Member Name: Darnetta M NIcholsD Patient Identification: Age-46-Years, Gender-female, Date of Birth- 4/3/1964D Address : 1030 Reunion PI Atlanta G A 30331 3 Telephone Number(s): 404-696-9429 (home) 999-999-9999 (work) ^ ^ Requester: Fulton County ^ ^ Employer: not applicable ^ S

Signature to authorize release of information (validation by R O l Staff): Y e s D ^ Rece ived patient authorization to release of information :Yes and portion complete: Y e s ^

tn

Who is the disability for, relationship to patient: Self -rr 5 Form type: Forms- DisabilityD ts> Purpose : F M L A ^ Cancer Pol ic ies: No:

When did you advise member to cease work? 3/30/201OD First date of Injury or Medical Condition: By History Diagnosis: T H O R A C I C / L U M B O S A C R A L NEURITIS/RADICULITIS UNSPEC[724.4 ] L U M B O S A C R A L S P O N D Y L O S I S WITHOUT MYELOPATHY[721 .3 ] Work related: No: Hospital ized: No Dates: N/A Treatment P lan : FoIIow-Up with provider as needed and take all prescribed medication. Referral to pain management Estimated Length of Condition, Disability: Approximately 8 weeks pending any complications. Frequency: N/A Duration: N/A Beginning Date: 3/30/20100 Return to Work Date: 6/1/201 o n ' ^ ^ . . ^ . ^ Last appointment Date:3/31/2010D Next Schedule Appointment:4/26/2010 with NephroiogyD ! \

I I Care for a family member requiring assistance: No | . . ^y | 9 20iO I Provide psychological comfort: No I " | Care intermittently and probable duration: No | ^..^-. .^•,y<r--n-:-^i^i^^\

T R E A T I N G P H Y S I C I A N . ^ > - — "

Nichols, Dametta M (MR # 0436325) Printed by Kathi-een M Laxi [S794242] at 4/29/10 10:05 A M

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10: ItWBftjMMS Z rrOB : KHmiMIJIO 04/Uf/ii lUioH mi rayc /.( ur

„ — , . -«».x>. , „ . t» x,jL i^x.iA ^ „ vj-r , ' ituuiiier i^aie: u t / z o / z u l u

Treatment, authorization (IVI.D. Name, Location and Department): G L Ferryman, IVID C a Internal Medicine Other treating Physician: not applicable Comments by Physician: not applicable Restrictions for patient: not applicable Objective findings: not applicableD Medications: Yes , as prescribed by provider 1st visit vi ith me 4/28/10.Q

Provider Signature: Electronically reviewed 4/28/2010 7:33 P M

Tax ID Number: 58-159-2076U

Follow-up Contact: Re lease of Information: Kaiser Permanente 4000 Dekalb Tech Parkway Building 200, Suite 200 Atlanta, G a . 30340 Telephone Number: 770-220-3870•

When appropriate, photocopies of medical records will have been provided to summarize information requested. •

and Authenticated by G L Ferryman, MD

^ -X.

- I -o

i t

MAY 1 9 2010

Nichols, Dametta M (MR # 0436325) Printed by Kathreen M Lau [S794242] at 4/29/10 10:05 A M

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G R I E V A N C E R E V I E W C O M M I T T E E

FUITDN COUNTY

F U L T O N C O U N TY G O V E R N M E NT C E N T ER 141 Pryor Street S.W., Suite 3054

Atlanta, Georgia 30303 404-613-0919; F A X 404-224-3549

Apr i l 27 , 2 0 1 0

CERTIF IED M A I L R E T U R N RECEIPT R E Q U E S T E D

CD

Darnetta M . N i c h o l s

1030 R e u n i o n P lace

At lanta, G A 30331

-< c

Re: G r i e v a n c e Case #04-01-10-1505

Dear M s . N i c h o l s :

Please be adv i sed that you r hearing before the G r i e v a n c e R e v i e w Commi t tee has

been rescheduled to Thursday , |uly 15 , 2010 at 9 :00 a . m . The locat ion of the

hear ing w i l l be 141 P ryo r Street, Con fe rence R o o m 4 0 5 6 , 4*^ F loor of the Ful ton

C o u n t y G o v e r n m e n t Cen te r bu i l d ing . F i rearms a re not a l l o w e d in the g r ievance

hear ing r o o m . If you a re in L a w Enforcement a n d have a f i r e a r m , p lease secure

w e a p o n b e f o r e a t tend ing gr ievance hear ing.

If there is going to be an attorney, legal counsel, and/or witness(es) present at this

hearing, p lease not i fy this o f f i ce at least one (1) week in advance. It is the

grievant''s and/or the department's so le responsib i l i ty to not i fy their attorney/legal

counse l of any cor respondence that is received f rom this o f f ice wi th regard to this

gr ievance. The length of t ime a l l owed for your g r i evance is l imi ted to one(1) hour.

^'No Shows^'- In the event that nei ther party to a g r i e v a n ce reports at the

schedu led da te and t ime for the hear ing, the hea r i ng w i l l be reschedu led . If one

par ty repor ts at the schedu led date and t ime a n d the o the r par ty does not, the

g r i evance w i l l be reso lved in favor of the party repo r t i ng as schedu led (after 30

minu tes of wa i t ing) .

If for some reason you cannot attend the schedu led g r ievance hear ing, this of f ice

must be con tac ted within tenflO) days f rom the date o f receipt of this m e m o . A

valid reason must accompany you r request to reschedule. P lease contact me or

M a r y Ma jo r , Gr ievance Coord ina to r at (404) 613-0919.

Thank you for your cooperat ion in this matter.

S incere ly ,

Chr is t ine Greene , Chai rperson

G r i e v a n c e Rev iew Commi t tee

c c : John F. Szabo, Director, L i b ra r / Department

A n n e T. Ha imes, Branch G r o u p Manager

And rea Ak i t i , Librarian P r i nc i pa l , Branch Manager

\ Sy lv ia C u l v e r A ld r idge , L ibrae/ H u m a n Resources M a n a g e r

N/ Paris B r o w n , Director, Personne l Department (201 File)

Dav id W a r e , County At torney

G r i e v a n c e Fi le

CO

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o •XL c-> CD a: —t -< -o m

o

N o cont inuances w i l l b e granted wi thout good cause s h o w n .

If you have any quest ions w i th regard to this matter, p lease contac t me or M a r y

Ma jo r , Gr ievance Coo rd i na to r at (404) 613-0919 .

Chns t ine Greene, Cha i rpe rson /

G r ievance Rev iew C o m m i t t e e

cc : John F. Szabo , D i rec tor , Library Depar tment

A n n e T. Ha imes , Branch G r o u p Manage r

Andrea Ak i t i , L ibrar ian Pr inc ipa l , Branch Manager

\ Sy lv ia Cu lve r A l d r i d g e , Library H u m a n Resources M a n a g e r

Paris B rown, D i rec tor , Personnel Depari;ment (201 Fi le)

Dav id Ware , C o u n t y At torney

Gr ievance F i le

Sincerely,

valid reason must accompany your request to reschedule. Please contact me or

M a r y Ma jo r , Gr ievance Coord ina tor at (404) 613-0919.

Thank you for your cooperat ion in this matter.

S ince re l y ,

Chr i s t i ne Greene , Chai rperson

G r i e v a n c e Rev iew Commi t tee

c c : John F. Szabo, Director , Library Depar tment

A n n e T . Ha imes , Branch G r o u p Manage r

A n d r e a Ak i t i , Librarian P r inc ipa l , Branch Manager

\ Sy lv ia C u l v e r A ld r i dge , Library H u m a n Resources M a n a g e r

v Paris B r o w n , Director , Personnel Depar tment (201 File)

D a v id W a r e , Coun ty At torney

G r i e v a n c e Fi le

I— J

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CO

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-o p-i cn o

G R I E V A N C E R E V I E W C O M M I T T E E

F U L T O N C O U N TY G O V E R N M E NT C E N T ER 141 Pryor Street S.W., Suite 3054

A t l a n t a , Georgia 30303

404-613-0919; F A X 404-224-3549

A p r i l 13, 2 0 1 0

C E R T I F I E D M A I L R E T U R N RECEIPT R E Q U E S T E D

l/"Darnetta M . N i c h o l s

1 0 3 0 Reun ion P lace

A t lan ta , G A 30331

Re : G r i e v a n c e C a s e #04-01-10-1505

D e a r M s . N i c h o l s :

Y o u r hear ing before the G r i e v a n c e Rev iew Commi t t ee has been schedu led for

Thursday, lune 10, 2070 at 10:30 a.m. The hear ing w i l l be held in the Ful ton

C o u n t y G o v e r n m e n t C e n t e r Bu i ld ing , 141 P r y o r Street, Conference Room 4056, 4 *

Floor, A t l a n t a , G e o r g i a . F i rearms are not a l l o w e d in the g r ievance hear ing r o o m . If

y o u are in Law Enfo rcement a n d have a f i r e a r m , please secure w e a p o n be fore

a t tend ing gr ievance hear ing .

// there is going to be an attorney, legal counsel and/or witness (es) present at this

hearing, p lease not i fy this o f f i ce at least one (1) week in advance. It is the grievant'_s

and/or the department's sole responsibi l i ty to not i fy their attorney/legal counse l of

any co r respondence that is received f rom this o f f ice wi th regard to this gr ievance.

T h e length of t ime a l l owed for your gr ievance is l imited to one (1) hour.

^^No Shows'' - In the event that neither party to a grievance reports at the scheduled

date and time for the hearing, the hearing will be rescheduled. If one party reports

at the scheduled date and time and the other party does not, the grievance will be

resolved in favor of the party reporting as scheduled (after 30 minutes of waiting).

Th is of f ice must be contacted in wri t ing within ten (10) days f rom the date of your

rece ip t o f this m e m o if for s o m e reason y o u canno t attend the schedu led gr ievance

hear ing . A valid reason in wr i t ing must a c c o m p a n y your request to reschedule.

g: c;

-< m

C3; •

c r

G R I E V A N C E R E V I E W C O M M I T T E E

F U L T O N C O U N TY G O V E R N M E NT C E N T ER 141 Pryor Street S .W., Suite 3054

A t l a n t a , Georgia 30303

404-613-0919; F A X 404-224-3549

A p r i l 13, 2010

C E R T I F I E D M A I L R E T U R N RECEIPT R E Q U E S T E D

l/' Darnetta M . N icho ls

1 0 30 Reun ion Place

A t lan ta , G A 30331

R e : G r i e v a n c e C a s e #04-01-10-1505

Dea r M s . N i c h o l s :

Y o u r hear ing before the Gr i evance Rev iew Commi t tee has been schedu led for

Thursday, lune 10, 2010 at 10:30 a.m. The hear ing w i l l be he ld in the Ful ton

C o u n t y G o v e r n m e n t C e n t e r Bu i ld ing , 141 P r y o r Street, Conference Room 4056, 4""

Floor, A t l a n t a , G e o r g i a . F i rearms are not a l l o w e d in t he g r ievance hear ing r o o m . If

y o u are in Law En fo rcement and have a f i r e a r m , please secure w e a p o n before

a t tend ing gr ievance hea r ing .

// there is going to be an attorney, legal counsel, and/or witness (es) present at this

hearing, p lease not i fy th is o f f i ce at least one (1) week in advance. It is the ^rievant's

and/or the department's so le responsibi l i ty to notify their attorney/ legal counse l of

any cor respondence that is received from this of f ice w i th regard to this gr ievance.

T h e length of t ime a l l owed for your gr ievance is l imited to one (1) hour.

'''A/o Shows" - In the event that neither party to a grievance reports at the scheduled

date and time for the hearing, the hearing will be rescheduled. If one party reports

at the scheduled date and time and the other party does not, the grievance will be

resolved in favor of the party reporting as scheduled (after 30 minutes of waiting).

This of f ice must be contacted in wri t ing within ten (10) days f rom the date of your

receipt o f this m e m o if for s o m e reason you canno t attend the schedu led gr ievance

hear ing . A valid reason in wr i t ing must a c c o m p a n y you r request to reschedule.

G R I E V A N C E R E V I E W C O M M I T T E E F U L T O N C O U N TY G O V E R N M E NT C E N T ER

141 Pryor Street S.W., Suite 3054 Atlanta, Georgia 30303

404-613-0919; F A X 404-224-3549

FULTON COUNTY

O c t o b e r 8, 2010

~i

C E R T I F I E D M A I L R E T U R N RECEIPT R E Q U E S T E D C3 — I o c:

CO -< -o m Darnet ta M . N icho ls

1 0 3 0 Reun ion P lace

A t l an ta , G A 30331 CO o

I—

RE: G r i e v a n c e Case #04-01-10-1505

D e a r M s . N icho l s :

O n Augus t 27 , 2 0 1 0 , a cert i f ied letter was mai led to y o u not i fy ing you of the

arbi t rat ion process. Since you did not respond in the t ime a l lo t ted, no arbitrat ion

can p roceed . ^

T h e Library Depar tment has been not i f ied that y o u d id not respond to the arbitrat ion

request not ice sent to you . This case is c losed , ef fect ive immed ia te ly .

M a r y M ^ o r

G r i e v a n c e Coord ina to r

c c : John F. Szabo , Director, Library

A n n e T. Ha imes , Branch G r o u p Manage r

A n d r e a Ak i t i , Librar ian P r i nc ipa l , Branch M a n a g e r

\ Sy lv ia C u l v e r A ld r i dge , H u m a n Resources M a n a g e r

^ Paris B rown , Di rector , Personnel Depar tment (201 File)

D a v i d W a r e , Coun ty At torney

Arbi t rat ion Fi le

S ince re l y ,

Page 1 of 2

Dan ie l s, Kr is ty

To:

Cc:

Sent:

From: Haimes, Anne

Tuesday, July 07, 2009 1:56 PM

Smith, Jeanelle

Culver Aldridge, Sylvia; Florence. Yvonne; Daniels. Kristy; Hasten, Eugene

Subject: RE: Darnetta Nichols

The family medical leave paperwork Ms. Nichols submitted was incomplete. Her manager has asked her to submit the certification of health care provider form.

