Printing - FECA-PT2 - National Association of Letter Carriers

STATEMENT OF ACCEPTED FACTS
IN THE CASE OF JAMES JONES
FILE NUMBER: xxxxxxxxx
James Jones, date of birth 03/22/1975, is employed as a maintenance worker with the Department of
Veterans Affairs. On April 14, 2009, he sustained an injury when a desk he was moving slid off a fork lift
and slammed into his left knee, pinning his knee between the desk and a wall. He received initial medical
attention at the Northwestern Medical Center on April 14, 2009.
The conditions of a left knee contusion and left knee sprain are accepted as causally related to the April
14, 2009 employment injury.
A left knee arthroscopy was performed on September 10, 2009. Mr. Jones has not returned to work to
date.
The duties of a maintenance worker require walking and standing for up to six hours per day; intermittent
squatting, bending and kneeling for up two hours per day; pushing/pulling up to one hour per day;
climbing stairs ½ hour per day; and occasional lifting up to 50 lbs.
Prior medical history: Claimant suffered a torn left knee medial meniscus as a result of a soccer injury at
age 16.
CE Name
Title
Date
Exhibits 2-Basic OD Sample
STATEMENT OF ACCEPTED FACTS
IN THE CASE OF JANE DOE
FILE NUMBER: xxxxxxxxxx
FECA-PT2 Printed: 06/08/2010 316