[1]t
[3]fl
[5]| ‘NW 88326
[7]Assassination Records Review Board
[8]Final Determination Notification
[10]AGENCY : HSCA
[11]RECORD NUMBER : 180-10070-10154
[12]RECORD SERIES : STAFF PAYROLL RECORDS
[13]AGENCY FILE NUMBER :..
[15]December 8, 1995
[16]Status of Document: Postponed in Part
[18]Number of releases of previously postponed information: 7
[20]Reason for Board Action: The Review Board's decision was premised on several factors
[21]including: (a) the significant historical interest in the document in question; (b) the
[22]absence of evidence that the release of the information would cause harm to the United
[23]States or to any individual. |
[25]Number of Postponements: 3
[27]Postponements: All the postponements in this document represent Social Security numbers.
[29]Reason for Board Action: The text is redacted because the public disclosure of the redaction could
[30]reasonably be expected to constitute an unwarranted invasion of personal privacy, and that invasion of
[31]privacy would be so substantial that it outweighs the public interest.
[33]Substitute Language: SSN
[35]Date of Next Review: 2017
[37]Board Review Completed: 10/24/95
[39]N
[41]| Decid:327244096 Page 1
[43]Date:08/20/93
[44]Page:1
[45]JFK ASSASSINATION SYSTEM
[47]IDENTIFICATION FORM
[49]AGENCY INFORMATION
[51]HSCA
[53]AGENCY :
[54]RECORD NUMBER : 180-10070-10154
[56]RECORDS SERIES
[57]STAFF PAYROLL RECORDS
[59]AGENCY FILE NUMBER :
[61]ORIGINATOR : HSCA
[62]FROM :
[63]TO 3;
[67]DATE
[68]PAGES
[70]07/11/77
[71]7
[73]SUBJECTS ;
[74]| HSCA; ADMINISTRATION
[75]| SELLECK, ELIZABETH kK.
[77]DOCUMENT TYPE : PRINTED FORM
[81]| CLASSIFICATION : U
[85]| CURRENT STATUS : P
[87]DATE OF LAST REVIEW : 07/16/93
[89]OPENING CRITERIA
[91]COMMENTS
[93]Box 3.
[95](R]) - ITEM IS RESTRICTED
[97]| NW 88326
[98]| Decld:32244096 Page 2
[100]4
[104]4
[106]W 88326 —
[108]“U.S. DEPARTMENT OF LABOR
[109]EMPLOYMENT STANDARDS ADMINISTRATION-.-
[111]Office of Workers’ Compensation Programs
[113]December 15, 1978
[115]File No: AQ3-146626
[116]Date of Injury: May 25, 1978
[117]- - SSN: 531-500-7761
[118].Ms, Elizabeth K. Selleck
[119]‘ 4201 Cathedral Avenue —
[120]Washington, DC. 20016
[121]2 We need additional information to make a determination regarding the
[123]claim you submitted for the injury indicated above. Please furnish the
[124]information requested in the items checked below and onthe reverse of
[125]this form, Use a separate sheet of paper numbering the answers to cor-
[127]respond with the question numbers,
[129][x | 1. The Federal Employees' Compensation Act requires an injured
[130]employee to give written notice of injury to his/her supervisor ©
[131]within 30 days. | State why. this injury was not reported to
[133]your supervisor within ,that time.
[135]x | 2. Describe in detail exactly how the injury occurred, (For
[136]example, if you fell, state. how far you fell, how you landed,
[137]etc. If lifting was the cause of injury, describe the object
[138]handled, its weight, what you did with it, etc.).
[140]~~ (
[142]Z| .3: Give the names of any persons who witnessed your injury or
[144]. had immediate knowledge of it.
[146]Supervisory Claims Examiner
[148]Select Comm. on Assass-inations
[149]~ .HOuse of Representatives <
[151]HOB #2 2
[153]Washington, DC. 20515
[155]Ltr. CA-1011
[157]’ a (+. Include your address, ZIP code, and file number on all correspondence June 1975
[159]rochd:32244096 Page 3
[161]5 x f
[162](poor Paed
[164]} Ex) to.
[166]Cpu.
[169]State the immediate effects ofthe injury~ and what you-did immedi-
[171]ately thereafter,
[173]Was: any. other. injury sustained, either on or off duty, between. the Bo
[174]‘date of: injury and the date it was first. reported to. (a) your super= >. oo
[175]visor and (b) to a doctor? | If so, describe: - eo J Of
[177]State the exact reason why you delayed seeking medical attention;
[178]-also. give the name and address of the doctor.you first consulted
[180]and the date you were first examined for this injury:
[182]Describe (a) your condition between the date of the injury and the
[184]-date you first received: medical attention, and (b) the nature.and
[186]frequency of any home treatment:
[188]Did you have any similar disability or symptoms before the injury? If
[190]so, describe the prior condition. Give the names and addresses of the
[192]‘physicians who: treated you.and the approximate dates you. were treated:
[194]Did you ever file a claim for workers' compensation benefits from
[195]any source? If so, give the date and nature of the injury, the name
[196]and address of the office where the claim was filed, and describe
[197]the benefits (if any) which you received:
[201]Arrange for submission of a medical report on the enclosed Form CA=20
[202]from the private physician who examined you as a result of this injury.
[204]ae ee et a we
[206]|
[207]|
[208]I
[209]l 2
[210]i
[212]| NW 88326
[214]1d:32244096 Page 4 ‘ oe ;
[216]cede ss = ee : SSS SS
[219]U.S. DEPARTMENT OF LABOR
[220]EmpLoyMENT STANDARDS ADMINISTRATION
[221]. Office of Workers’ Compensation Programs | ae
[222]December 15, 1978 oo, File No.: A25-146626
[223]. . Date of Injury: May 25, 1978
[224]Employee:. Selleck Elizabeth Kk.