Anne T. Haimes

Branch Group Manager

Atlanta-Fulton Public Librar y System

Central Librar y

One Margaret Mitchell Square

Atlanta, Georgia 30303

Telephone; 404.730.1881

Efax: 404.335,5291

Email: anne.haimes@fultoncountyga.gov

www.afpls.org

From: Smith, Jeanelle Sent; Tuesday, July 07, 2009 9:47 AM To: Haimes, Anne Cc: Culver Aldridge, Sylvia; Florence, Yvonne; Daniels, Kristy ; Hasten, Eugene Subject: FW: Dametta Nichols Importance: High

Please let us know the status of Darnetta Nichols request for a leave of absence. Thanks.

From: Daniels, Kristy Sent: Monday, July 06, 2009 9:40 AM To: Smith, Jeanelle Subject: Darnetta Nichols

7/7/2009

Page 2 o f2

Importance: High

Jeanelle;

Please let me know the status on Ms. Nichols, she was placed off payroll last pay period dne to not leave and no paperwork to verify status. I need to get some infonnation regarding this employee to ensure that all records are accurate and updated for next pay period.

Thanks,

K r i s t y N , D'ainitels

IFulton Couiriiity Peirsonnet Departinnieinit

Pa i y ro ll & L e a ve SpeciaSiist

(4O4)|6n3~O9'0'i,- OHice

(404)214-11405; Fax

7/7/2009

Page 1 o f2

Dan ie l s, Kr is ty

To:

Cc:

From

Sent:

Haimes, Anne

Tuesday, July 07, 2009 1:56 PIVI

Smith, Jeanelle

Culver Aldridge, Sylvia; Florence, Yvonne; Daniels, Kristy; Hasten, Eugene

Subject: RE: Darnetta Nichols

The family medical leave paperwork Ms. Nichols submitted vi/as incomplete. Her manager has asked her to submit the certification of health care provider form.

Anne T. Haimes

Branch Group Manager

Atlanta-Fulton Public Librar y System

Central Librar y

One Margaret Mitchell Square

Atlanta, Georgia 30303

Telephone; 404,730.1881

Efax; 404.335,5291

Email; anne.haimes@fultoncountyga.gov

www/ afpls.org

From: Smith, Jeanelle Sent: Tuesday, July 07, 2009 9:47 AM To: Haimes, Anne Cc: Culver Aldridge, Sylvia; Florence, Yvonne; Daniels, Krisb/; Hasten, Eugene Subject: FW: Darnetta Nichols Importance: High

Please let us know the status of Darnetta Nichols request for a leave of absence. Thanks.

From: Daniels, Kristy Sent: Monday, July 06, 2009 9:40 AIM To: Smith, Jeanelle Subject: Darnetta Nichols

7/7/2009

To: 4048931661 Froil)^ (404730737?)

J "^Employee Profile Management

03/24/11 P 41 PM Page 3 oP 5

Page 1 o f2

E m p l o y e e P r o f i l e M a n a g e m e n t Menu

Employee ID : 0000015937 Name : NICHOLS. DARNETTA M

Appointment ID:

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Reason Position Number

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Position Number Desc : IlIB ASST, SR

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-•''Applican t Information -

Applicant ID: j Job Notice ID:

•''Probatio n Date Information-

Probation Start Date: 06/23/2010

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3/24/2011

4048931661 From^ (4047307377)

E m p l o y e e Profile Management

03/24/11 e^2 PM Page 4 oP 5

Page 2 o f 2

Probation End Date : j 12/22/2010

•Progress io n Date Information

Pay Progression Start:

Benefits Progression Start:

Leave Progression Start: 02/12/1997

•Classif icat io n Attributes

Payroll Number: OFFPR Title: 202352

Payroll Number Desc : jOFF PAYROLL

Pay Class : |EXCA [

Title Desc : JL IBRARY A S S T S R ;

Sub-title : I \

Pay Class Desc : jBIWK S A L A R Y

Civil Sen/ice Status : I LWOP

Sub-Title Desc : |L1B A S S T . S R

Assignment Type : i Permanent [ •• j

Civil Service Status D e s c : [ L E A V E W O P A Y

Time Class : F U L L

Time Glass Desc : F U L L TIME

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Pay Policy : Grade : A 1 3

Pay Policy D e s c : 1 Grade Desc: DBM R/\TING

Leave Policy : | F L S A FLSA : JNO Overr ide

Leave Policy D e s c : F L S A i FLSA Profile: l... : Benefits Policy : 1 FLSA Profile Desc: 1

Benefits Policy D e s c : 1

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Opt-Out: +

To: 4048931661 Froi»-- (4047307377)

Employee Profile Management

03/24/11 0 42 PM Page 5 oF 5

Page 1 o f2

E m p l o y ee P r o f i l e M a n a g e m e nt Menu

Employee ID : 0000015937 Name : NICHOLS, DARNETTA M Appointment ID :

Complete Timeline

Personnel Personnel Action Position Employment j Title

Sub- From To Action l^eason Number Status j Title title From To

U u UP V GB U GB U UP ABl

ILL FAIVl FAM

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0002448 0002448 0002448 0002448 0002448 0002448 0002448 0002448 0002448 0002448

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06/23/2010 04/28/2010 03/30/2010 08/12/2009 07/22/2009 07/18/2009 06/24/2009 05/10/2009 04/24/2009 07/11/2007

12/31/9999 06/22/2010 04/27/2010 03/29/2010 08/11/2009 07/21/2009 07/17/2009 06/23/2009 06/09/2009 04/23/2009

First Prev Next Last Download CurrentTimellnB Complete Timeline Custom Timeline Attachments

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First Name : DARNETTA

Middle Name; M

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12/31/9999

Original Appointment Date : 06/12/1996

•Ass ignmen t Information-

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Personnel Action Desc : L W O P

Personnel Action Reason : j iLL

Personnel Action Reason Desc : jlLLNES S

Employment Status:

Employment Status Desc:

Home Department:

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Home Department Desc: (Librar/

Home Unit: 6540 ;

Home Unit Desc; Library - South

Position Number: 0002448

Step:

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Percent Full-time:

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Union Member: r [Jr..

Union Affiliation:

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http://prod-webl/webapp/HRPROD/Advantageijsessionid=0000NjZ0pTlFvyFxgIrqOs2GI... 3/24/2011

Opt-Out: +

0 0

DAIUNTETTA N I C H O L S 260.39-6724

J O B DESCRIPTION

UGHT-DXJT Y L IBRARIA N ASSISTIAN T

Essgntia l Dutieg !

Th e employee, Dametta Nichols, may process librao^ books to include wTiting , stapling, stamping books wit h rubber stamp, light data ent^, scanning and other job tasks so designated by the employer. The employee may perfor m customer service duties to indiid e staffing the librar y coverage desk to process librar y books, answering telephones and perfor m general clerical, libraria n end other customer service job tasks so designated by the employer.

The employee is not required to l i f t in excess of work restrictions Issued by the authorized treatmg pbys idsa oa Februaiy 20,20 04 (Sae attached report), shalw books or push carts whil e imderlight-dutywor k restrictions. The employee is released to work 8 hours per day.

As the autboriied treating pbygiciiinj I certify that Ma. Dametta Nichols is released to perfor m the above essential jol j duties and may retur n to work .

Dr . Marvi n Royster, Authorized Treatiag Physician Date

PEACHTREE ORTHOPAEDI C CLINI C

RETURN TO WORK FORM

2001 Peachtree Road Suite 705 Atlanta, GA 30309 (404) 355-0743 (404) 355-2136 fax

2045 Peachtree Road, N.E. Suite 700 Atlanta, GA 30309 (404) 355-0743 (404) 603-9887 fax

1901 Phoenix Blvd. Suite 200 College Park, GA 30349 (404) 355-0743 (770) 991-6477 fax

5505 Peachtree Dmwoody Road Suite 600 Atlanta, GA 30342 (404) 355-0743 (404) 943-0641 fax

3855 Pleasant Hill Road Suite 480 Duluth, GA 30096 (404) 355-0743 (770) 813-8944 fax

Michael R Bernot, M.D.

James L. Beskin, M.D.

Xavier A. Duralde, M.D.

Carl D. Fackler, M.D.

Letha Y Griffin , M.D.

Anuj Gupta, M.D.

John D. Henry, ]r., M.D.

hee A, Kelley, M.D.

Edward C. Loughlin, In, M.D.

Stephen M. McCollam, M.D.

Allen R McDonald, M.D.

Thomas J. Moore, M.D,

Douglas H. Murray , M.D.

H. Herndon Murray , M.D.

Eric R. Oser, M.D.

R. Howard Pike, M.D,

Ashok S. Reddy, M.D.

R. ^ afv r RoysterJ TD .

D. Hal Silcox, 111, M.D.

Stephen W Smith, M.D.

Physical Medicine and

Rehabilitation

Donald F. Langenbeck, M.D.

Shevin D. Pollydore, M.D.

David A. Schiff, M.D.

Date: ^

Patient

Diagnosis: .

Work Status :

Date to return to light duty

I M a t i r ^ n . . - 473,1,1 IAi\\l{ K 1 ^ / ' i - . f j ' < ^ ^ 5

• • •

Date to return to full duty:

May not return to work

Will return to medical office for re-evaluation on:

Other Comments:

A-

Date Physician Signm ure / _ M.D.

PEACHTREE ORTHOPAEDI C CLINI C

RETURN TO WORK FORM

2001 Peachtree Road Suite 705 Atlanta, GA 30309 (404) 355-0743 (404) 355-2136 fax

2045 Peachtree Road, N.E. Suite 700 Atlanta, GA 30309 (404)355-0743 (404) 603-9887 fax

1901 PhoenhBhd. Suite 200 College Park, GA 30349 (404)355-0743 (770) 991-6477 fax

5505 Peachtree Dunwoody Road Suite 600 Atlanta, GA 30342 (404) 355-0743 (404) 943-0641 fax

3855 Pleasant Wll Road Suite 480 Duluth, GA 30096 (404) 355-0743 (770) 813-8944 fax

Michael R Bemot, M.D.

James L. Beskin, M.D.

Xavier A. Duralde, M.D.

Cari D. Fackler, M.D.

Letha Y. Griffin , M.D.

Anuj Gupta, M.D.

lohn D. Henry, In, M.D.

Lee A. Kelley, M.D.

Edward C. Loughlin, Jn, M.D.

Stephen M. McCollam, M.D.

Allen R McDonald, M.D.

Thomas I. Moore, M.D.

H. Herndon Munay, M.D.

Eric R. Oser, M.D,

R. Howard Pike, M,D.

Ashok S. Reddy, M.D.

R. NJarvnfRoysten Mift .

D.Hal Silcox, III , M.D.

Stephen W Smith, M.D.

Physical Medicine and

Rehabilitation

Donald P. Langenbeck, M.D.

Shevin D. Pollydore, M.D.

DavidA. Schiff, M.D.

Date:. ^ - f i O ' O ^

Patient:

Diagnosis

Work Status:

Date to return to light duty:

LimitationsL -^n( \ P t t f ^ i / C p t ^ i l ^ ^ f c i ^

• • •

Date to return to full duty:

May not return to work

Will return to medical office for re-evaluation on:

Other Comments:

1 '

I

jREC'D j

Date Physician Signature

i~ J.o Ulr;ii."^ I UK i u U PAGE 0

Atknta-Fidto n Public Librar y System

FttlMftHT f I N T E R O F F I CE M E M O R A N D U M

T O ; Dametta Nichols, Library Assistant Sr. Southwest Regional Library

C Ci Sylvia Culver, Library Human Resource Manager Teffeny Edmondson, Librarian Senior Southwest Regional Library Dariene McDade, Librarian Senior Southwest Regional Library Dorothy Moseley, Library Associate Southwest Regional Library

F R O M: .Anne T, Haimes, Interim Library Director ^ -

D A T E : Januarys 2005

S U B J E C T: Change in Work Assignment

To clarify my December 29, 2004 memorandum, you are to report to, work in and be scheduled for the Soutliwest Regional Libraiy Children's Department, Tlii s wi l l ensure consistency in your work assignment and facilitate developing a work plan.

. 4

Araie T. Haimes, Interim Director of Libraries

Om MAspmt Mitch«ll Squire. Ailauita, Geoipi 39303-1089 (404) 730-1972, fW(4«M)

PERFORMANCE APPRAISAL - FULTO N COUNTY

Department T.ihrary / Nnrf-h.q1dlp. Branch Employee's Name Darnetta Nichols

Social Security Number ?f,n-' Q-fi7?.i Date of Hire 6/96 Ray Range A-13

Classification Senior Librar y Assistant pate of Last Appraisal " ' ^

FLSA Category Exempt ^ --Non-Exempt EEO Classification Clerical

Type of Appraisal Annual Period of Review "7 - I - o | ta U - tOg

OVERA U PERFORMANCE RATIN G FOR EMPLOYEE' S PERMANENT PERSONNEL RECORDS: Rating Score ^

Outstanding (y\cceptabley' Fair: Failing Failed: ° — ^ Needs Improvement

BASIC TERMS AND CONDITION S OF EMPLOYMENT :

Qf rformanc e fulfill s tenns and conditions of employment (Satisfactory)

QPerformanoe needs improvement in fulfillin g terms and conditions of employment (FVovide Explanation.)

3 •Berformanc e does not fulfil l terms and conditions of employment (Unsatisfactory Attach copy of suspension.) D . ^ -I .

5 • . — — t g PERFORMANCE SUMMARY : Summarize reason for employee's overall rating, including any strengths or weaknesses that are pertinent - to the appraisal. ^ « -

Signature of Immediate Supervisor: c Ia - —e-^ /r\-^—^^^^^ Pate: <C? - - o 'X^

Signature of Next Level Supervisor: ^ ^ ' FJ'^— Date: ^ / 5 / <^'^

EMPLOYEE' S COMMENTS:

Employee's Date: ^^'^^/YJ^

Signing this review does not constitute agreement or disagreement and only indicates employee has read and received a copy of Perfor-mance Appraisal.

RATIN G SUMMAR Y

Rating Weighted Responsibility Area Weight (Whole Numbers) Rating

1.Performs Circulatio n Desk dutieg 300 ) X 2 = 600

2. Search "Claim s Returned" List s ( 50 ) X 3 = 150

3.Paperback Coordinator ( 100 ) X 2 200

4.Return books to other agencies ( 50 ) X 2 = 100

5.Assist Mends Coordinator ( 50 ) X 2 100

6. In-House Material s Circulatio n ( 50 ) X 2 100

7-Shelves Librar y Material s ( 200 ) X 3 600 Barcoding Coordinator . Pulls daily routers l i st I 150 ) X 2 — 300

9-Revise Branch New Book Lis t ( 50 ) X 2 = 100

1,000 20 2250-

OVERAL L PERFORMANCE

RATING *

WEIGHTE D TOTAL = 1,000 = 2.25

*Once overall performance rating has been calculated, the rating should be rounded. Anything .5 or above should be rounded up to the nearest whole number. Anything .4 or below should be rounded down to the nearest whole nunrtber.

