Washington State Tort Claim Form Packet Please carefully read all of the information in this packet before completing and presenting your Washington State Tort Claim. Tort claims are subject to public disclosure pursuant to RCW 42.56. NOTE: all documents received by the Office of Risk Management (ORM) become the property of CHM and will not be returned. Please keep a copy for your records and do not send original attachments if you may want them returned. RCW 4.92.100 requires citizens to present the Standard Tort Claim form with the Office of Risk Management (ORM). The law also requires ORM to post on its website the Standard Tort Claim form with instructions. in compliance with these requirements and for the convenience of citizens, ORM developed the Washington State Tort Claim Form Packet. Instructions for completing the Standard Washington State Tort Claim Form Standard Washington State Tort Claim Form (SF 210) Medical Authorization (only for tort claims involving bodily injury) Vehicle Collision Form [only for tort claims involving vehicle accidents/collisions) Mandatory Medicare Beneficiary Reporting Form ln orderto verify the claim and additional supporting information, the law requires that the Standard Tort Claim form be signed by: - 0 Claimant; or 0 Person holding a written power of attorney from the Claimant; or a. Attorney in fact for the Claimant; or I "i Attorney admitted to practice in Washington state on the Claimant?s behalf; or A court?approved guardian or guardian ad litem on behalf ofthe Claimant Department of Enterprise Services Office of Risk Management 1500 Jefferson Street MS 41466 Olympia; WA 98504-1466 Phone (360) 407-9199 Fax (360) 407?8022 Email: Claims@des.wa.gov Business Hours: Monday?Friday; 8:00 am. to 5:00 pm. Closed on weekends and official state holidays. August'2017 INSTRUCTIONS FOR COMPLETING A TORT-CLAIM FORM General Liability Claim Form 210 Before filing a Tort Claim, please read these instructions, the Tort Claim form and other appropriate forms in their entirety. Type or print clearly in ink and sign the Tort Claim form. Do not Staple or tape documents. Do not put in claim form in binders or add divider tabs as all documents must be scanned. Provide all requested information and any available documents or evidence supporting your. claim, such as medical records or bills for personal injuries, photographs, proof of ownership for property damages, receipts for property value, etc. lfthe requested information cannot be supplied in the space provided, please use additional blank sheets so your claim can be easily read and understood. The following are examples on how to complete the Tort Claim Form 210: 1) Smith, Karen Micheile 02/20/1985 #809234 (for use by Department of Corrections inmates only) 3) 1234 College Way NW, Apt. 56, Seattle WA 98178' 4) PO Box 910, Seattle WA 98178 5) Same (or residence at the time of'incident) 8) (206) 123?4587 (206) 987?6543 7) KMSmith@hotmail.com 8) 8/9/2010 8:00 am, - 9) If the incident that caused the damages occurred over a period of time, please provide the . beginning time and the ending time in item 8. 10) Washington, Thurston, Tumwater, Campus of South Puget Sound Community College, Building number 22. 11) l-5, Southbound, Milepost 109, near the Martin Way Exit 12) Washington State Department of Transportation, Highway 13) Smith, Thomas Arthur, 1234 College Way NW, Apt. 58, Seattle WA 98178 (360) 456-3456; Tow Truck Driver, Nisqually Towing 14) Unknown 15) List all other witnesses having knowledge of the incident in question, with their names, addresses, and telephone numbers that are not listed within items 13 and 14. Also include a description of'their knowledge. For example, if your sister was with you when the alleged incident occurred, please include her name, address, telephone number, and indicate she witnessed the incident. 16) Pleasedescl?lbe?t .e22iri?ident that.resvltedz-inrih? injury "the .vvh'y. 17) if you reported this incident to law enforcement, safety, or security personnel, please provide a copy of the report or contact information to the person you spoke with. 18) Please provide all of your medical providers with their names, address, telephone numbers, and the type of treatment. If you were treated for a personal injury, please include your medical records and bills. - . 19) Please attach any additional documents that support your claim. 