WORKPLACE SAFETY AND INSURANCE BOARD
APPEALS RESOLUTION OFFICER DECISION
DECISION NUMBER: 20180046
OBJECTING PARTY: Worker
REPRESENTED by: Paralegal
RESPONDENT: Employer
HEARING: Oral Hearing on August 16, 2018
HEARD by: C. Marr, Appeals Resolution Officer
DATE: August 22, 2018
ISSUES
The worker is objecting to the following decisions, all made by Case Managers (CM):
The denial of entitlement to benefits for chronic pain disability (CPD) dated June 28, 2017.
The determination that his compensable concussion resolved by December 7, 2015 with no ongoing impairment dated December 7, 2015.
The denial of entitlement to benefits for a psychotraumatic disability dated June 28, 2017.
The denial of loss of earnings (LOE) benefits after December 8, 2015 dated June 8, 2017.
BACKGROUND
On June 11, 2015 this labourer was struck on the forehead above the nose by the leg of a table that he was moving. This was his fourth work-related head injury since November 2013. The worker was nearly 27 years of age at the time of the workplace accident under this claim.
The worker was granted entitlement to benefits for a concussion. The CM determined that his compensable concussion resolved by December 7, 2015 with no ongoing or permanent impairment. As explained in correspondence dated December 7, 2015, any ongoing symptoms were determined to be due to pre-existing conditions.
This decision was reconsidered and upheld on June 8, 2017. Entitlement to ongoing health care or LOE benefits related to the concussion beyond December 7, 2015 remained denied.
The worker requested entitlement to benefits for a psychological condition. As explained in correspondence dated June 28, 2017, entitlement to benefits under the policies for either CPD or a psychotraumatic disability was denied as the available medical and non-medical evidence did not support that the worker’s non-organic or psychological issues were directly related to the workplace accident and injury.
Worker’s Position
The worker representative argued in part that the medical evidence supports that the worker has a permanent organic impairment as a result of his work-related head injury, and that the workplace accident and injury permanently aggravated his pre-existing psychological condition. In the alternative, the criteria for benefits under the CPD policy have all been met. The worker has not been able to work since December 8, 2015 and is totally disabled. He is seeking full LOE benefits.
The worker representative also requested consideration for LOE benefits while the worker was on a graduated work reintegration (WR) program with the employer from August to December 2015. This issue is not presently before me. The worker was paid partial LOE benefits for this period. The worker representative should request a decision from the Operating Area on further partial LOE benefits if the worker believes he was not paid correctly for his lost time during this period. There is no decision on additional LOE benefits for this period beyond what was paid in any of the decision letters regarding the issues that are presently before me.
EXHIBITS
Note that rather than provide testimony as planned, the worker representative decided to have the worker’s mother submit a written statement and just observe the hearing. This document was accepted and marked as Exhibit 1.
AUTHORITY
Operational Policies
11-01-05 Determining Permanent Impairment
15-02-04 Aggravation Basis
15-04-02 Psychotraumatic Disability
15-04-03 Chronic Pain Disability
18-05-02 Payment and Reviewing LOE Benefits (Prior to Final Review) dated July 15, 2011
ANALYSIS
1. Chronic Pain Disability
I find that the worker is entitled to benefits under the policy for chronic pain disability (CPD). The medical and non-medical evidence supports that the criteria for entitlement to benefits under the policy for CPD have been met.
Entitlement to benefits for conditions such as somatoform pain disorder and post-traumatic head pain is considered under WSIB Operational Policy 15-04-03 Chronic Pain Disability. The worker was diagnosed with these conditions. The policy lists five criteria, each of which has to be met, in order for a worker to be entitled to benefits for CPD. These criteria are:
A work-related injury occurred.
The chronic pain is caused by the injury.
The pain persists six or more months beyond the usual healing time.
The degree of pain is inconsistent with the organic findings.
The chronic pain impairs earnings capacity and causes a marked life disruption.
This worker sustained a head injury in a work-related accident that occurred on June 11, 2015. This was his fourth work-related head injury since November 2013. Individually, each incident and injury was relatively minor. The worker made a good recovery from the first three head injuries. However, he has had lingering issues following the fourth incident. The first criterion has been met as a work-related injury occurred.