OVERALL P E R F O R M A N C E LEVELS

Outstanding 3 Acceptable 2 Fair, But Needs Improvement 1 Failing/Failed 0

. l O ^ i ^ o i ! b i n

Rater Sifflature: ( ^ ^ / n ^ ^ ^ y ^ - Y^-T'—^^ . Date 6 -Y

RATIN G SUMMAR Y

Responsibility Area Weight Rating

(Whole Numbers) Weighted

Rating

1

2 .

3 .

4 .

5 .

6 .

7.

8 .

9 .

•Perform s Circulatio n Desk duties • Serves as Shelving Coordinator

or shelving

Provides Customer Services

Processes Materia l

Processes and Distributes Book Return

Performs router l ist,Tracers, Claims Returned and branch loan act iv i t ies,Assist with Holds

Attends meeting and Trainin g Sessions

250

225

100

150

100

100

75

X

X

X

X

X

X

X

X

X

3

p .

1,000 5

OVERALL PERFORMANCE

RATING*

WEIGHTE D TOTAL = 4- 1,000 =

*Once overall performance rating has been calculated, the rating should be rounded. Anything .5 or above should be rounded up to the nearest whole number. Anything .4 or be ow should be rounded down to Ifie nearest whole number.

OVERALL P E R F O R M A N C E LEVELS

Outstanding 3 Acceptable 2 Fair, But Needs Improvement 1 Failing/Failed 0

Rater Signature: ^- /^-^^^- y Date C^- Xuf - ^ 2^

PERFORMANCE APPRAISAL - FULTON COUNTY

Department Librar y Employee's Name Darnetta M. Nichols

Social Sehjrity Number 260-39-6724 \ Date of Hire 05/96 Ray Range A-13

Date of Last Appraisal July 1999 Classification Librar y Assistant Senior

FLSA Category Exempt X Non-Exempt EEO Classification Cler ical

Annual Type of Appraisal Fteriod of Review July 1.2000 to June 30,2001

OVERAL L PERFORMANCE RATING FOR EMPLOYEE S PERMANENT PERSONNEL RECORDS: Rating Score <X.

Outstanding Acceptable Fair: But Needs Improvement

Failing/Failed:

BASIC TERMS AND CONDITION S OF EMPLOYMENT :

•rformanc e fulfill s terms and conditions of employment (Satisfactory)

•Fterformanc e needs improvement in fulfillin g terms and conditions of employment (Provide Explanation.)

I •Pedbmnanc e does not fulfil l terms and conditions of employment (Unsatisfactory. Attach copy of suspension.) ) •

i — — ' ^ '•

j PERFORMANCE SUMMARY : Summarize reason for employee's overall rating, including any strengths or weaknesses that are pertinent • to the appraisal.

Signature of Immediate Supervisor: p^u

Signature of Next Level Supervisor:

EMPLOYEE' S COMMENTS :

Date:

Date: "V/^lnl r

Signing this review does not constitute agreement or disagreement and only indicates employee has read and received a copy of Perfor-mance Appraisal.

PERFORMANCE APPRAISAL - FULTON COUNTY

Department Librar y Employee's Name Darnetta M. Nichols

Social Security Number - 260-39-6724 - . Date of Hire 07/01/96 F y Ranse 20.068.00

Classification Librar y Assistant Sr. Date of Last Appraisal June 1999

FLSA Category Exempt Mon-Exempt EEO Classification (<f ' I

Type of Appraisal >^u^4 Period of Review "7— / ~ "T to - 3a - caJ

OVERAL L PERFORMANCE RATIN G FOR EMPLOYEE' S PERMANENT PERSONNEL RECORDS: Rating Score 3 . , . _

/tDutstandingJ> Acceptable Fair: Failing/Failed: I — B u t Needs Improvement

BASIC TERMS AND CONDITION S OF EMPLOYMENT :

Ii3l rformanc e fulfill s ternis and conditions of employment (Satisfactory)

•Fterformanc e needs improvement in fulfillin g terms and conditions of employment (Provide Explanation.)

•Fterformanc e does not fulfil l terms and conditions of employment (Unsatisfactory Attach copy of suspension.)

PERFORMANCE SUMMARY: Summarize reason for employee's overall rating, including any strengths or weaknesses that are pertinent to the appraisal.

Signature of Immediate Supervisor: ^ Date:

Signature of Next Level Supervisor: / •— ^

EMPLOYEE' S COMMENTS :

Date: / J ^ /

Employee's Signature: Date: •1± Signing this review does not constitute agreement or disagreement and only indicates employee has read and received a copy of Perfor-mance Appraisal.

RATIN G S U M M A R Y

Responsibility Area Weight

Rating

(Whole Numbers) Weighted

Rafa'rtg

T. P r o c e s s e s and p r e p a r e s new bo{^ks200 ) and m a t e r i a l s f o r c i r c u l a t i o n

2-Helps c h i l d r e n and t h e i r p a r e n t s ( 200 ) w i t h books and m a t e r i a l s a t c h i l d r e n s desk

3 -Prepa res b o o k s , d v d s , and :.i.adio | iooks200) f o r d i s p l a y

4 . S h e l v e s and c l e a r s m a t e r i a l s i n ( 200 ) c h i l d r e n s depar tment

5. P r e p a r e s f l y e r s f o r programs ( 100 ) i n c h i l d r e n s depar tment

6- A s s i s t s w i t h c h i l d r e n ' s program^ 200 ) w i t h p a r e n t s and c a r e g i v e r s

7. (

8 .

9 .

(

X

X

X

X

X

X

X

X

X

600

-3

•J2

•60 0

400

^600

1(1(00

200

2500

OVERAL L PERFORMANCE

RATING *

WEIGHTED TOTAL = ^ 1,000 =

*Onoe overall performance rating has been calculated, the rating should be rounded. Anything .5 or ahiove should be rounded up to the nearest whole number. Arrything .4 or beiow should be rounded down to the nearst whole number.

OVERAL L PERFORMANCE LEVEL S

OutaHTidir ^ 3 AtxEprtaH e 2 Fair, But Needs Improvement 1 Failing/'Failed 0

Rater Signature: Dale

PfcpvrORMANCi APPRAISAL - FULTON C O U . , iY

Department SovH-hwft.sf- Rr^nrh T.T^vary

Sodal Security Nun±>er 260-39-6724

Qass'rfication L i b r a r y A s s i s t a n t S e n i o r

FLSACategory Exempt

Empfoyee Nan>e ; p a r n e t t a N i c h o l s

DateofHire 0 6 / 9 6 _Ray Range_ A13

Dateof LaaAppfBisal -July 2008

NravB<empt EEO Casafication

• Type(rfAppfabal Pe r f o rmance A p p r a i s a l PferkxJ of Review J u l y 2008 to June 2009

OVBWU-PEItfORMANCIRATIN G R 3 R E ^ « J O Y f f i S P m A 4 A N ^ Ratn Soore_

Ouldanding Acceptable Fain But Needs Improvement

Failing/feiled:

BASIC TIRM S AND CX)NDniONS OF EMPLOYMEW :

QFterfomnance fuffill s temis and conditions of employment (SatfetactDry.)

QFterfomnance needs improvement in fiifillir g temis and cx>nditions of employment (Provide Expbnation.)

D •Fterformanc e do^ not fiifii l terms and condrtiorB of employment (UnsafefEKlory. Attadi copy of suspensioa) O ^ ^ : . ^ _ _ _ _ _ u.

^ . . _ a. ——-—— ' u.

o •- —• — — _ ^ . ^ — § PBtFOifMAJSfCE SUMMARY Summarize reason for enployee's overall rating, including any strer rfi s or weaknesses that are pertiner I- t» tbe appraisal. M r s . N i c h o l s c o n t i n u e s to do o u t s t a n d i n g work i n the c h i l d r e n ' s depar tment

She p r o c e s s books aiid. m a t e r i a l s ; , s e t s up d i s p l a y s , s h e l v e s and o r g a n i z e s the c h i l d r e n ' s -d e p a r t m e n t . She s t a y s l a t e and a s s i s t s w i t h s p e c i a l p rograms and our Pr ime Time' R e a d i n g P r o g r

Si iatur e of Immediate Supervison_

S nature of Next Level Supervisory

BMimEESOMMENfTS:

Date: tjnjo^ Date:

7

Emprfoyee's SignatureJoj Date:

Signing tfiis review does net con lute reenrent or dis^een«nt aid only ir«iicates emffcyee has read and received a copy of Fterf manoe ApfHaeal.

Departnrtent L i b r a r y

P t ^ R A 4 A N C E APPRAISAL • F U L T O N C O t . . -Y

Emptoyee'sName D a r n e t t a N i c h o l s

SocofSeburity Number M-^^Sit

Classification L i b r a r y A s s i s t a n t S e n i o r

FLSACat^or y DcempE

DateofHire 06 /96 _RayRange_ A13

_ Date of Last Appraial 07/07

Non-Exempt EEO Classification

Type of Apf>rafeJ_ Reriod of Review J u l y 2007 to June 2008

O V e A I X P B O ^ m A f c i ^ R A T l N G K ^ B m O Y H S P m M A N e ^ r a ^ RattngScore ^

Gftiistanding y AcceptaUe Fain FailinsT led: ' But Needs Improvement

BASIC ItRM S AND CX»<4DniOhS Or EMPtOVMENT :

EJFterformance fulfill s terms and conditions of employment (Satisfactory.)

•Fterformanc e needs improvement in fulfiHin g terms and conditions of emfrfoymenL (Provide Bcplanation.)

D •FterfbrrrBno e does not fiifil l tarr s and oondhjons of employment (Unsatisfactory. Atlach copy of aBpension.) o ; a.

^ .. ^ ^ ^ u, • — - —•— O — ^ _ ™ ^ ^ ^ ^ ^ ^ _ ^ ~ — g f^MFC^MANC E SUMMARY Summarize reason for anployee's overall rating, including any strer ths or weaknesses that are pertinei h- to the appraisal.

M r s . N i c h o l s does a w o n d e r f u l j o b h e l p i n g t h e p a t r o n s i n the c h i l d r e n ' s D e p a r t m e n t . She does wha tever i s needed f o r the department^ f u n c t i o n i n s t a f f a b s e n c e s and m e e t i n g s . M r s . N i c h o l s p r o c e s s e s books and m a t e r i a l s i n a t i m e l y but i , needs to g e t the m a t e r i i ou t t o t h e p u b l i c a f t e r they have been p r o c e s s e d .

Signature of Immediate Supervison ""^^^( ^ §hl4i^-^^ Date: '^/ihjOB' Sfenaftire of Next Level Supovtajr: fyO^^ Yj^-j Date: 0 7'/I''OK.

S^ir ^ this review does net conaitute mnent or dfe^eement and only tndkates anpfcyee has read and received a copy of Fterl nranoe Appraial .

PERFORMANCE APPRAISAL - FULTON COUN IT

Departm^t T.ihrgry

S(XBi Security Nunroer L i b r a r y A s s i s t a n t Sen io r

Classification

Empfoyee's Nbme D a r n e t t a N i c h o l s

DateofHire Q6/96

FLSACat^or y _B<empE Non-Exempt

Date of Last Appraisal_

EEO Oasafication

_F^Range_

7/06

A13

Type of Appraisal A n n u a l Paiod of Review J u l y 2006 to June .2007

OVHem-PBaHm|AfcKSRATINGFOR^4MJ^ ^ Rating SGOfe_

Outaanding Aoc jtaH e Fain But Needs Improvement

Railir Failol :

BASIC TERMS AND CONDITIO! ^ EMPlOVMENT t

CiFterfomrance fulfill s tseims and conditions of employment (Satislactory.)

•Fterformanc e n^ds improvement in fulfiHin g terms aiKl conditions of emfJoyment (PrD\flde Explanation.)

O

s

u. 0 et 25

•Fterfbrnranc e dros notfdfil l terms aixl conditions of employment (Unsatfefactory. Attach copy of suspension.)

PBtFC^MANC E SUMMAfHi i Summarize reason for employee's overall ratmg, including any strergths or weaknesses tiiat are pertirer

totheappraiffll. N i c h o l s does a w o n d e r f u l j o b h e l p i n g pa t rons i n the c h i l d r e n ' s departmer She e n j o y s w o r k i n g the c h i l d r e n ' s r e f e r e n c e desk and does not mind l & l p i n g when t h e r e a re s h o r t a g e s m t h e d e p a r t m e n t . M r s . i N l h h o l s does a w o n d e r f u l j ob Broc(#ssiBg-mrt ' f f rra: irmi ^'°'°Bed ' to be more t img^ly g e t t i n g the m a t e r i a l s out to t he p u b l i c . i W c X ' Y r i ^ ^ - \

AUG 2 3 2007 j

S nature of Immediate Supervisor:

S nature of Next Level Supervison

EMPlOVff'S COMWef fS:

Date:

Date: ^ / f o h l .

Emf opyee's S' natur< Date:

Signir thi s review do^ rwA constitute ^eenient or disageeinent and only indicates emffcyee tes re^ and reoerved a copy of Fterf marKf i Apjwaial .

iATIN G SUMMARY

Responsibiiity Area Weight Rating

(Whole Numbers) Weighted

Rating

T . D e l e t e s b o o k s and m a t e r i a l s { 300 J X

2 . P r e p a r e s d i s p l a y s and e x h i b i t s { 200 ) X

f o r h o l i d a y s and f l y e r s {

3. P r o o e s s B s a and p repa res new ( 200 ) X bnew books

( X

4 . C o n v e r s t s new books i n t o ( 2D0'. i.) X - . . . c i r c u l a t i o n sys tem

(

5 . A s s i s t I n c i r c u l a t i o n departmenfy 100 ) X when needed

6. ( ) X

7. ( ) X

8- ( ) X

3. ( ) X

600

600

600

600

200

1,000 2600

WEIGHTED TOTAL =

OVERAL L PERFORMANCE

RATING *

1,000 =

*Once overall |>erformance rating has been caloilated, the rating should be rounded. Anything .5 or above should be rounded up to the neareS w/hde number. Anything .4 or below should be rounded down to the nearet M/ho)e number.