20) Please provide the dollar amount for your damages, including your time loss, medical costs, property damage loss, etc. This amount should represent your opinion of total compensation. if you are filing a personal injury claim, please sign and attach the Medical Release. if your claim involves a motor vehicle accident, please complete, sign, and attach the vehicle accident form. August-2017 WASHINGTON STATE TORT CLAIM FORM General Liabilily Claim Form 210 Pursuant ID Chapter 432 this torrn is [or filing a tort ciaim against me state of Washington Some oi the iniormalion requested on this form is required by ROW 4.92 '00 and is sublecl |o pubiic disclosure pursuant to RCW 42 56' PLEASE TYPE OR PRINT CLEARLY IN INK Mail or deliver Department ofEnterprise Services original claim to omce of Risk Managemenl 1500 Jellerson Street SE. MS 41466 Olympia Wasninglon 98504-1466 Phone: (350) 407--9199 Fax 350) 407--3022 Email: Claims@des wagov Business Hours: Monday -- Friday 5 on aim. -- 5:00 pm. Closed on weekends and official state nol ays Hodel David Last name First Middle 1' Clalmant's name: 2. Inmate DOC number (ilapplicable): For onicial Use Only Dale 0! him 3' Current residentiai address -- 4. inning address (immeremi -- Business of Ce 5. Residential address at the time of the incident: (it different from current address) 6. Claimant's daytime teiephone number: Home 7. eiaimani-semaiiadmss,-- pm. (check one) e, Daleoflheincident: 01/03/2018 Time2M'00 am. 9 lithe incident occurred overa period oltime, dale offirsl and last occurrences (mm 03/01/2018 Time: 04:00 am [mm/ddiYYyY) 01/03/2018 Time: 11:00 an, Various Washington State State and counly Clly, ilapplicable 10, Location of lnciden pm, pm. Piace where occurred ?ii. ifthe incident occurred on a street or highway: Various Name of street or highway Milepost number At the intersection with or nearest intersecting street '12. State agency or department you believe is responsibie for damage/injury: Washington State Petrol 13. Names and telephone numbers of all persons involved in or witness to this incident: 14. Names and telephone numbers of all state employees having knowledge about this incident: David Hodei, Dean Gaiianger,Austin Lauer, Steven Townsend, Jacob Payne, Chad Prentice Ford Fieet supervisor, Chief Batiste 15. Names and teiephone numbers of ail individuals not already identified in #13 and #14 above that have knowledge regarding the liability issues involved in this incident, or knowledge of the Claimant's resulting damages. Please include a brief description as to the nature and extent of each person?s knowledge. Attach additional sheets if necessary. . Linda Winter i.&i Moei235@ini.wa.gov 16. Describe how the state ,of Washington caused your injuries or damages (if your injuries or damages were not caused by the State, do not use this form. You must file your claim against the - correct entity). Explain the extent of property toss or medical, physicai or mental injuries. Attach additional sheets if necessary. Washington State Patrol utilized Ford Vehicies that they knew had carbon monixide ieaks and exposed . Troopers to Carbon Monoxide poisoning. Washington State Patio! failed to remedy the problem Washington State Patrol failed to implement an ongoing program to ensure that carbon monoxide would not continue to be exposed to Troopers operating WSP vehicies. Washington State Patrol failed to notify members of the danger, felted to train members .- Faiied to piece carbon monoxide detectors in vehicies and failed to remove the vehicles from service when they had been identified as having carbon monoxide issues. 17. Has this incident been reported to iaw enforcement, safety or security personnel? If so, when and to whom? Please attach a copy of the report or contact information. yes. Lynda Winter, i_&l 360-896-2332 15 Names addresses and ieiephone numbers orireaimg medicai providers Submil copies ofaii medical repons and be suppiemented 15. Piease aliach documents which supponlhe ailegatiuns ofiths claim, 20 i claim damages (rem the state oiWsshingion in the sum ol$1r000v000r000 This Ciaim iorm musi be signed by one at me (allowing (check appropriaie box), Claimanl Psrsun holding a wriflen power of attorney from (he Claimanl Anoiney in fact (or the Claimant Allomey admiiled Io practice in Washington State on Ihe Claimant's behalf Conn-approved guardian or guardian ad [Item on behalf of ihe Claimant i declare under penaiiy oi perjury undsr ms laws oi the state of Washingion ihai iris loreguing is ime and correci. Signature 0! Clalmanl 4 iabi i \{mm a D319 and place (residenu'al address, clty and county) :C'Dwk WAY-mum; r0 ER Li;% Print Merrie of Representative Bar Number (if applicable) he! at? STATE OF WASHINGTON DEPARTMENT OF LABOR AND INDUSTRIES Division ofOcczwatlonal Safety and Health gl?? 312 SE Stonemill Dr. Ste 120 Vancomier, WA 98684 August31,2018- In response to your complaint regarding alleged health hazardset State Patrol, an inspection was conducted on March 6, 2018. You alleged that: . On February 14th 201 7, an employee stgfered?om carbon monoxide poisoning while working in their assigned 2014 Ford Explorer Police Interceptor and was hospitalized as a result. The employee?s vehicle was transferred to a Ford dealership for evaluation. Apparently, the WSP ?eet section knew about the potential exhaust problem but had not notified any WSP vehicle custodian. The Ford dealership Service Manager stated that he had no way to test for carbon monoxide and could not guarantee that the vehicle would not kill the employee. The vehicle was then driven to the WSP fleet section in Tumwater and a carbon monoxide detector installed The patrol vehicle was later returned to the same employee with no operating procedures provided for the carbon monoxide detector. On