In the months following the workplace accident the worker reported improvement in the frequency and severity of his headaches. He told his family doctor (FD), treating chiropractor, and the specialist who assessed him at the Regional Evaluation Centre (REC) that his symptoms were improving. He was able to attempt a graduated work reintegration (WR) program with the accident employer in August 2015. At times his headaches were suspected as being related to medications he was taking, to muscle tension, or to the weather. The diagnosis and treatment of headaches often involves such process of elimination. Unfortunately he continued to experience headaches and was unable to continue working. He went off of work as of December 8, 2015 and has not worked since.
The worker testified that he gets persistent headaches to date. The degree of pain he experiences may change on a daily basis but he is never totally pain free.
The worker denied suffering from headaches that required medical treatment in the pre-accident period. Some medical reports mention that he had a history of headaches. He said that he may have had some headaches due to sinus issues or his previous work-related head injuries, but he was never diagnosed with migraines or treated for these. He had longstanding treatment relationships with several doctors dating back years before he was injured at work and these have said that he did not complain of headaches to them in the pre-accident period.
Dr. Lee, the neurologist who previously monitored the worker for epilepsy assessed him on October 26, 2015. No new pathology was noted on an MRI of the brain or EEG testing. He suspected that the worker had tension headaches or chronic pain. A follow-up appointment was not planned for another two years. Dr. Lee later reported that the worker had never complained of headaches to him in the years he monitored him for a neurological condition.
I must address the Medical Consultant’s (MC) discussion with the FD that occurred on December 1, 2015. According to the FD’s chart notes, when he was contacted by the MC the FD reviewed his notes on the worker from the previous year as well as consultation reports from the neurologist and psychiatrist. At that time the FD expressed that “considerably less than 50% of (the worker’s) symptoms are related to the Head Injury.” The MC documented that the worker’s many pre-existing factors, including migraines, were contributing to the worker’s symptoms. This discussion largely formed the basis for denying further entitlement to benefits under this claim.
The worker representative wrote to the FD requesting clarification. In his response dated April 15, 2016, the FD said that he never treated the worker for headaches prior to the first work-related concussion in November 2013. The FD said that he was unable to say for certain what was causing the worker’s headaches at the time of his letter to the representative. Now realizing that his previous concussions were work-related, he stated that the worker’s head symptoms were fully attributable to the four work-related head injuries to some degree.
The FD treated the worker following the previous accidents and injuries and indicated that he reviewed his notes before providing an opinion to the MC. He certainly should have been aware of the worker’s history of work-related head injuries. The representative argued that when the MC called the FD, the FD did not have time to give a proper review of the medical record. His written response to her inquiry reflects such a review. I place more weight on the reporting from the treating specialists in determining the worker’s ongoing impairment and entitlement to benefits under this claim. I do note that the MC recommended obtaining outstanding reports from the neurologist and psychiatrist to thoroughly review the contribution of any pre-existing conditions to the worker’s ongoing impairment.
In early 2016 the worker reported that his condition was improving. His headaches were less frequent and severe. He was trying to become more socially active and attempted to participate in sporting activities. He testified that he was unable to maintain these gains, however. As he continued to have pain from his headaches, his pre-existing depression worsened, which in turn caused him to have worse headaches.
The worker does not complain of pain from other organic areas of injury. He consistently reported that he has headaches. No other physical injuries or conditions are contributing to his pain profile. He had a history of issues with his temporomandibular joint (TMJ) but the dentist who treats the worker for this expressed that this was not contributing to his post-accident pain profile. The dentist related the worker’s headaches to the concussion.
On May 4, 2016 the worker was assessed by another neurologist, Dr. Tator. The worker reported having developed migraines after the concussion sustained on June 11, 2015. The worker had some balance issues on examination. The worker was diagnosed with a post-concussion syndrome and migraine headaches. Medical management was recommended. It was suggested that he avoid working in an area where he could sustain further concussions.
The worker does have significant pre-existing psychological issues. He was in active treatment and on medication for psychological conditions for many years leading up to the date of injury under this claim, and beyond. He was diagnosed at times in the pre and post-accident period with major depressive disorder (MDD), post-traumatic stress disorder (PTSD), attention deficit hyperactivity disorder (ADHD), anxiety, and bi-polar disorder. He also had sleep issues prior to the date of injury. He testified that active regular counselling and medications allowed him to manage these conditions in the pre-accident period. While he was symptomatic prior to June 2015, his psychological issues were stable in that he did not have a pre-accident psychological impairment, as defined under policy 15-02-04 Aggravation Basis. He did not miss time from work or require accommodated work duties due to his psychological issues since he was hired by the accident employer in September 2013.