OVERAL L PERFORMANCE LEVEL S

Outstandir^ 3 Acceptable 2 Fair, But Needs Improvement 1 failir^faile d 0

Rater Sigoature: I3ate

R A T I N G S U M M A R Y

Responsibif itv Area Weight

1. D e l e t e s Books and m a t e r i a l s , 300 X

on m i s s i n g book r e p o r t

2 . P repa res d i s p l a y s and e x h i b i t s / 200 , X

f o r h o l i d a y s and f l y e r s 200 . 3 . P r o c e s s e s and p r e p a r e s new books 200 .

X

4 . Conver ts new and o l d books i n t O / 200 . X

c i r u l a t i o n sys tem X

5 . A s i s t s i n c i r u l a t i o n s t a f f i n / 100 , X

c i r c u l a t i o n depar tment

6. ) X

7- ) X

8- ) X

9 . ) X

Rating

(Whole Numbers) Weighted

Rating

600

600

600

600

200

2600

OVERALL P E R F O R M A N C E

R A T I N G *

WEIGHTE D TOTA L = 1,000 2.6 = 3

"Ones overall performance rating has l^en calculated, tfie rating should be rounded. Anyiiirng .5 or above should be rounded up to the nearest whole number. Anything .4 or below should be rounded down to the nearet whole number.

OVERALL PERFORA4ANCE LEVELS

Outdandrr ^ 3 AcceptaUe 2 fair . But Needs Improvement 1 feilir^Failed 0

D e a r b o r n ^ N a t i o n a l "

One Riverfront Plaza • Westbrook, Maine 04092-9700 • (866) 537-7632 • Fax (866) 537-7682

August 16, 2011

Darnettc Nichols , , , . . ^ . -1030 Reunion Place W - i M ^ l n l X/A\i.rrf%€>^^^ Atlanta, GA 30331

Dear Ms. Nichols,

This letter acknowledges receipt of copies of your medical records from Kaiser Permanente. At this time, we are still waiting for the Attending Physician's statement stating exact restrictions and limitations to go along with the medical records already in your claim file. We also may require additional medical records from other providers that we become aware of during the claim review.

To be eligible for benefits, you must full y satisfy the definition of disability as stated below:

"DISABILIT Y OR DISABLED

The definition of Disability changes after LT D benefits have been paid for 24 months.

1. Until LT D Benefits have been paid for 24 inonths, you are only required to be D ISABLED from your own occupation.

You wil l be considered Disabled from your own occupation i f as a result of your sickness, accidental bodily injury, or pregnancy, you are either:

a. Unable to perform with reasonable continuity the material duties of your own occupation; or

b. Unable to earn more than 80% of your Indexed Predisability Earnings while working in your own occupation.

Until LT D benefits have been paid for 24 months, you wil l be considered Disabled while working in another occupation i f you are Disabled from your occupation. During the first 24 months of LT D benefits, L T D benefits wil l be paid even i f your earnings from work in a new occupation exceed 80% of your indexed Predisability Earnings. The Return to Work Provision in Part 8A explains the effect your work earnings wil l have on the amount of your LTD benefit.

2. After LT D Benefits have been paid for 24 months, you must be Disabled from all occupations.

Products and services marketed under tlie Dearborn National™ brand and the star logo are underwritten and/or provided by Fort Dearborn Life Insurance

Company® (Downers Grove, IL) in all states (excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin Islands and Guam,

D e a r b o r n ^ N a t i o n a l "

One Riverfront Plaza • Westbrook, Maine 04092-9700 • (866) 537-7632 • Fax (866) 537-7682

September 16, 2011

Darnette Nichols 1030 Reunion Place Atlanta, GA 30331

Dear Ms.. Nichols,

We are writin g to advise you of the status of your Long Term Disability benefits.

We are notifying you that due to special circumstances we will be extending the investigation of your claim by an additional 30 days.

We are waiting for the Attending Physician's Statement This statement provides the restrictions and limitations that are placed upon you by your treatment provider.

Your cooperation in providing the above information is greatly appreciated and will serve to expedite the handling of this claim. If you should have any questions, please contact me at the number beigvj.

CC: Fort Dearborn Life Insurance Co

Products and services marl<eted under the Dearborn National™ brand and the star logo are underwritten and/or provided by Fort Dearborn Life Insurance

Company® (Dovi/ners Grove, IL) in all states (excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin Islands and Guam.

Darnette Nichols Page 2

You are Disabled from all occupations if , as a result of your sickness, accidental bodily injury, or pregnancy, you are either:

a. Unable to perform with reasonable continuity the material Duties of any gainful occupation for which you are reasonably fitted by education, training, and experience; or

b. Unable to earn more than 80% of your Indexed Predisability Earnings while working in your own or any other occupation."

Once all the information required to review your claim is submitted, we wil l evaluate the complete fil e to determine if you satisfy the definition of disability as stated above along with contractual eligibility .

Products and services marketed under tlie Dearborn National™ brand and the star logo are undenAfritten and/or provided by Fort Dearborn Life Insurance

Company® (Downers Grove, IL) in all states (excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin Islands and Guam.

RE: Dametta Nichols 9

PSYGHOMETRICS- :

Waddell's Non-Organic Signs: 0 out of 4 categories positive. A score of 3 or greater suggests the presence of non-organic problems for client's with low back pain.

Waddell's Inappropriat e Symptoms Questionnaire: 4 out of 7 categories positive. A score of 2 or more positive answers are indicative of behavioral symptoms separate from common mechanical symptoms of back pain.

Ransford Body Drawing: 6. A total score of 3 or more suggests poor psychometrics.

McGiII>30 : 51. A score of 30 or greater indicates poor psj'chometrics.

Pain Scale (0-10): Atbeginningof evaluation: 7/10 At best past 30 days: 7/10 At end of evaluation: 7/10 At worst past 30 days: 10/10

Dallas Pain Questionnaire >50''' percentile: 4 out of 4 factors. Scores above the 50* percentile are graded as having significant interference with functional and/or emotional aspect of client's life. Factor I: 90% Daily Activity Interference Factor II: 100% Work and Leisure Activities Interference Factor III : 65% Anxiety/Depression Interference Factor IV : 85% Social Interest Interference

Oswestry Low Back Questionnaire: 58% 0% - 20% Minimal Disability

20% - 40% Moderate Disability 40% - 60% Severe DisabOity 60% - 80% Crippled 80% -100% Bed Bound or Exaggerating Symptoms

Termination of tests was primaril y related to: There are three reasons a test/activity can be terminated during the Functional Capacity Evaluation. They are as follows: 1) The client meets or exceeds maximum permissible target heart zone, 2) The client meets his or her biomechanical limit as evidenced by upper or lower extremity weakness, instability, unsafe body mechanics or range of motion limits, or 3) The client chooses to discontinue the test because of subjective pain complaints or subjective fatigue.

17 of 17 tests were completed by the client as indicated.

Appropriat e Cardiac Response: Yes

Should you have any further questions regarding the results of this Functional Capacity Evaluation, please contact our clinic at 770-947-5440. Thank you very much for allowing us to perform this assessment.

Doug Akers, PT, DPT, MTC Date G L Perryman, M D Date

RE: Dametta Nichols 8

Kneeling: The client was able to complete the kneeling test to 5 of 5 minutes. HR start to tennination: 113 to no BPM. Demonstrated Performance/Comments: The client was observed to kneel with equal weight on both knees.

Crawling: The client was able to complete the crawling activity to 30 ft. forward with normal body mechanics, normal alteration of bilateral upper/lower extremities, normal trank rotation, and normal weight shifts in 41 seconds. HR start to termination: 112 to 114 BPM.

Overhead Reaching: The client was able to complete the overhead reaching activity by transferring cones at approximately eye level for 5 minutes. HR start to termination: 108 to 102 BPM. Demonstrated Performance/Comments: Client demonstrated normal weight transfer between right and left legs and normal mechanics with this activity.

RE: Dametta Nichols 7

FREQUENT MATERIAI . HANTDLING

Starting Values Termination Values

Floor to Waist Lif t 5 lbs. 5 lbs./20 reps. Overliead Lif t 2 lbs. 2 lbs./20 reps. Bilateral Carry 2 lbs 2 lbs./20 reps.

Time: 15 minutes and 14 seconds. HR start to termination: 109 to 111 BPM. Demonstrated Performance/Comments: The client demonstrated a safe technique with the frequent lift/carry circuit. The client was observed to be fatigued during this activity and required verbal instraction to maintain proper technique/form with lifting .

NON-MATERIAL HANDLIN G

Sitting: The client was observed to sit for over 1 hour during the initial intake paperwork and interview with two standing rest breaks. Demonstrated Performance/Comments: Client demonstrated what would be considered normal weight shifting during this time and was able to maintain the sitting position.

Stand/Walk: The client was observed to stand/walk for over 1 hour during the material and non-material handling activities, with no objective limitation noted.

Standing: Observed to static stand for 5 minutes, with no objective limitation noted.

Walking: The client was observed to walk for 20 minutes on the tireadmill at 1.5 MPH. HR start to tennination: 104 to 101 BPM. Demonstrated Performance/Comments: The client utilized bilateral hand support intermittentiy on the handrails and demonsfrated normal upright posture.

Stair Climbing: The client was observed to ascend/descend 50 steps in 4 minutes and 3 seconds. HR start to termination: 95 to 109 BPM. Demonstrated Performance/Conunents: Client demonstrated good technique with this activity with alternative use of left and right legs.

Ladder Climbing: The client was observed to climb 3 mngs of a standard ladder for 20 repetitions in 4 minutes and 47 seconds. BR start to termination: 103 to 121 BPM. Demonstrated Performance/Comments: The client demonstirated normal technique with this activity, alternately using left vs. right legs as dominant and bilateral upper extremities for assistance/support.

Balance: The client's balance was observed to be fully functional on all material and non-material handling activities. Demonstrated Performance/Conunents: The client demonstrated normal balance throughout the material handling section of the test, as well as with heel walking, and toe walking for 30 feet each.

Bending: The client completed the repetitive bending test to 20 of 20 repetitions in 1 minute and 46 seconds. HR start to tennination: 97 to 97 BPM. Demonstrated Performance/Conunents: Client demonstrated normal mechanics with this activity.

Repetitive Squatting: The client completed the repetitive squatting test to 20 of 20 repetitions in 1 minute and 49 seconds. HR start to termination: 96 to 112 BPM. Demonstrated Performance/Comments: Client consistenfly used the left hand to reach to the floor.

RE: Dametta Nichols

^ U P I ^ EXTREMlTYA/AIi lDrn Y TESTING:;

6

Hand Dominance: Right

Five Position Handgrip Curve Analysis: This test uses the Jamar hand dynamometer to measure isometric force generated by the hand in five handle positions. If a client is providing maximum effort on the Jamar, a bell curve pattern of score distribution is expected. A non-hell shaped curve is suggestive ofsubmaximal effort.

Position 1 2 3 4 5

Right 25 lbs. 40 lbs. 30 lbs. 20 lbs. 20 lbs. Left 30 lbs. 35 lbs. 40 lbs. 30 lbs. 20 lbs.

Bell-shaped curve evident: Right: Yes Left: Yes A non-bell shaped curve may be suggestive of a submaximal effort.

Rapid Exchange of Grip : High Right 35 lbs. High Left 30 lbs.

Comments: The maximum value of the Rapid Exchange of Grip did not exceed the maximum value of the Hand Grip test by greater than 12 lbs. suggesting that conscious or subconscious effort of grip are consistent.

Repeated Grip Strength

Average Grip Strength Coefficient of Variation

Right Left

33.33 lbs. 33.33 lbs. 14.14% 7.07%

(for 3 trials at position 2) (for 3 trials at position 2)

^OCCASIONAL MATERL\ L HANDLIN G

Floor to Waist Lift : The client was able to complete the floor to waist lif t with 10 lbs. over 5 repetitions in 1 minute and 16 seconds. HR start to termination: 90 to 110 BPM. Demonstrated Performance/Comments: In attempting to determine the safe liftin g load the client lifted 10 lbs. The client was observed to stand in a split stance, with her left leg forward. The client was observed to have bilateral lower extremity weakness with return to stand. The client was observed to have met a safe biomechanical limit.

Overhead Lift : The client was able to complete the overhead lif t with 5 lbs. over 5 repetitions in 1 minute and 7 seconds. HRstarttoterminafion : 94to 104BPM. Demonstrated Performance/Comments: In attempting to determine the safe liftin g load the client lifted 5 lbs. The client was observed to demonstrate increased bilateral elbow flexion to lif t the box. The client was observed to have met a safe biomechanical limit.

Bilateral Carry : The client was able to complete the 30 ft. bilateral carry with 5 lbs. over 5 repetitions in 1 minute and 7 seconds. HR start to tennination: 96 to 104 BPM. Demonstrated Performance/Conunents: The client demonstirated good mechanics with this activity, with upright posture throughout the test. The client reported the box felt 'heavy' during this activity.

Pushing/Pulling: The client was able to complete the 30 ft. push/pull of a sled with 60 lbs. over 10 repetitions in 4 minutes and 12 seconds. HR start to termination: 86 to 107 BPM. Demonstrated Performance/Comments: i The client demonstirated good mechanics with this activity. The client pushed the sled forward with equal use of bilateral extiremities and pulled it back again with use of both arms in a backwards walking fashion.

RE: Dametta Nichols 5

.;t/^;ASSESSMENT FINDINGS'^ '

A musculoskeletal evaluation was performed on Ms. Nichols prior to any functional testing. The evaluation was performed on the entire body and the results are as follows:

Height: 5 ft. 2 in. Weight: 178 lbs. Resdng Pulse: 76 BPM Resting BP: 112/76

Exercise Target Heart Rate (60-85% HR): 103 to 147 BPM

Appropriat e Cardiac Response: Yes

The client displayed an appropriate cardiac response, with the heart rate remaining above 60% of the projected maximum level on most of the test activities. This reflects an appropriate level of physical exertion on test activities.

I:' - - ' MUSCULOSKELETA L SCREEN : \ ^

Postime: 1. Posture: Mil d forward head, rounded shoulders, protracted scapulae. 2. Posture: Level pelvis, reduced lumbar lordosis, apparent equal leg length, no apparent scoliosis, apparent

equal weight bearing bilateral lower extremities.

SOFT TISSUE ASSESSMENT/EVALUATION :

SKI N QUALITY : Within nomial Umits.