February 21 st 201 8, the carbon monoxide detector sounded in that same vehicle. The employee was directed to the ?eet section for protocol on carbon monoxide exposure. The employee was then transfer ed for medical evaluation andresults showed elevated levels ofear bon monoxide The potentially fatal problems that have been known by the Washington State Patrol and Ford Motor Company have not been addressed with the seriousness that they deserve. The alarms installed by the WSP?eet section are inadequate. The Washington State Patrol is?gambling with employee?ls' lives to save a few dollars. til/otter During the inspection, these allegations were confirmed. In addition to your complaint, there are Have Been dozens more documented trooper exposures, associated with faulty exhaust systems. Washington State Patrol Troopers and other staff who have been driving Ford Interceptor SUVs have been experiencing signs and of carbon monoxide exposure. Exhaust issues have been discovered as the source of the exposure in most of the vehicles: cracked manifolds, warped manifolds, and other leaks in the exhaust system. In the summer of 2017, WSP ordered home carbon monoxide (CO) alarms to be installed in the cabs of their Ford SUV ?eet vehicles. These devices are inappropriate for evaluating workplace exposure as they don't detect CO at unsafe levels. Additionally, employees were not trained on the operating instructionst?activation levels of the home alarms, On March 22, 2018, a meeting was held with WSP and DOSH management, including Anne Soiza, Assistant Director, where The Department of Labor and Indestries required WSP to install appropriate personal monitoring devices for CO in each car. These datalogging devices have been programmed to alarm at the WA State Permissible Exposure Limits for CO: 35 ppm, 8 hour time weighted average (TWA) for CO and also at 100 ppm, as a high level alarm. These BW Clip monitors were installed over a two week period in July 2018. Since then, over 50 alarms have been reported to have been activated at the 35 level. All of these vehicles have been taken to Ford dealerships and major exhaust problems were discovered. WSP will be issued a citation with the following violations: 1?1: Not conducting exposure evaluations for employee exposure 1-2: Not training employees on the hazards of carbon monoxide 2~l: Not allowing employees access to exposure records If you disagree with the inspection results you may ask for a review of the inspection ?ndings by writing to Matthew Ludwick, Region 4 Compliance Manager, at the following address: Matthew Ludwick - Region 4 Compliance Manager . PO Box 44810 Olympia, WA 98504-4810 If any employer takes action against you for reporting this hazard, this may be discrimination. Even when we have not revealed your name, we cannot guarantee that your employer won?t find out who ?led this complaint. If you believe an employer has taken action against you for reporting hazards or for participating in workplace safety and health activities, you may call or write us. To consider your WISHA discrimination complaint, we must receive it within 30 days of the alleged discrimination. Callour WISHA discrimination section at (360) 9026480 for more information on discrimination or for help ?ling a complaint. I Washington State Department of Labor 81 Industries H. Divisiee ei? Sciepetiamt! Safety and Health Invoice Inspection: 317948485 342008334 tease; Legal Name: WA ST PATROL Opening Conference: DBA Name: WASHINGTON STATE PATROL Closing Conference: Inspection 1264 Scale House Road Inspector ID: .. Site: ?Goldendale, WA 98?2_0_ .. Summarv of Assessed Penalties Due The Citation and Notice of Assessment includes a full deso1iption of each violation. Serious .Ao mesa-20005 1 I 10/2/2018 Serious AC 296-901-14016 i Corrected Match 6, 2018 August 27, 2018 F9196 General AC 296?802?30005 10/2/20] PAYMENT ENFORMATION Payment is due 15 working gays from receigt of this citation. Make check payable to the Department of Labor and Industries. Write inspection number 317948485 on the cheek and mail to: Attn: DOSH Cashier Department of Labor and industries PO Box 44835 Olympia, WA 98504-4835 Or deliver to: Any office August 30, 2018 $4 900.00 $4 900.00 $0.00 $9 800. Washington State of Document . Industries. Citation and Notice of Assessment Division Harmonie-net Safetyand Health Inspection 31 794848 5 . W. Issuedi'Augtis't' 3.0, 201-8 . Legal Name: WA ST PATROL Opening Conference: March 6, 2018 DBA Name: WASHINGTON STATE PATROL Closing Conference: August 27, 2018 Inspection 1264 Scale House Road Goidendale, WA 93620 Inspector 1D: F9196 I Site: Violation 1 Item 1 i . Violation Type: Serious WAC 296?841?20005(1) The employer did not conduct an exposure evaluation to determine whether employees are or could be exposed to an airborne contaminant above the permissible exposure limit (PEL) listed in Table 3: Permissible Exposure Limits for Airborne Contaminants. At the time of the inspection, the employer had not evaluated employees' exposure to exhaust contaminants, primarily, carbon monoxide (CO), to determine