The medical evidence supports that the worker’s pre-existing psychological condition also contributed to his developing a pain disorder in the post-accident period. On May 2, 2016 one of the worker’s treating psychiatrists, Dr. Goldstein, reported that he had been treating the worker for depression over the previous decade. He states that the worker’s headaches were making his depression worse. He believed the headaches were related to the concussions as the worker had not complained to him about headaches previously.
The worker participated in a multi-disciplinary assessment at the Neurology Specialty Clinic over several dates between July and October 2016. The reports are quite extensive. In my opinion, the key points from this assessment are as follows:
Brain injury-related headaches typically do not worsen over time. Thus the worker’s reported worsening of his headaches was likely due to mental health issues, sleep disturbances, somatic symptoms disorder, stressors, and disabled messaging from previous health care practitioners.
The worker’s chronic headaches with migraine features were likely initiated by the workplace accident and head injury and have been perpetuated and exacerbated by the psychological issues listed above. At this time the worker was in a “chronic migrainous state”.
Symptoms of dizziness and visual disturbances were likely side-effects from medication.
The worker’s subjective cognitive issues were likely due to the reaction to his pain and the mental health issues, not an organic brain injury.
Other than perhaps the first incident in November 2013, it is questionable as to whether he actually sustained brain injuries in any of the three subsequent workplace accidents reported.
In terms of the workplace accident and injury under this claim, the worker was diagnosed with a “possible somatic symptom disorder, with predominant pain, persistent, moderate severity.” There were no neurologic barriers to the worker returning to work. Headaches were a barrier to the worker returning to work, but not a restriction. The FD’s recommendation that the worker be off of work and Dr. Tator suggesting that the worker find work in another field was seen as having had a detrimental effect on the worker’s perception of his disability. From a neuropsychological perspective, the worker was fit for full hours and job duties. It was important that all of the worker’s community health care providers assist the worker in developing life goals and encourage him to participate in all aspects of daily living. Consistent messaging from these individuals was said to be of the utmost importance.
A comprehensive multi-disciplinary treatment program to address his overall well-being and psychological issues was recommended. The representative noted that this treatment program was not approved under the claim. The worker has continued to receive treatment for his headaches and psychological issues on his own.
A degree of over-reporting bias was noted by the team at the Specialty Clinic. However, this was not assessed to be sufficient to render the test results invalid. The worker’s clinical presentation to the team at the Specialty Clinic as well as the medical records since the date of injury contained “features typical of a chronic pain disorder maintained and/or exacerbated by psychological factors.” The team at the Specialty Clinic expressed that when individuals with somatoform psychological traits are actually injured, their symptoms can be worse or persist beyond what would typically be expected.
The worker was also concurrently assessed by a neurologist at a headache clinic, initially on July 13, 2016. The physical and neurological examination was normal. The worker was diagnosed with chronic migraines and possibly post-traumatic headaches, complicated by multiple mild traumatic brain injuries and psychological issues. It was recommended that he continue to see the psychiatrist and that he makes some lifestyle changes. Medication management was also provided. Subsequent reports from Dr. Lagman-Bartolome indicate that the worker was not adhering to the lifestyle changes that were recommended. He continues to see this doctor currently and receives botox injections for his headaches. The worker said that this gives him some relief but never makes the pain go away entirely. The Specialty Clinic recommended that the worker continue to be followed by this doctor for his headaches.
The worker has consistently reported having headaches to some degree since the date of injury. Initially he may have had days where he was relatively symptom-free, but by 2016 he complained of regular headaches. He was treated for these. There definitely is a psychological component to his pain profile due to his significant pre-existing and concurrent psychological conditions. The medical evidence supports that these non-work-related psychological issues contributed to his developing the chronic post-traumatic head pain. However, the workplace accident and injury, which was usually diagnosed as a concussion, was identified by multiple specialists as having also caused his chronic head pain. There is an interdependent relationship between the work-related head injury and the non-compensable psychological issues. In my opinion, the medical evidence supports that the worker’s head pain was caused by the work injury. The second criterion under the CPD policy is met.