R A N G E OF MOTION : Active ROM was within functional limits with the exception oft Shoulder Right Flexion 110 degrees Abduction 85 degrees External rotation 60 degrees Internal rotation To iliac crest

Cervical right rotation limited by 50%.

Lumbar ROM measured with dual inchnometry: Left Right

Hexion 25 degrees — Extension 10 degrees -Lateral flexion 20 degrees 10 degrees Rotation 25% of normal movement 25% of normal movement

STRENGTH: With manual muscle testing, the client has grossly 4+/5 right upper exti-emity strength in her available range of motion as well as 5/5 stirength left upper extiremity and bilateral lower extremity.

NEURO-SENSORY/SPECL TESTS: 1. Reflex testing: Normal bilateral Biceps, Triceps, Patellar, and Achilles reflexes. 2. Waddell's Testing: Negative all categories 3. Heel Walk: Client was able to heel walk forward 30 ft. without loss of balance in 17 seconds. 4. Toe Walk: Client was able to toe walk forward 30 ft. without loss of balance in 15 seconds. 5. Single Leg Stance/Balance Maneuver: Right: 13 seconds; Left: 10 seconds 6. Tandem Ambulation: Client was able to tandem ambulate 30 ft. without loss of balance in 26 seconds.

RE: Dametta Nichols 4

FUNCTIONA L CAPACIT Y EVALUATIO N REPORT

INFORME D CONSENT: Testing procedures were explained to the client. An informed consent was read and explained to the client by the therapist. The client signed the informed consent prior to beginning the Functional Capacity Evaluation.

PURPOSE OF EVALUATION : Ms. Nichols was referred to Physiotherapy Associates for a Functional Capacity Evaluation to assess current level of physical capacities.

ABBREVIATE D CASE HISTORY: Ms. Nichols reported that she injured her right shoulder at work in 2004/2005. The client was under worker's compensation at that time. The cUent stated that she underwent a right rotator cuff repair in 2005. The client was briefly out of work due to her shoulder surgery. The client stated that she developed neck pain following the shoulder surgery. The client was able to return to work on modified duty in 2005. The cHent reported an insidious onset of lower back pain. The client was able to continue at work until 3/31/10. At that time, the client reported that her job no longer supported light duty and her position was terminated.

CURRENT SUBJECTTVE COMPLAINTS : 1. Right lateral neck pain into right shoulder. 2. Right shoulder, elbow, and wrist joint pain. 3. Occasional shooting sharp pain through the right upper extremity. 4. Constant pain left shoulder and scapulae. 5. Hypersensitivity of left middle finger. 6. Denied any numbness/tingling bilateral upper extiremity. 7. Reported bilateral lower arm/hand swelling right greater tiian left with activity. 8. Lower back pain into buttocks. 9. Right lateral thigh pain into posterior knee and calf 10. Left hip pain into anterior groin.

MEDICA L HISTORY : 1. Osteoporosis 2. Arthritis 3. Shortness of Breath 4. Fibromyalgia 5. Anemia 6. Right rotator cuff repair 2005

CURRENT MEDICATIONS : 1. Gabapentin 2. Tretinoin

EMPLOYMEN T HISTORY: 1. Fulton County Government as a Library Assistant for 14 years. The client reported that she lost her job due

to there being no modified duty available to meet her functional limitations as set forth by her shoulder physician.

2. Macy' s for 4 years in the Jewelry Department.

ACTIVITIE S OF DAIL Y LIVING : The client reported being independent with activities of daily living including self dressing, bathing, toileting and household tasks. The client stated that she requires help to manage her hair and to carry items. The client stated that she is only able to fold small clothing items. CLIENT' S GOALS: Would like to return to a desk type job if able.

To: 4048931G61 Froi8 4047307377) 03/24/11 P-^l PM Page 2 oF 5

WC-6 WAGE STATEMENT

GEORGIA STATE BOARD OF WORKERS' COIWPENSATION W A G E S T A T E M E N T

Board Claim No. Employee Last Name Employee First Name M.I. Sodal Security Nimber Date of Injury 2011-002927 Nichols Darnetta 260-39-6724 3/10/2010

A. IDENTIFYING INFORMATION

EMPLOYEE County of injury Fulton

Address 1030 Reunion Place, SW

E-mail Address City Atlanta

stale GA

Zip Code 30331

EMPLOYER Name Fulton County Government

Address 141 Pryor Street-Suite 5070-A

E-mail Address Valarie.howard®fultoncountvaa.aov

City Atlanta

Slate GA

zip Code 30303

INSURER/ SELF-INSURER

Name Fulton County Government

Address 141 Pryor Street-Suite 5070-A

CLAIMS OFFICE Name Fulton County Workers' Compensation

SBWG I0# (five digit number)

20599

Address 141 Pryor Street-Suite 5070-A

E-maj) Address Insurer/SelMnsurer FilB# Valan'e.howardiQlfuItoncountvaa.aov

City Atlanta

Slate GA

Zip Code 30303

B. COMPUTATION OF AVERAG E WEEKL Y WAG E If Itie weekly benefit is less than ttie maximum, complete the schedule below for thirteen {13) weel<s Immediately preceding the accident If the employee has not been in your employ for Hie thirteen (13) weeks, complete this schedule showinfl flfoss weeMy eaminss of a similar employee in the same employment.

X 13 Weeks of Employee's Wages • 13Weeksofa Similar Employee's Wages • Full time weekly wage of injured employees

Wage al dale of injury per weeic

521.38

SCHEDULE OF WEEKLY EARNINGS

Week From Date

To Date

HM/DDr<YYY

No. of Days

Worked

Gross Amount Paid

Including Overtime or Extra Work

Value of Additional Compensation Total

Earnings Week From Date

To Date

HM/DDr<YYY

No. of Days

Worked

Gross Amount Paid

Including Overtime or Extra Work

Meals Lodging Rent Tips other

Total Earnings

1 12/09/09 12/15/09 5 521.38

2 12/16/09 12/22/09 5

3 12/23/09 12/29/09 5

4 12/30/09 01/05/10 5

5 01/06/10 01/12/10 5

6 01/13/10 01/19/10 5

7 01/20/10 01/26/10 5

8 01/27/10 02/02/10 5

9 02/03/10 02/09/10 5

10 02/10/10 02/16/10 5

11 02/17/10 02/23/10 5

12 02/24/10 03/02/10 5

13 03/03/10 03/09/10 5 521.38

Total 6777.94

Average Weekly Earnings 521.38

REMARKS: REQUIRED OFF Q Mon • Tue Q Wed Q Thur c . TO

COMPLETE: DAYS Q Fri X Sal X Sun

Type or Print t ama Valarie H. Howard

Dale 03/24/2011

E-mail Address Val3rie.lioward(a>fultoncountvqa.qov

Phone Number 404 612-6749

IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF WORKERS' COMPENSATION AT 404-656-3818 OR 1-B00-533-O6B2 OR VISIT http:;/www.sbwc.georgia.gov WlLLFUU-YKAKIfJGAFALSESTATEMEHtFOR THE PURPDSEOFOBTAINIMG OR DENYING BENEFTTSIS A CRIME SUBJECTTOPEMALTIES OF UP TO510.OQOJIO PER V10LAT]OH(0.C.GA.§34-9-18 AND §34-9-19).

W C - 6 REVISION . 07/2009 W A G E S T A T E M E N T

Opt-Out: *

WC-1 EMPLOYER'S FIRST REPORT INJURY OR OCCUPATIONAL DISEASE,—

GEORGIA STATE bOAR D OF WORKERS' GOfVIPENSATfO N EMPLOYER' S FIRST REPORT OF INJURY OR OCCUPATIONA L DISEAS E

NOTE: FAILUR E TO SUBMIT THIS REPORT TO INSURER IMMEDIATEL Y MAY RESULT IN PENALTY . MUST BE TYPED OR PRINTED IN BLACK INK. Boar d Clai m No . Employe e Las t Name Employe e Firs t Name M.I . Sodal Securit y Number Date o f Injur y

Nichols Damett a 260396724 03/30/2010

A. IDENTIFYING INFORMATION EMPLOYEE

Male

X Female Binhdala 04/03/1984

Phone Number Employee E-mail

Address 1030 Reunion Place, SW

City Atlanta

Slate GA

Zip Code 30331

EMPLOYER Name Fulton County Government

NAICS Coda Nature of Business (Trade, Transport. Mfg..ela) Government

Address 141 Pryor Street - Suite 5070-A

Phone Number 404 612-6749

Employer FEIN

City Atlanta

Stale GA

Zip Code 30303

Employer E-mail Valarle.hovi/ard(S)fultoncountvqa.qov

INSURER/ SELF-INSURER

Name Fuiton County Government

Insurer/Self-tnsurer FEIN Insurer/ Self-Insurer File U

20599 CLAIMS OFFICE Name

Fulton County Workers' Comp. Claims Office FEIN # Claims Office Phona

404 612-6749 Claims Office E-mail Valarie.howard(g>fultoncoLintvqa.qov

SBWC ID# (five digit no.) 20599 141 Pryor Street

City Atlanta

Slale GA

Zip Code 30303

EMPLOYMENT/WAGE Dale Hired by Employer

06/12/1996 Insurer Type Code Q I-Insure r X S-Self-insure r • Grou p Fun d

Job Classified Code No.

9410

Number of Days Worked PerV\/eek

5 List Normally Scheduled Days Off Saturday & Sunday

N/A

• per Hour • per Day • per Week X per ti/lonlh

INJURY/ILLNESS & MEDICAL

Time of Injur/ am pm

County of Injury

N/A

Date Employer had knowledge of Injury

2/04/2011

Enter First Data Employee Failed lo Work a Full Day

N/A Did Employee Receive Full Pay on Date of injury?

X Yes • No

Did Injury/Illness Occur on Employer's premises?

Yes X No

Type of Injury/Illness N/A

Body Part Affected

N/A How Injury or Illness / Abnormal Health Condition Occurred

N/A Treatint] Physician (Name and Address) Initial Treatment Given:

• None Hospital / Treating Facility {Name and Address) If Returned to Wor1<, Give Dale:

• •

filinon By Employer Minor: Clinical/Hospilal

Returned at wlial wage per Week

• •

Emergency Room Hospitalized > 24hrs

If Fatal. Enter Complete Date of Death

Report Prepared By (Print or Type) Telephone Number Date of Report

B. INCOME BENEFITS Form WC-6 must be filed if weekly benefit is less than maximum Previously Medical Only

Yes No Averag e Weekl y Wage: $ Weekly benefit : $ Date of disability:

Dat e o f firs t Paymen t Compensatio n paid : $ or Dat e salar y paid :

FOR:

Temporar y tota l disabilit y • Temporar y partia l disabilit y Q Permanen t partia l disabilit y o f % t o

Penalt y paid : $

fo r weeks.

UNTIL WHEN TH E EMPLOYEE ACTUALLY RETURNED T O WORK WITHOUT RESTRICTIONS. AL L OTHER SUSPENSIONS REQUIRE

THE FILIN G O F FORM WC-2 WIT H TH E STAT E BOARD OF WORKERS' COMPENSATION AND TH E EMPLOYEE.

C. NOTICE TO CONTROVERT PAYMENT OF COMPENSATION Benefits will not be paid because: Did not arise out of the course of employment

D. MEDICAL ONLY INJURY • No disability paid or controverted

(Insurer / Self-Insurer: Type or Print Name of Person Filling Form) Valarie H. Howard k

Dafe 02/09/2011

Phone and Bit 404 612-6749

E-mail - • • Valarie.howardtgfu ltoncountyga.gov

IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF WORKERS' COMPENSATION AT 404-656-3818 OR 1-800-533-0682 OR VISIT http:;;www.sbwc.georgia.gov WILLFULLY MAKING A FALSE STATejJlENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO 510,000.00 PER VIOLATION (O.C.G.A. §34-9-18 AND §34-9-19).

WC-1 REVIS ION. 07/2009 1

1 OF 2

EMPLOYER'S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE

IN TH E STATE BOARD OF WORKERS' COMPENSATIO N STAT E OF GEORGI A

Darnetta Nichols,

Claimant,

vs.

Fulton County,

Eraployer/Self-Insurer,

C L A I M NO: 260-39-6724

D/A : 3/30/2010

SBWC No.: 2011002927

EMPLOYER/SELF-INSURER' S FIRST REOUEST FOR PRODUCTIO N OF DOCUMENT S

C O ME NOW Fulton County, Employer/Self-Insurer in the above-styled matter, and

pursuant to O.C.G.A. § 9-11-34 request the claimant to comply with said Section by producing

the documents, objects or other things described herein at the offices of DREW E C KL &

F A R N H A M , L L P, 880 West Peachtree Street, Atlanta, Georgia 30309, within thirty (30) days of

receipt hereof, and permit the Employer/Self-Insurer or its attorney to inspect, copy or otherwise

duplicate each of the following documents, objects or things:

1.

Any and all documents of any kind whatsoever or nature related to or reflecting on your

response to Interrogatory No. 5 (d). f '

Any and all documents of any kind whatsoever or nature related to or reflecting on your

response to Interrogatory No. 7.

3.

Any and all documents of any kind whatsoever or nature related to or reflecting on your

response to Interrogatory No. 8. lA*-^

4.

Any and all documents of any kind whatsoever or nature related to or reflecting on your

response to Interrogatory No. 9.

5.

Any and all documents of any kind whatsoever or nature related to or reflecting on your

response to Interrogatory No. 10.

6.

Any and all documents of any kind whatsoever or nature related to or reflecting on your

response to Interrogatory No. 11.

Any and all documents of any kind whatsoever or nature related to or reflecting on your

response to Interrogatory No. 12.

Any and all documents of any kind whatsoever or nature related to or reflecting on your

response to Interrogatory No. 13.

9.

Any and all documents of any kind whatsoever or nature related to or reflecting on your

response to Interrogatory No. 14. """ ' *"

10.

Any and all documents of any kind whatsoever or nature related to or reflecting on your

response to Interrogatory No. 15, including, but not limited to, the application with all supporting

documents and the award of benefits.

-2-

11.

Any and all documents of any kind whatsoever which support the claimant's contention

that workers' compensation benefits are due. ' ^ '^

12.

Any and all documents of any kind whatsoever, including, but not limited to, letters,

correspondence, memoranda or other writings, which were sent to or received from any medical

provider concerning the claimant's physical or mental condition. ' * " "

13.