whether their Troopers? exposure levels exceed the Washington State Permissible Exposure Limits (PELs). Washington State has three PEL values for CO: 1) 35 ppm, 8 hour time-weighted ayerage (TWA) 2) 200 ppm, 5 minute time-weighted Short Term Exposure Limit (STEL) 3) 1500 ppm, Ceiling Limit (an instantaneous limit) Washington State Patrol (WSP) Troopers and other staff who have been driving Ford Interceptor SUVs have been experiencing signs and of carbon monoxide exposure. Exhaust issues have been disoowred as the source of the exposure in most of the vehicles: cracked manifolds, warped manifolds, and other leaks in the exhaust system. In the summer of ordered home carbon monoxide alarms to be installed in the cabs of their Ford SUV ?eet vehicles. These devices are inappropriate for evaluating workplace exposure. Exposure to carbon monoxide impedes the blends ability to carry oxygen to body tissues and vital organs. Common of carbon monoxide exposure are headache, nausea, rapid breathing, weakness, exhaustion, dizziness, and confusion. Hypoxia (severe oxygen de?ciency) due to acute carbon monoxide poisoning may result in reversible neurological effects, or it may result in long-term (and possibly delayed) irreversible neurological (brain damage) or oardiologieal (heart damage) effects; The following additional correction documentation is required for violatibn: Include all exposure data for CO monitors that have alarmed with your Employer Certification of Abatement Form. Also, provide documentation describing method(s) employees may use to download their exposure data from the monitors, or the process in place for employees to obtain said data (if someone else will download and provide it to them). I Post This Document Citation and Notice of Assessment Inspection: 317948485 Washington State Department of Labor 81 Industries Beasts; easiest: salary and Health Violation 1 Item 2 I Violation Type: Serious WAC 296~901~14016(1) .The employer did not provide employees with effective information and training on hazardous chemicals in their work area, as required by this standard andde?ned in WAC in that the employer did not train employees on: . The methods and observations that may be used. to detect the presence or release of a hazardous chemical in the work area (such as monitoring conducted by the employer, continuous monitoring devices, visual appearance or odor of hazardous chemicals when being released, etc); - The health hazards of the chemical in the work area; and . The measures employees can take to protect themselves from these hazards. At the time of the inspection, Washington State Patrol Troopers driving Ford Interceptor SUVs were experiencing signs and of carbon monoxide (CO) exposure. Their vehicles were. found to have exhaust issues which was the source of the exposure. Troopers were not trained on the hazards of carbon- monoxide exposure nor the operation of the CO home alanns installed in their vehicles. The employer had not informed Troopers of the alarm activation set points nor that they were inadequate for employee protection. Exposure to the chemicals in the workplace, such as carbon monoxide, are more readily controlled through a properly developed and implemented Hazard Communication Training Program. Exposure to carbon monoxide impedes the blood?s ability to carry oxygen to body tissues and vital organs. Common of carbon monoxide exposure are headache, nausea, rapid breathing, weakness, exhaustion, dizziness, and confusion. Hypoxia (severe oxygen de?ciency) due to acute carbon monoxide poisoning may result in reversible neurological effects, or it may result in long?term (and possibly delayed) irreversible neurological (brain damage) or cardiologioal (heart damage) effects. i i i I I Washington State Department of i This Document Citation and Notice of Assessment Division i Inspection: 317948485 Vialation 2 Item 1 Violation Type: General WAC 296-802-30005 The employer did not inform employees about their exposure records. Washington State Patrol installed BW/Honeywell CO datalogging monitors into every Ford Interceptor SUV. Employees have not had access to their exposure information. Employees must be allowed access and/or download their exposure data: patticularly when 1) when the alarms are activated or 2) employees begin experiencing signs and of CO exposure. . You must inform employees covered by this rule about medical and exposure records when they first start employment; and then at least annually. Include the following information: Where the records are located Who is responsible for the records Who to contact for access to the records Their rights to copy the records. The following additional correction documentation is required for this violation: With your Employer Certification of Abatement Form. please provide documentation demonstrating that you have informed all exposed staff of how to obtain and where their exposure data records are located, of who is responsible forthe records, of who to contact to access the records,?and that staff have been informed of their rights to copy said records.