The Specialty Program indicated that the expected recovery time for a mild traumatic brain injury is twelve to 24 weeks. The worker’s head pain has persisted more than six months beyond this period.
The degree of head pain reported by the worker is greater than would normally be expected. He states that his pain levels vary but never goes away entirely. Some days are better than others. He has continued to seek medical treatment and has tried various interventions for his headaches. There were no unusual findings on the MRI or other tests. Neurological examinations performed on the worker were normal. The degree of head pain that the worker reports is not consistent with any physical findings.
Policy 15-04-03 states the following regarding marked life disruption:
Marked life disruption indicates the effect of pain experienced by the worker and the effect on the worker's activities of daily living, vocational activity, physical and psychological functioning, as well as family and social relationships.
There must be a clear and distinct disruption to a worker's life, but there is no particular requirement for this disruption to be either major or minor. The disruption in the worker's personal, occupational, social, and home life must be consistent, though the degree of disruption in each need not be identical.
The presence of "and" in the statement "social, occupational, and home life" suggests that all 3 must be present. However, there is no requirement that all 3 aspects of a person's life must be disrupted to the same degree.
The worker attempted a graduated WR with the accident employer between August and December 2015. He testified that he performed light tasks but was unable to sustain the work due to his headaches. He said that he missed days due to headaches. He has not worked in any capacity since December 8, 2015. He said that the employer typically has a seasonal layoff in January. He previously took advantage of this to travel to Cambodia in 2015. As his WSIB benefits had been cut-off he agreed to take the layoff in 2016 so that he could get employment insurance benefits while seeking treatment.
I note that the team at the Specialty Clinic stated that the worker had no restrictions from working full hours and duties. However, additional treatment was recommended to support and sustain any return to work given the time he had been off of work, his pain and psychological issues, and the disabled messaging he had received from other doctors. The worker maintains that he is not fit to work. There has been a clear disruption to his occupational life to some degree.
Some of Dr. McLean’s notes are on file. She is one of the worker’s treating psychiatrists. At times in the pre-accident period the worker said that he was not socially active. He did not maintain strong friendships with people from his home city when he went away to university. However, he was able to participate in martial arts and did travel to Cambodia in early 2015. He testified that he had friends in Cambodia and intended to return there to teach English and possibly start a business.
In the post-accident period, the worker reported to the health care practitioners that he was trying to be more socially active beginning in 2016. He recommenced participating in martial arts and was trying to get out with his friends more. He was encouraged by some of the specialists to return to full activities, and that it was important that he do so. Yet as his pain symptoms worsened and persisted, he was unable to maintain these gains. He testified that he is now essentially home-bound and generally only goes out for medical appointments. He has seen his friends achieve milestones in their lives and he feels left behind. His has not pursued his plans to return to Cambodia.
The worker expressed that he now feels as though he is a burden to his parents. He is not able to help out around the house as he did before. His mother, a judge, provided a statement in which she indicated that the worker no longer wants to visit the family cottage as it reminds him of things he can no longer enjoy. The worker does not have a personal relationship with a partner. Since the accident he travelled to England for his sister’s wedding but was unable to partake in nearly all of the events, remaining alone in his room. He has declined attending concerts and museums with friends and family. He did not attend the wedding of a good friend.
Thus, the worker has had a marked disruption to some degree in his social, occupational, and home life. This criterion of the policy has been met.
The available medical and non-medical evidence supports that all five of the criteria for entitlement to benefits under the CPD policy has been met. The work-related head injury and subsequent related symptoms combined with his pre-existing symptomatic psychological conditions to cause the worker to develop a pain disorder.
Policy 11-01-05 Determining Permanent Impairment defines maximum medical recovery (MMR) as the time in recovery when a plateau has been reached and it is unlikely that there will be any further significant improvement in the work-related condition. Under policy 15-04-03, workers who have met the entitlement criteria under the policy are considered to have achieved MMR and are entitled to a Non-economic Loss (NEL) assessment.
I find that the worker achieved MMR for his CPD condition by January 26, 2017, the date of the final neuropsychological report from the Specialty Clinic. Although the further treatment that was recommended by this clinic was not approved under the claim, the worker continued to seek treatment for his headaches and for psychological issues in the community without reported significant improvement. The worker was diagnosed with the somatic symptom disorder by this clinic. The worker is entitled to a NEL assessment for CPD.