A copy of any application(s) submitted for social security benefits together with all

V-e<,. l i t documents submitted in support of that application(s) and any award(s) or decision(s). ^j^^ f

14.

A printout or listing of all disability benefits (showing the source) received by the

claimant or paid to any person or entity on behalf of the claimant during any time period in

which workers' compensation benefits are requested.

15.

A printout or listing of all unemployment benefits received by the claimant during any tvOi^^

period in which workers' compensation benefits are being requested.

16.

Please produce any recordings of any kind taken from any witness, party, or other person f j j r e ,

in connection with this matter.

-4-

•

I

I j

I N T H E S T A T E B O A R D O F W O R K E R S ' C O M P E N S A T I O N

S T A T E O F G E O R G I A

C L A I M N O: 260-39-6724

S B WC No.: 2011002927

Dametta Nichols,

Claimant,

vs.

Fulton County,

Emp loyer/S elf-Insurer,

and

Fulton County,

Insurer.

R E O U E ST F O R P R O D U C T I O N O F D O C U M E N T S

TO: R. Marvin Royster, M . D. Peachtree Orthopaedic Clinic 2045 Peachtree Rd N E Ste 700 Atlanta GA 30309

C O M E N OW Fulton County and Fulton County and serve upon you this Request for

Production of Documents pursuant to O.C.G.A. § 9-1 l-34(c).

You are hereby requested to produce copies of the documents designated below which

are i n your possession, custody or control pertaining to Dametta Nichols. Y ou may do so by

mail ing copies of said documents to the undersigned at D R EW E C KX & F A R N H A M , L L P , P.

0. Box 7600, Atlanta, Georgia 30357, within thirty (30) days after receipt of this request.

The documents that we are requesting from your f i l e should include the following:

1. Any and all correspondence, writings, reports, or documents of any kind to or from govemlnental agencies, insurance carriers, legal counsel or other representative(s) of the patient, including family members or friends, and/or any other entities or individuals.

2. Any and all other records of any kind relating to the patient, including, but not

limited to:

a) patient history sheets, patient information sheets, or patient intake sheets;

i I

b) radiology reports, nurses' notes, lab reports, or reports from any testing of any kind;

c) narrative reports of any kind;

d) office notes of any kind, including those taken during any testing, examination, or evaluation of the patient;

e) any and all correspondence, notes, letters, or writings of any kind;

f ) bil l in g summaries and claim forms completed and/or signed by the patient or fi l le d out from information provided by the patient from the first visit to your office to the present;

g) social security records or claim forms;

h) claim forms or requests for payment to group health carriers or other medical providers;

i ) copies of the j acket/folder in which any record of the patient is kept;

j ) any writing submitted by the patient or anyone on his/her behalf;

k) any and all information stored on computer disk;

1) the results from any psychological or psychiatric testing together with copies of any notes made during testing, documents which were generated as a result of testing, or documents which contain the raw data on which the results of said tests were based;

m) the entire file(s) of the above-named patient.

NOTE - if any document is removed or is not produced in response to this request, please describe the document(s) in sufficient detail so that a court may rule on the issue of whether it should be produced.

-2-

Respectfully submitted,

D R EW E C K L & F A R N H A M , L L P

H . Michael Bagley Georgia Bar No.: 031425 Attorney for Employer/Self-Insurer

D R EW E C K L & F A R N H A M , L L P P. O. Box 7600 Atlanta, G A 30357 (404)885-6415

^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^

m a properly •

Th is 1 7 * day of M a y , 20 U .

H . M i c h a e l Bag ley^ S e o r g i a B a r N o . : 031425

IN TH E STATE BOARD OF WORKERS' COMPENSATIO N STATE OF GEORGIA

C L A I M N O: 260-39-6724

S B WC No.: 2011002927

Dametta Nichols,

Claimant,

vs.

Fulton County,

Employer/Self-Insurer,

and

Fulton County,

Insurer.

RESPONSE TO REOUEST FOR PRODUCTION OF DOCUMENT S

C O M ES N OW , representative of Peachtree Orthopaedic

Cl inic, and responds to the Request for Production of Documents served pursuant to O.G.G.A. §

9-11 -34 by Fulton County and Fulton County as follows:

(1) Copies of the requested documentation pertaining to Dametta Nichols are attached to this Response as required by law.

This day of _ 2011.

R. Marvin Royster, M . D. Title:

J O H N A . FERGUSON, JR. J O H N P. REAIE STEVASI A. MILLER H. MICHAE L BAGLE Y HAL L F. McKINLE Y III G. RANDAL L M O O D Y PAUL W. BURK E DANIEL C. KNIFFEN J O H N C. BRUFFEY, JR. J O H N G. B L \ C K M O N , JR. GAR Y R. HURST KATHERIN E D. DIXON BRUC E A. TAYLOR , JR. JOSEP H C CHANCE Y DAVI D A . SMITH JAME S P. ANDERSO N JULIE Y . J O H N SANDR A S. C H O BARBAR A A. MARSCHAL K B. KAY E KAT2-FLEXE R TERRENCE T. ROCK ROBERT L WELC H MICHAE L L MILLER

ANDRE W D. HOROWITZ J. C. ROPER, JR. BRIAN T MOORE BURK E A NOBL E JIMMY JANARIOU S BRIAN W.JOHNSO N DOUGLA S K. BURRELL KARE N K. KARABINO S NICOLE D. TIFVERMAN D O U G L \ 5 G. SMITH, JR. ROBERT D. GOLDSMITH LISA R- RICHARDSON ANDRE W NEISON CHRISTOPHER A. BENNETT AARAT I T. SUBRAMANIA M BONNIE S. TIMMS ANDRE W C. HAEBERL E ANDREA R. MITCHELL J . BENSON WARD MATTHE W A. NANNINGA RYAN V KLEE NICHOLA S P. SMITH DEA N A DELLINGER

D r e w E c k l & F a r n h a m , l l p

A T T O R N E Y S A T L A W 880 W E S T P E A C H T R E E STREET (STREET ZIP C O D E : 30309)

P.O. B O X 7600

A T L A N T A , GEORGI A 30357-0600 T E L E P H O N E (404) 885-1400

FACSIMILE (404) 876-0992

www.deflaw.co m

Q\SSANDR A A. WILLIAM S STEPHEN J. GRAHA M MATTHE W D. WALKE R C H A D ERIC JACOB S NATHA N E. W O O D Y MAR K E. IRBY

PATRICIA P. CUNNINGHA M E. ANDRE W TREESE J O H N E. ADKIS50N , III TAYLO R J. STEVENS ERIC R. MUL L GARY D. BEELE N ABD l AMMAR I

MEREDITH RIGGS GUERRERO ANN E MARIE D U TOIT DAVID SCOTT THOMPSON NICHOLA S S. SALTER INGRID NUSS DAVID H. SCHULT E MICHAEL J. ESHMA N JASO N M. PRINE DAVID A . OLSO N MYLES LEVELL E

SAR\ H E. SMITH ICATHRYN E. STA2A K

OF COUNSEL CHARLE S L DREW W. WRAY ECKL CLAYTO N H. FARNHA M JEFFREY A. BURMEISTER JUDY GREENBAU M CROY KELLEE N HUAN G HUBB S KATHRY N S. WHITLOCK STEPHANIE F. BROW N LESLIE P. BECKNEL L

LEIGH L \ W S O N REEVES (1963-2009)

DENNIS M. HAL L (1947-1998)

Apr i l 11, 2011 WRITER'S DIRECT ACCESS

(404) 885-6415 mbagley(@deflaw.com

Robert R. Pagniello Law Offices of Robert R. Pagniello, P .C.

1400 Scott Boulevard

Decatur, GA 30030

R E: Dametta Nichols v. Fulton County D / A : 3/30/2010 Our File No. 3677-78782 S B WC Claim No. 2011002927

Dear Robert:

Enclosed please f ind the Employer/Self-Insurer's Responses to Claimant's First Interrogatories, First Request for Production of Documents and First Request for Admissions.

Very traly yours.

Drew , E c k l & Farnham , L L P

H . Michael Bagley

H M B / l p h Enclosures

cc: Valarie Howard, Fi le No.

A t l a n t a • B r u n s w i c k

CERTIFICAT E OF SERVICE

THI S IS TO C E R T I FY that I have this date served opposing counsel with a copy of the

within and foregoing Employer/Self-Insurer's Responses to Claimant's First Interrogatories by

depositing same i n the U . S. Ma i l in a properly-addressed envelope with sufficient postage

affixed thereon addressed to:

Robert R. Pagniello

Law Offices of Robert R. Pagniello, P.C. 1400 Scott Boulevard Decatur, GA 30030

This

IN TH E STATE BOARD OF WORKERS' COMPENSATIO N STATE OF GEORGIA

Dametta Nichols,

Claimant,

vs.

Fulton County,

Employer/S elf-Insurer,

C L A I M NO: 260-39-6724

D/A : 3/30/2010

SBWC No.: 2011002927

EMPLOYER/SELF-INSURER' S RESPONSES TO CLAIMANT' S FIRST REOUEST FOR PRODUCTION OF DOCUMENT S

COMES NOW, Fuhon County, Employer/Self-Insurer, in the above-styled case and

respond to Claimant's First Request for Production of Documents as follows:

1

A copy of the entire personnel fil e on the Claimant.

RESPONSE: Please see attached personnel file.

Copies of any statements made by the Claimant relating in any way to this claim.

RESPONSE: Please see attached documentation prepared by Claimant for her FMLA leave.

AH photographs, videotapes, or films of any kind relating to this claim in any way.

RESPONSE: Employer/Insurer objects to this request on the grounds that it seeks documentation and information that is privileged and confidential and prepared in anticipation ofhtigation. Without waiving said objection, none.

4

Copies of all payments made by the Employer/Insurer to the Claimant for any workers' compensation benefits.

RESPONSE: None. There was no accident or report of injury in the course and scope of employment. Please see attached W Cl denial of claim.

5

Copies of all payments made to any medical providers, including pharmacy bill s of the Claimant's after the date of accident.

RESPONSE: None. There was no accident or report of injury in the course and scope of employment. Please see attached W Cl denial of claim.

6

Copies of all written communications between the Claimant and the Employer/Insurer, or any of Employer's agents, concerning this claim.

RESPONSE: Please see attached documentation prepared by Claimant for her FMLA leave.

7

A copy of the medical panel card, if any, which was posted on Employer's premises on the date of accident.

RESPONSE: Please see attached signed posted panel of physicians.

8

Copies of all medical records and bill s of any kind relating to the Claimant.

RESPONSE: The only medical records Employer/Self-Insurer has in its possession regarding the alleged claim have been provided by Claimant's counsel.

9

Copies of all offers of employment made to the Claimant after the date of accident.

RESPONSE: None.

2

I

10

Copies of all accident or incident reports and witness statements, made of the alleged injury or injuries by the Employer/Insurer or any agent of either.

RESPONSE: None. There was no accident or report of injury in the course and scope of employment. Please see attached W Cl denial of claim.

11

Wage records of the Claimant beginning the 13 weeks immediately preceding the date of accident through the last date of employment by the Claimant.

RESPONSE: Please see attached wC6.

12

Copies of all documents or tangible things which Employer/Insurer contends support their having denied, suspended, or controverted Claimant's entitlement to workers' compensation benefits.

RESPONSE: Please see attached documentation prepared by Claimant for her FMLA leave.

Respectfully submitted,

DREW ECICL & F A R N H A M , LL P

H. Michael Georgia Bar No.: 031425 Attorney for Employer/Self-Insurer

P. O. Box 7600 Atlanta, Georgia 30357 (404) 885-6415

3

CERTIFICAT E OF SERVICE

THIS IS TO CERTIFY that I have this date served opposing counsel with a copy of the

within and foregoing Employer/Self-Insurer's Responses to Claimant's First Request for

Production of Documents by depositing same in the U. S. Mail in a properly-addressed envelope

with sufficient postage affixed thereon addressed to:

Robert R. Pagniello

Law Offices of Robert R. Pagniello, P.C. 1400 Scott Boulevard Decatur, GA 30030

This

IN TH E STATE BOARD OF WORKERS' COMPENSATIO N STATE OF GEORGIA

Dametta Nichols,

Claimant,

vs. C L A I M NO: 260-39-6724

Fulton County, D/A : 3/30/2010

Employer/S elf-Insurer, SBWC No.: 2011002927

EMPLOYER/SELF-INSURER' S RESPONSES TO CLAIMANT' S FIRST REQUEST FOR ADMISSION S

COMES NOW, Fulton County, Employer/Self-Insurer, in the above-styled case and

respond to Claimant's First Request for Admissions as follows:

The Georgia State Board of Workers' Compensation has jurisdiction to hear this matter.

RESPONSE: Admitted.

Venue is proper in the county as listed on the claimant's WC-14.

RESPONSE: Denied.

3

The Employer in this action is subject to the Georgia Workers' Compensation Act.

RESPONSE: Admitted.

The Employee/Claimant was in the general employment of the Employer on the listed date(s) of accident and at the time(s) of the alleged accident(s).

RESPONSE: Admitted.

1

2

4

5

The injury(s) by accident, which is the subject matter of this claim, arose out of, and occurred, within the course and scope of this claimant's employment with this employer.

RESPONSE: Denied.

6

The Employer/Insurer had timely notice of the accident/injury pursuant to O.C.G.A. Section 34-9-80.

RESPONSE: Denied.

7

The Employer/Insurer did not have a properly posted panel of physicians pursuant to O.C.G.A. Section 34-9-201 (b).

RESPONSE: Denied.

8

The Employer did not explain the purpose and use of the medical panel card to the Claimant as required by statute.

RESPONSE; Denied.

9

The Employer did not give appropriate assistance in contacting medical panel members on or after the date of accident.

RESPONSE: Denied.

10

Since the date of injury, the Claimant has suffered a loss of earnings as a result of the injury complained of

RESPONSE: Denied.

2

11

The Claimant is entitled to benefits for temporary total disability.

RESPONSE: Denied.

12

The Claimant is entitled to benefits for temporary partial disability.

RESPONSE: Denied.

13

The Claimant is entitled to benefits for permanent partial disability.

RESPONSE: Denied.

14

The Claimant is entitled to assessment of his attorney's fees against the employer/insurer pursuant to O.C.G.A. Section 34-9-108.

RESPONSE: Denied.

15

The Employer/Insurer cannot avoid liabilit y for payment of workers' compensation benefits as a result of any conduct by the Claimant.

RESPONSE: Denied.