I note that the representative requested that coverage for the course of treatment recommended by the Specialty Clinic in January 2017 be approved now. It is questionable as to whether this would be beneficial to the worker at this time as MMR for the CPD has been achieved. Also, the worker testified that he continues to participate in various forms of treatment for his headaches and psychological issues. Should additional medical evidence from these specialists and programs come to file, the Operating Area may reconsider covering the program the Specialty Clinic had recommended, now that entitlement to benefits under the CPD policy has been granted.
2. Permanent Impairment for Organic Injury
3. Psychotraumatic Disability
CPD is a holistic condition that accounts for organic pain and non-organic symptoms. As the worker has entitlement to benefits under the CPD policy I have determined that his pain issues are predominantly due to psychological issues other than PTSD or a conversion disorder. As per policy 15-04-03, the worker will be compensated for the CPD condition under this policy. He is not entitled to benefits for an ongoing organic impairment or a psychological condition under policy 15-04-02 Psychotraumatic Disability.
4. LOE Benefits
I have determined that the worker is entitled to a period of full loss of earnings (LOE) benefits from when he stopped working due to his injury on December 8, 2015.
Policy 18-05-02 Payment and Reviewing LOE Benefits (Prior to Final Review) states in part:
If the nature or seriousness of the injury completely prevents a worker from returning to any type of work, the worker is entitled to full LOE benefits, providing the worker co-operates in health care measures as recommended by the attending health care practitioner and approved by the WSIB. If the worker does not co-operate, the WSIB may reduce or suspend the worker’s LOE benefits.
The worker went off of work as of December 8, 2015 due to his headaches. His FD supported that he was unable to work at the time. Following this date he underwent medical evaluations with multiple specialists in order to treat his headaches, subsequent pain disorder, and his non-compensable psychological issues. I accept that he was unable to work in any capacity for a period while he was being treated and evaluated for his headaches. However, the available medical evidence does not support that the worker remains totally disabled and incapable of working in any capacity due to his compensable CPD.
The worker will be rated for a NEL for his CPD. The NEL assessment and determination will likely account for the significant symptomatic pre-existing and co-existing psychological issues, which include MDD, PTSD, and ADHD. The NEL rating will be based on the same medical evidence that is before me presently, so even though the quantum of the NEL benefit is not yet known, I can comment on the worker’s level of impairment from the compensable CPD.
There is outstanding medical information. The Case Manager (CM) made extensive efforts to obtain all relevant medical information from the period prior to June 2017. According to correspondence from the CM dated June 8, 2017, the worker representative requested that the CM make a decision with the information that was available. By submitting the Appeal Readiness Form on April 24, 2018 the representative also declared that a decision was requested to be made with the information that was available.
Dr. Goldstein, the worker’s other longstanding treating psychiatrist, provided a report dated May 2, 2016 stating that the worker’s headaches were due to his concussion. The psychiatrist did not comment on the worker’s fitness to work in this report.
On May 4, 2016 Dr. Tator recommended that the worker seek employment where he is unlikely to sustain another concussion. This supports that the worker was considered to be fit to work by this doctor at that time.
The worker was assessed for his headaches by Dr. Lagman-Bartolome on July 13, 2016. Various medical interventions were recommended to treat the worker’s headaches. Lifestyle changes were also recommended, which the worker reportedly did not adhere to. The doctor noted that the worker was off of work at the time, but did not comment specifically on his fitness to work.
The worker underwent a multi-disciplinary assessment at the Specialty Clinic over several dates from August 2016 to October 2016. He was seen by a neurologist, neuropsychologist, physiotherapist and occupational therapist. I place significant weight in this comprehensive report. In summary, the team at the Clinic found that there were no neurological restrictions for the worker returning to work. Headaches were a barrier, but not a restriction. The worker was advised to gradually increase his exposure to lights and sounds and to return to full pre-accident activities. Supportive treatment and messaging from his other treatment practitioners was also recommended. The worker testified that he continues to participate in various forms of treatment for his headaches and psychological issues.
The worker was seen by Dr. Tator again on May 3, 2017. He complained of daily headaches which increased with mental activities and decreased with marijuana use. Dr. Lagman-Bartolome had advised the worker to discontinue using marijuana as this was seen as a contributor to his headaches. The worker was still in regular active treatment for his depression. His memory and executive function were intact. The examination was normal. The worker was advised to continue the aerobic activities he reported doing but to also maintain an activity level below which symptoms occur. A follow-up assessment was not required.
The worker testified that the side effects he experienced from medication, such as dizziness, ceased when he stopped taking the triggering medication.
The worker representative arranged for the worker to be assessed by Dr. Pilowsky, psychologist, on August 8, 2017. The worker testified that he had stopped seeing Dr. Goldstein around early 2017 but that he remained in treatment with Dr. McLean, psychiatrist, as well as with a social worker through to the present. An updated comprehensive report could presumably have been obtained from Dr. McLean. Dr. Pilowsky only reviewed the limited medical documentation provided to her by the representative. The worker states that he only saw this psychologist once.
The worker reported to the psychologist that he was struggling with his memory, concentration and decision-making which differed greatly from what the neurologist observed just three months previous. The psychologist’s report states that the worker showed cognitive deficits in the days following the workplace accident, which is inconsistent with the extensive medical reporting that was reviewed by the team at the Specialty Clinic. She also states that it is evident that the worker’s “psychological, cognitive, and emotional functioning significantly declined” post-accident, that there was “evidence of significant cognitive decline from his previous level of performance in attention and memory,” and that the worker was functioning at a very high level prior to the workplace accident. Having only seen the worker on one occasion without reviewing the full medical record, it is unclear to me how the psychologist can determine evidence of decline in function or how the worker was functioning in different periods in years prior to seeing him.
For the reasons outlined above, I do not place significant weight on the psychologist’s report.
In my opinion, the worker was fit to work by January 26, 2017 when MMR for his CPD was achieved. As outlined above, Dr. Tator expressed that the worker could work and the team at the Specialty Clinic recommended that he do so. Dr. Lagman-Bartolome did not specify, but did not indicate that he was totally disabled from working. The worker has a degree of disability from his CPD which is complicated and effected by his significant pre and co-existing psychological issues. In terms of his compensable condition, he was fit to work by the MMR date.
The worker is granted full LOE benefits to January 26, 2017.
The worker testified that the nature of the accident employer’s business is somewhat seasonal. He was laid off in the winter of 2015 to be recalled again in the spring. In January 2016 he remained off of work due to his injury. He said that as he was not receiving LOE benefits and was unable to work anyway he agreed to accept a layoff so that he would at least be eligible for employment insurance benefits. He is not certain how many other employees were laid off in January 2016. He believes he likely would have been laid off at this time regardless of his level of impairment.
The employer informed the CM in May 2017 that they had not heard from the worker at all since he stopped working. It is not known if an employment relationship remains, but this is unlikely given the time that has passed since the worker last worked.
The worker has not worked in any capacity since December 2015. He does not believe that he is able to do so. He said that he tried to complete some online training but was unable to finish it. When asked if he would be interested in work transition (WT) services if this was made available to him he said that he is not confident that he would be able to participate in any type of program.
The worker earned $12.00 per hour over a 40 hour work week at the time of the accident. He has a Bachelor of Arts degree and is certified to teach English as a second language.
I direct the Operating Area to determine the worker’s entitlement to LOE benefits after January 26, 2017. A WT assessment should be conducted so that a suitable occupation (SO) can be identified. The SO should be a field of work in which the worker could have obtained employment without any additional training. The Specialty Clinic did not outline specific restrictions, but given his headache issues the worker should likely avoid working in a very loud environment performing tasks that require a high degree of sustained focus and concentration or requiring complex decision-making.
Once a SO is identified a decision should be made as to whether there is any ongoing wage loss related to the compensable CPD after January 26, 2017. The worker has the usual right to appeal any subsequent entitlement decision made by the Operating Area.
CONCLUSION
The worker is entitled to benefits under the CPD policy. He is granted a NEL determination for this condition.
The worker does not have a permanent impairment due to his organic head injury.
The worker does not have entitlement to benefits under the psychotraumatic disability policy.
The worker is granted full LOE benefits from when he last worked on December 8, 2015 to January 26, 2017. Entitlement to LOE benefits beyond this date are to be determined by the Operating Area following the completion of a WT assessment and SO identification.
The objection is allowed in part.
DATED: August 22, 2018
C. Marr
Appeals Resolution Officer
Appeals Services