16

The Employer terminated the Claimant from employment.

RESPONSE: Denied.

3

/

p. O. Box 7600 Atlanta, Georgia 30357 (404)885-6415

Respectfiilly submitted,

DREW E C KL & F A R N H A M , LL P

H. Michael Ba^

Georgia Bar No.: "o31425

Attorney for Employer/Self-Insurer

4

CERTIFICAT E OF SERVICE

THIS IS TO CERTIFY that I have this date served opposing counsel with a copy of the

within and foregoing Employer/Self-Insurer's Responses to Claimant's First Request for

Admissions by depositing same in the U. S. Mail in a properly-addressed envelope with

sufficient postage affixed thereon addressed to:

Robert R. Pagniello

Law Offices of Robert R. Pagniello, P.C. 1400 Scott Boulevard Decatur, GA 30030

This /( day of ( M\\^ , 2011.

H.^Michael Ba^ey Georgia Bar No.: 031425

IN TH E STATE BOARD OF WORKERS' COMPENSATIO N STATE OF GEORGIA

Darnetta Nichols, Employer/Claimant,

vs.

Fulton County Public Library, Employer/Self-Insurer,

and

Fulton County. Insurer.

CLAIIVIANT' S FIRST REOUESTS FOR ADIVIISSIONS TO ElVIPLOYER/INSURER

Comes now the above claimant and pursuant to O.C.G.A. 9-11-36 and 34-9-1, et. Seq. Requests that the Employer/Insurer admit that each of the following statements are true.

Please note that if any request for admission is denied, and Claimant subsequently proves the truthfulness thereof, Claimant shall apply for an award of expenses, including attorney fees necessaiy to prove the truthfulness of the admission pursuant to the Georgia Civi l Practice Act, Section 36 (a).

PLEASE ADIVII T THE FOLLOWING:

1

The Georgia State Board of Workers' Compensation has jurisdiction to hear this matter.

2

Venue is proper in the county as listed on the claimant's WC-14.

3

The Employer in this action is subject to the Georgia Workers' Compensation Act.

SS#: 260-39-6724

D/A : 03/30/2010

4

The Employee/Claimant was in the general employment of the Employer on the listed date[s} of accident and at the time[s] of the alleged accident[s).

5

The injury(s] by accident, which is the subject matter of this claim, arose out of, and occurred, within the course and scope of this claimant's employment with this employer.

6

The Employer/Insurer had timely notice of the accident/injury pursuant to O.C.G.A. Section 34-9-80.

7

The Employer/Insurer did not have a properly posted panel of physicians pursuant to O.C.G.A. Section 34-9-201 (bJ.

8

The Employer did not explain the purpose and use of the medical panel card to the Claimant as required by statute.

9

The Employer did not give appropriate assistance in contacting medical panel members on or after the date of accident.

10

Since the date of injury, the Claimant has suffered a loss of earnings as a result of the injury complained of

11

The Claimant is entitled to benefits for temporary total disability.

12

The Claimant is entitled to benefits for temporary partial disability.

13

The Claimant is entitled to benefits for permanent partial disability.

14

The Claimant is entitled to assessment of his attorney's fees against the employer/insurer pursuant to O.C.G.A. Section 34-9-108.

15

The Employer/Insurer cannot avoid liabilit y for payment of workers' compensation benefits as a result of any conduct by the Claimant.

16

The Employer terminated the Claimant from employment.

CLAIIVIANT' S FIRST INTERROGATORIES TO ElVIPLOYER/INSURER

Comes now the Claimant and submits the Claimant's First Interrogatories to the Employer/insurer, pursuant to O.C.G.A. Section 9-11-33 and the Georgia Workers' Compensation Act at O.C.G.A. Section 34-9-1, et seq.

These Interrogatories wil l be continuing in nature until the time of trial. The Employer/Insurer is required to submit supplemental answers thereto in accordance with the provisions of O.C.G.A. Section 9-11-26 (e).

"Date of Injury" or "date of accident," unless otherwise specified, means the date of accident as specified on the Claimant's WC-14 form, or in the case of multiple dates of accident, all dates of accident.

"Identify" means to disclose the full name, business, and home telephone numbers and addresses, where applicable.

1

If you denied Request or Admission number 1 above, state: a) Each and every factual and/or legal reason for said denial; b) Each and every person with knowledge of facts that support said denial.

2

If you denied Request for Admission number 2 above, state the venue you contend is proper for this action, and state each and every factual and/or legal reason for this contention.

3

If you denied Request for Admission number 3 above, state each and every factual and/or legal reason for said denial.

4

If you denied Request for Admission number 4 above, state each and every factual and/or legal reason for said denial.

5

If you denied Request for Admission number 5 above, state each and every factual and/or legal reason for said denial.

6

If you denied Request for Admission number 6 above, state when you contend you received notice of the accident complained of; the names of all persons receiving said notice; the way in which said notice was received; by whom notice was given; the content of said notice.

7

If you denied Request for Admission number 7 above, state each place where you contend the medical panel card was posted on the date of accident, and the name of the person[s} in charge of maintaining said panel.

8

If you denied Request for Admission number 8 above, state the names of the person who explained the use of the medical panel card to the Claimant, the date, the place and time of the explanation, and the substance of the explanation.

9

If you paid any physician, hospital, drug, or other dispenser of medical products or services, please state the following:

a) The dates of payment; b) To whom said payments were made; c) The amounts paid.

10

If you paid any workers' compensation benefits to the Claimant, please state the following: a) The dates ofall such payments;

b) The amounts of each payment; c} The statutory provisions applicable to each such payment.

11

Please state the Claimant's average weekly wage for the 13 weeks immediately preceding the date of accident.

12

Please state all periods of absence from work by the Claimant since the date of accident. If you contend that any such absences were not due to injuries the Claimant claims to have sustained as a result of the accident, please state all facts and circumstances that support your contention.

13

A t any time subsequent to the date of accident, did you offer any light-duty work to the Claimant or offer to modify his/her job in anyway to accommodate her alleged limitations. If so, state the names of all persons making such offers, whether any such offers were in writing, a description ofall such jobs offered, the names of any physicians who approved any such light-duty or modified jobs, and the dates these physicians approved said jobs.

14

Have you received from any physicians or medical provider any rating for permanent partial disability pursuant to O.C.G.A. 34-9-263. If so, state the names of the medical providers issuing said rating, the dates the ratings were issued, and the details concerning the ratings.

15

Identify all persons known by the Employer/Insurer who have any knowledge of any facts related to this claim. As to each person identified, state separately and with specificity the substance of that person's knowledge.

16

Has the Employer/Insurer or any agents thereof performed any surveillance upon the Claimant since the date of accident. If so, state whether any videotapes or photographs were made.

17

Do you contend that the Claimant has engaged in any physical activity that is inconsistent with her disability status as alleged in her WC-14. If so, describe the activity undertaken, the locations and dates thereof, and identify all known witnesses.

18

Name all persons who had supervisory authority over the Claimant on the date of accident.

19

State the names and County of Residence of each claims representative who has handled this matter for the insurer of servicing agent.

20

Please state each and every factual and/or legal reason upon which the Employer/Insurer allege or wil l allege is a basis to deny, suspend, or controvert payment of any workers' compensation benefits to the Claimant.

CLAIIVIANT' S FIRST REOUEST FOR PRODUCTION TO ElVIPLOYER/INSURER

Comes now the Claimant in the above styled action and submits this First Request for Production to the Employer/Insurer pursuant to O.C.G.A. 9-11-34. Said documents are to be produced within 30 days for inspection and copying by Claimant's counsel at their offices. In lieu of same, Employer/Insurer may make copies thereof and mail the copies to Claimant's counsel at the above address.

Please produce the following:

1

A copy of the entire personnel fil e on the Claimant.

2

Copies of any statements made by the Claimant relating in any way to this claim.

3

Al l photographs, videotapes, or films of any kind relating to this claim in any way.

4

Copies of all payments made by the Employer/Insurer to the Claimant for any workers' compensation benefits.

5

Copies of all payments made to any medical providers, including pharmacy bill s of the Claimant's after the date of accident.

6

Copies ofall written communications between the Claimant and the Employer/Insurer, or any of Employer's agents, concerning this claim.

7

A copy of the medical panel card, if any, which was posted on Employer's premises on the date of accident.

8

Copies ofall medical records and bill s of any kind relating to the Claimant.

9

Copies ofall offers of employment made to the Claimant after the date of accident.

10

Copies ofall accident or incident reports, and witness statements, made of the alleged injury or injuries by the Employer/Insurer or any agent of either.

11

Wage records of the Claimant beginning the 13 weeks immediately preceding the date of accident through the last date of employment by the Claimant.

12

Copies ofall documents or tangible things which Employer/Insurer contends support their having denied, suspended, or controverted Claimant's entitlement to workers' compensation benefits.

THIS THE DAY OF FEBRUARY, 2011.

I James B. Doyle Attorney for Claimant Georgia Bar # 076152

The Law Offices of Robert R. Pagniello, P.C. 1400 Scott Boulevard Decatur, GA 30030-1424 [404] 373-5550

CERTIFICAT E OF SERVICES

This is to certify that I have this day served counsel for the opposing party in the foregoing matter with a true and correct copy of Claimant's First Request for Admissions to Employer/Insurer, Claimant's First Interrogatories to Employer/Insurer, and Claimant's First Request for Production of Documents to Employer/Insurer by depositing a true copy of same in the United States IVIail within sufficient postage affixed thereon.

Sent to:

Fulton County 141 Pryor Street, S.W. Suite 5021 Atlanta, GA 30303

This day of February, 2011.

Georgia Bar #076152 Attorney for Claimant/Employee

Law Offices of Robert R. Pagniello, P.C. 1400 Scott Boulevard

Decatur, GA 30030-1424 Phone#: 404-373-5550

Fax#: 404-373-3062

J O H N A, F E R G U S O N , JR, J O H N P. REALE STEVAN A. IVIILLER H. MICHAEL BAGLEY HALL F. McKINLEY III G . RANDALL M O O D Y PAUL W. BURKE DANIEL C. KNIFFEN JOHN C. BRUFFEY, JR. JOHN G, B L A C K M O N , JR. GARY R. HURST KATHERINE D. DIXON BRUCE A. TAYLOR, JR. JOSEPH C. C H A N C E Y DAVIDA , SMITH JAMES P. A N D E R S O N JUUE Y. J O H N SANDRA S. C H O BARBARA A . MARSCHALK B. KAYE KATZ-FLEXER TERRENCE T. ROCK ROBERT L W E L C H MICHAEL L MILLER

ANDREW D. H O R O W I T Z j, C, ROPER, JR. BRIAN T. M O O R E BURKE A. NOBLE JIMMY JANARIOUS BRIAN W. J O H N S O N DOUGLAS K. BURRELL KAREN K. KARABINOS NICOLE D, TIFVERMAN DOUGLAS G . S M I T H . JR. ROBERT D. G O L D S M I T H USA R. R ICHARDSON ANDREW NELSON CHRISTOPHER A. BENNETT AARATI T, S U B R A M A N I A M BONNIE S, T I M M S ANDREW C. HAEBERLE ANDREA R. MITCHELL J, BENSON W A R D MATTHEW A, N A N N I N G A RYAN V, KLEE NICHOLAS P . S M I T H DEAN A, DELLINGER

D r e w E c k l & F a r n h a m , l l p A T T O R N E Y S A T L A W

880 WEST PEACHTREE STREET (STREET ZIP C O D E : 30309) P.O. BOX 7600

A T L A N T A , G E O R G I A 3 0 3 5 7 - 0 6 0 0 TELEPHONE (404) 885-1400 EACSIMILE (404) 876-0992

www.deflaw.com

CASSANDRA A. W i L L M M S STEPHEN J, G R A H A M M A T T H E W D. WALKER C H A D ERIC l A C O B S N A T H A N E. W O O D Y M A R K E. IR8Y PATRICIA P, C U N N I N G H A M E. A N D R E W TREESE J O H N E. A D K I S S O N , IM TAYLOR J. STEVENS ERIC R. M U L L GARY D. BEELEN A B D l A M M A R I MEREDITH RIGGS GUERRERO A N N E MARIE D U TOIT DAVID SCOTT T H O M P S O N NICHOLAS S. SALTER INGRID NUSS DAVID H. SCHULTE MICHAEL 1. E S H M A N l A S O N M . PRINE DAVID A. O L S O N MYLES LEVELLE

SARAH E. SMITH KATHRVN E, STA2AK

OF COUNSEL CHARLES L DREW W, WRftV ECKL C U Y T O N H . F A R N H A M JEFFREY A, BURMEISTER JUDY GREENBAUM CROY KELLEEN H U A N G HUBBS KATHRYNS, WHITLOCK. STEPHANIE F. B R O W N LESLIE P. BECKNELL

LEIGH L A W S O N REEVES (1963-2009)

DENNIS M . HALL (1947-1998)

February 18, 2011 WRITER'S DIRECT ACCESS

(404)885-6415 mbagley@deflaw.com

Robert R. Pagniello Law Offices of Robert R. Pagniello, P.C. 1400 Scott Boulevard Decatur, GA 30030

RE: Darnetta Nichols v. Fulton County D/A : 3/30/2010 Our File No.: 3677-78782 SBWC Claim No. 2011002927

Dear Robert

Enclosed are the Employer/Self-Insurer's First Interrogatories to Claimant and Employer/Self-Insurer's First Request for Production of Documents. I have also enclosed a WC207, which I request you have the claimant sign and return.

With personal regards, I am

Very truly yours,

DREW, E c ia & FARNHAM , L L P

H. Michael Bagley

HMB/f l ^ Enclosures

A t l a n t a • B r u n s w i c k

IN TH E STATE BOARD OF WORKERS' COMPENSATIO N STATE OF GEORGIA

Dametta Nichols,

Claimant,

vs. C L A I M NO: 260-39-6724

Fulton County, D/A : 3/30/2010

Employer/Self-Insurer, SBWC No.: 2011002927

EMPLOYER/SELF-INSURER' S RESPONSES TO CLAIMANT' S FIRST INTERROGATORIE S

COMES NOW, Fulton County, Employer/Self-Insurer in the above-styled case and

respond to Claimant's First Interrogatories as follows:

If you denied Request or Admission number 1 above, state: a) Each and every,factual and/or legal reason for said denial; b) Each and every person with knowledge of facts that support said denial.

RESPONSE: Not applicable. This request was admitted.

If you denied Request for Admission number 2 above, state the venue you contend is proper for this action, and state each and every factual and/or legal reason for this contention.

RESPONSE: There was no accident or report of injury in the course and scope of employment.

If you denied Request for Admission number 3 above, state each and every factual and/or legal reason for said denial.

RESPONSE: Not applicable. This request was admitted.

1

2

3

4

If you denied Request for Admission number 4 above, state each and every factual and/or legal reason for said denial.

RESPONSE: Not applicable. This request was admitted.

5

If you denied Request for Admission number 5 above, state each and every factual and/or legal reason for said denial.

RESPONSE: There was no accident or report of injury in the course and scope of employment.

6

If you denied Request for Admission number 6 above, state when you contend you received notice of the accident complained of; the names of all persons receiving said notice; the way in which said notice was received; by whom notice was given; the content of said notice.

RESPONSE: There was no accident or report of injury in the course and scope of employment. The first notice of an alleged injury was upon Employer/Self Insurer's receipt of the WC14 filed by the Claimant's attorney, on or about February 4, 2011.

7

If you denied Request for Admission number 7 above, state each place where you contend the medical panel card was posted on the date of accident, and the name of the person(s) in charge of maintaining said panel.

RESPONSE: There was no accident or report of injury in the course and scope of employment. However, Claimant was instructed on the use of the posted panel of physicians. Please find attached the posted panel of physicians signed by the Claimant.

8

If you denied Request for Admission number 8 above, state the names of the person who explained the use of the medical panel card to the Claimant, the date, the place and time of the explanation, and the substance of the explanation.

RESPONSE: Please find attached the posted panel of physicians signed by the Claimant.

2

9

If you paid any physician, hospital, drug, or other dispenser of medical products or services, please state the following:

a) The dates of payment; b) To whom said payments were made; c) The amounts paid.

RESPONSE: No medical bill s have been paid in connection with this claim. There was no accident or report of injury in the course and scope of employment. Please see attached W Cl denial of claim.

10

If you paid any workers' compensation benefits to the Claimant, please state the following: a) The dates ofall such payments; b) The amounts of each payment; c) The statutory provisions applicable to each such payment.

RESPONSE: No benefits have been paid in connection with this claim. There was no accident or report of injury in the course and scope of employment. Please see attached W Cl denial of claim.

11

Please state the Claimant's average weekly wage for the 13 weeks immediately preceding the date of accident.

RESPONSE: Please see attached WC6.

12

Please state all periods of absence from work by the Claimant since the date of accident. If you contend that any such absences were not due to injuries the Claimant claims to have sustained as a result of the accident, please state all facts and circumstances that support your contention.

RESPONSE: Please see attached documentation regarding Claimant's personal leave.

13

At any time subsequent to the date of accident, did you offer any light-duty work to the Claimant or offer to modify his/her job in any way to accommodate her alleged limitations.

3

If so, state the names of all persons making such offers, whether any such offers were in writing, a description of all such jobs offered, the names of any physicians who approved any such light-duty or modified jobs, and the dates these physicians approved said jobs.

RESPONSE: No light duty jobs have been offered to the Claimant. There was no accident or report of injury in the course and scope of employment. Please see attached W Cl denial of claim.

14

Have you received from any physicians or medical provider any rating for permanent partial disability pursuant to O.C.CA. 34-9-263. If so, state the names of the medical providers issuing said rating, the dates the ratings were issued, and the details concerning the ratings.

RESPONSE: No. There was no accident or report of injury in the course and scope of employment. Please see attached WCl denial of claim.

15

Identify all persons known by the Employer/Insurer who have any knowledge of any facts related to this claim. As to each person identified, state separately and with specificity the substance of that person's knowledge.

RESPONSE: Valarie Howard, Anne Haimes, John Szabo, Tiffany Edmondsun, Andrea Akiti , Darlene McDade Fulton County, 141 Pryor Street, Suite 5021, Atlanta, Georgia 30303.

16

Has the Employer/Insurer or any agents thereof performed any surveillance upon the Claimant since the date of accident. If so, state whether any videotapes or photographs were made.

RESPONSE: Employer/Insurer objects to this request on the grounds that it seeks documentation and information that is privileged and confidential and prepared in anticipation of litigation. Without waiving said objection, none.

17

Do you contend that the Claimant has engaged in any physical activity that is inconsistent with her disability status as alleged in her WC-14. If so, describe the activity undertaken, the locations and dates thereof, and identify all known witnesses.

4

RESPONSE: Employer/Self-Insurer is without sufficient information to respond to this request. However, Employer/Self-Insurer further states that there was no accident or report of injury in the course and scope of employment. Please see attached WCl denial of claim.

18

Name all persons who had supervisory authority over the Claimant on the date of accident.

RESPONSE: Anne Haimes, John Szabo, Andrea Akiti , Fulton County, 141 Pryor Street, Suite 5021, Atlanta, Georgia 30303.

State the names and County of Residence of each claims representative who has handled this matter for the insurer of servicing agent.

RESPONSE: Employer/Insurer objects to this request on the grounds that it is overly broad and burdensome and not reasonably calculated to lead to discovery of material evidence. Without waiving said objection, Valarie Howard, Fulton County, 141 Pryor Street, Suite 5021, Atlanta, Georgia 30303.

Please state each and every factual and/or legal reason upon which the Employer/Insurer allege or wil l allege is a basis to deny, suspend, or controvert payment of any workers' compensation benefits to the Claimant

RESPONSE: There was no accident or report of injury in the course and scope of employment. Please see attached W Cl denial of claim.

19

20

Respectfully submitted.

DREW E C KL & F A R N H A M , LL P

H. Michael B a g l e y T j - — Georgia Bar No.: ^ Attorney for Employer/Self-Insurer

P. O. Box 7600 Atlanta, Georgia 30357 (404) 885-6415

5

67-07 RATIN G SUMMARY ,

1.

2.

3 .

4 .

5 .

6 .

7 .

8-

9 .

ResponsibililyArea

Delete s Book s an d mate r ia l s on missin g boo k repor t

Prepare s d i sp lay s an d e x h i b i t s f o r ho l iday s an d f l y e r s Processe s an d prepare s ne w book i

Convert s ne w an d o l d book s i n t o c i r u l a t i o n syste m As is ts ' i n c i r u l a t i o n s t a f f i n c i r c u l a t i o n departmen t

Weigh t

300

200

200

200

100

Rating (Whole Numbers)

X

X

X

X

X

X

X

X

X

Weighted Rating

600

600

600

600

200

2600

OVERAL L PERTORMANCE

RATING *

WEIGHTE D TOTA L = 1,000 = 2.6= 3

*Once overall perfomnancfi rating has been calculated, the rating should be rounded. Any ing S or above should be rounded up to the nearest whole number. Anything .4 or below should be roundel down to the nearest whole number.

OVERAL L PERFORMANCE LB/EL S

Outaanding 3 >*i£XEptabie 2 Fair, But Needs Improvement 1 FaHir Failed 0

Rater Signature:_ Date

RATIN G SUMMARY

Rating Weighted Responsibility Area Weight (Whole Numbers) Ratiii g

1.Delete s book s an d mater ia l s { 300 J X

2 600

2.Prepare s d i s p l a y s an d exh ib i t s { 200 J X

3 600

fo r h o l i d a y s an d f l y e r s 3. P r o o e s s B S S an d prepare s ne w ( 200 ) X

3 = 600

bnew book s 4 . Converst s ne w book s in t o ( 200; X 3 = 600

.. .c irculat io n syste m 5 . A s s i s t i n c i r c u l a t i o n department; ^ 100 ) X

2 = 200

when neede d

6. ( X —.

7. ( ) X

8 . ( ) X

9 . ( ) X =

1,000 2600

OVERAL L PERFORMANCE

RATING *

WEIGHTE D TOTA L = ^ 1,000

*Once overall performance rating has been calculated, ihe rating should be rounded. Anything .5 or above should be rounded up to the nearest whde number. Anything .4 or below should be rounded down to the nearest whole number.

OVERAL L PERFORMANCE IB^EIS

Outstandir^ 3 AoGeptaWe 2 Fair, But Needs Improvement 1 fenir^feiled 0

Department T . - i ^ ra r^ r

PERFORMANCE APP8AISAL - F U L T O N C O U N l Y

Darnett a Nichol s

Sodal Security Nuni)er_

Classification

FLSACat^>i y

L i b r a r y A s s i s t a n t Senio r

Empbyee's Name

E>ateofHire 06/9 6

Bcempt _Non-Exempt

Date of Last Appraisal_

EEO Classification

_F^Ran^ _

7/0 6

A13

Type of Appraisal Annua l Perkxl of Review Ju l y 200 6 to

OVBWlLPBaKmiAfcKJRATINGFOREMPLOyBESPBW ^ Ratii^ Score,

Otrtstandii ^ Aoc AaHe Fain But Needs Improvenient

Failir Failed :

BASIC TERMS AND CONDITION S CM= EMPLOYMENT t

QFterfontWM X fulfill s temris arKi oorKiition s of emjrfoyment (SatisJac^

•Fterformanc e needs improvement in fulfillii termsan d cwiditionsof emjJoymeriL (Provide Explanation.)

D •Rerfbnmano e does notfitffil l temis and conditions of employment (UresiM^xtotY, Attach copy of suspensioa)

2 5

g P^TORMANC E SUMMARY: Sunrimarize reason for employee's overall ratir ^ induding any strer tiT S or v>«a I - totiieappraial- j j ^ . ^ ^ N icho l s doe s a wonderfu l jo b h e l p i n g patron s in th e ch i l d ren ' s departme r

She enjoy s workin g th e ch i l d ren ' s referenc e des k an d doe s no t min d P ip in g whe n ther e ar e

shortage s xn th e department . Mrs .j .-Nibhol s doe s a wonderfu l jo b nrocefesiBg-ma't 'ffrraHr'Iui ^^ed '

t o b e mor e t i m e l y g e t t i n g th e mater ia l s ou t t o th e p u b l i c . • | p f | f IStI |

AUG 2 3 2007

S%nature of Immediate Supervisor:

S nature of Next Level Supervison

EMPlO¥ffiS C O V I M e J I S :

Signing this revievt'does net constitute teenent or dis reement and only indicate emptoyee has leai and recerwed a copy of Fterf nrance Apfwaisal.

Department L i b r a r y

P t ^ R M A N C E APPRAISAL - FULTON COL .

Empbyee's Name Darnett a Nichol s

Sodaf S«xirily Nunte-_

Classification L i b r a r y Ass is tan t Senio r

DateofHire 06/9 6 _RayRange_ A13

FLSACat^or y _Exemp£ _NcM>B(emFft

Date of Last Apprai ^ 07/0 7

EEOdasafication

Type of Apprai^ _ Fteriod of Review J u l y 200 7 to Jun e 200 8

OVKAILP E i RATING FOR E M P L O y f f i S P m M A N E N T P i ^ O N N a R K D O R D S : Ratii Soore ^

efijfetanding Acceptable Fair: But Needs Improvement

feilir^/Failed:

BASIC TERMS AND CWDITlOh S EMPtOYMENT ;

ElFterfonrance fulfill s temis and conditions of em rfoyment (Satisfactory.)

•Fterfbnnano e needs imprcjvement in fulfillir termsan d conditbnsof emfrfoynrienL (Provide Bcplanation.;

O DFteribmrence does not fiifil l tenms arxl conditions of employmenL (UrsatBfactory. Attach copy cf suqiensioa) P ^

, . ^ & ^ — 0 ^ ^ ^ ^ •

g PSIFORMANCE SUMMARY Sunrannarize reason fbr employee's overall ratii ^ including any strer ths or weaknesses that are pertinei I- to the appraisal.

Mrs . N icho l s doe s a wonderfu l jo b he lp in g th e patron s i n th e c h i l d r e n ' s Department . Sh e doe s whateve r i s neede d fo r th e depar tmen ^ f unc t io n i n s t a f f absence s an d meetings . Mrs : N icho l s processe s book s an d ma te r i a l s i n a t imel y buti , need s t o ge t th e materi . ou t t o th e p u b l i c a f t e r the y hav e bee n processed .

Stature of Immediate Supervisor:

S nature of fsiext Level Suptervison

EMPLOY E C O M M H ^ :

Emplt e' s Signature;

Sgning this reviews does not constitute ^cement or disaaeement and only indicalES emfAjyee las read and received a copy cf Fteri mance Appraisal.

Pfc^iORMANC E APPRAISAL - FULTON COU., .Y

Depaitment SoutWft.st - R-ranp- h T.-iKra-r^ r

Sodal Security Nuntier 260-39-672 4

Classification L i b r a r y A s s i s t a n t Senio r

FLSACat^jr y Exempt

Empfoyee's Name Darnett a Nicho l s

DateofHire 06/9 6 _PayRange_ A13

DatBof LaaApprafeal J u l y 200 8

NravBcempt EEO Clasafication

TypeofApprasal Performanc e App ra i sa l Ra-iod of Review J u l y 200 8 to Jun e 200 9

OV/BeALLPERFORMA^CE RATING FOR B ^ > U 7 t ^ P e e A 4 A N E N T P ^ S C ^ Ratir^Score_

Outsfanding AoDeptalale. Fair: But Needs Improvement

feiling/Fiailed:

BASIC TtRM S AND CONDITION S OF EMPLOYMENT :

QRerfbrmance fulfill s tenns arxJ conditions of employment (Satfefactofy.)

OFterfbmnance needs improwement in fiifiHh ^ terms and conditior>s of employmenL (Provide Explanation.)

O •Fterfonnano e do^ not fuffil i terms arxl conditions of employmenL (Unsatfefactory. Attadi copy of suspensioa) O

< u. 0

PERFORMANCE SUMMARIi ^ Sunmiarize reason for anployee's overall rating, induding any sfrer tfi s or weaknesses that are pertiner to the appraisal. Mrs . N i c h o l s continue s t o d o outstandin g wor k i n th e ch i l d ren ' s departmen t

She proces s book s and . materials; , set s u p d i s p l a y s , shelve s an d organize s th e c h i l d r e n ' s • department . Sh e stay s l a t e an d a s s i s t s wi t h s p e c i a l program s an d ou r Prim e Tim e Readin g Prog r

S nature cf Immediate Supervison

S THtur e of Next Level Supervisor: IT

Date:

Date:

7 ^

S^ir ^ this review does net constitute agreement or disagreement and only indicates employee ias waA and received a copy of fterf manoe Af ^aisal .