[226]_ Noncontroverted [_] Controverted [_]
[228]Select Com. on Assassinations
[229]House of Representatives iy
[230]HOB #2 _— a oe
[231]Washington, DC. 20515 |
[233]We have received Form CA-1 reporting an injury and your agency's response
[234]‘to the evidence submitted. It has been determined that:
[236][| 1. The facts of the injury and employment support the employee's
[237]contention that he/she was a Federal employee who sustained a
[238]traumatic disabling injury in the performance of duty. You
[239]should, therefore, continue his/her pay, for the period of dis-— -
[240]ability not to exceed 45 days. - \
[242][X] 2. The information of record is insufficient to make a decision on \
[243]the case;. however, you should continue the employee's pay without
[244]interruption. Additional information is required as noted on. the
[245]reverse of this letter.
[247]aaa cal
[249]BLT and ms Examiner — | , |
[251]| Ms. Elizabeth K. Selleck
[252]4201 Cathedral Avenue
[253]. Washington, DC. 20016
[255]Ltr. CA-1038
[256]Include your address, ZIP code, and file number on all correspondence . Rev. Apr. 1977
[258]| NW 88326 | a pe
[259]rochd:32244096 Page 5 ‘ et , :
[262]-SELLECK, Elizabeth. | - | eer ee
[264]Hime of Employee
[266]OFFICE OF THE CLERK” Se
[267]a ae U.S, HOUSE OF REPRESENTATIVES DALANce nnoucut
[268]7 — ae . ; a a ORWAPD FROM
[269]a — PERSONAL LEAVE RECORD © ARG
[271]. 7 . ; ” . Famer aamean soaeentunneereaebenenninaetaeed os . _ . . 7 . . o
[272]: - Audress . . : oe ee YEAR .
[273]— a . WHAT LRAY -. ; 7 oy
[274]_ DATE OF APPOINTMENT ANN Gone 7 a
[275]. Phone Number : a _ CATEGORY ae ;
[276]J-1-77. THOR ts
[277]| | Ww Oo PO oot,
[278]Tee ee ee ee ematianammeneamennnemenmanetedl . co ‘ . Lo
[279]Posilion Title . : . . . _ a
[280]oo PRIOR FEOERAL scavice | . 25 . (]
[281]enamine = tee on oe saree es een ae ony ererenencne rain rotted ‘| seeeesnvreesesen | Pawn neenecoaen ‘i 7 CCR! AVAILASL ; : USE . RALANSE |
[282]2 Position Number bevel _ Step Yeats Menths 20 0 miswonn | otis wontd | ting Mone | oe Ages 34
[283]. ; no MOUTH os
[284]¥ ~ 7 RT and
[285]: Heath Annual Sick Annual Sick Anaual Sick 22
[286]- Leave Leave Leave Leave | Leave Leave
[288]Soe wenemucenteteanammante
[289]ba. Z L1&
[290]an a - _- f :
[291]Feb. 7 f Do / 7
[292]Mar. —f | oF Kl.
[293]Apt. 7 . / }
[294]"May - A& lo
[295]o {
[296]“3 June | PF | (ft
[297]~ guly . ad |/a
[298]ae Aug. . oy .
[299]i Se reinemmmnnendl
[300]Sept. - ; ;
[301]| Oct. ~
[302]i Nov,
[304]; Dee.
[305]Q.5 day annual leave CERTIFIED CORRECT:
[306]1.0 day annual leave ere , coe :
[307]= 05 day sick leave . . . . :
[308]oof - eae cS eee UR PET ELL CE Pen CY Sos eeenenenenneneeseeienaed
[309]= 1.0 day sick leave an _ _ - Employeo's Signature Pte ; " Chiaf's Signature : Date
[310]me . co + if employee ecfuses to sign, state reason below) oe so _
[311]= 0.5. day administrative leave re
[312]4.0 day administrative Icave Be Os So Approved: _- soem —_————
[313]ow ; : . ; ae : ; ‘ Clerk cf the Houso . ; - ; Dato
[314]oz 0.5. day unauthorized absence Se , ; : , : . ; : er : _ >
[315]This record. will be forwarded to the Clerk of the House at the end of cach cafenddr year, or In case of termination, along | :
[317]1.0 day unaulhorized absence - "with the request for termination. Upon approval, the record will be filed in the employee's official personnel foider, -
[319]a 0.5. day leave without pay
[321]; 1.0 day leave without
[323]pay
[328]i
[329]| W 88326
[330]| ocld:32244096 Page 7
[332]tbe TED
[333]yrhv od
[338]- (If type of action is an Appointment, Salary Adjustment, or Title Change, complete appropriate information below.)
[340]PAYROLL AUTHORIZATION FORM
[342]. (Please Use Typewriter . Cc} U.S. HOUSE OF REPRESENTATIVES) (Any erasures, corrections, or changes
[344]or Ballpoint Pen) Washington, D.C. 20515 suthotieing official} initialed by the
[346]To the Clerk of the House of Representatives:
[348]| hereby authorize the following payroll action:
[350]Employee Name (First-Middle-Last)
[352]7/15/78
[354]Type of Action
[356]C1 Appointment
[357]O Salary Adjustment
[358]Of Title Change
[360]Ci{termination (At close of business on effective date) —
[362]Llizgabeth Kk. Selleck
[364]Employee Social Security Number
[366]537-50-7761
[367]Employing Office or Committee/Subcommittee
[369]Assassinatians
[371]0) Leave without pay (Beginning with effective date above and ending |
[373]close of business... -§. § >= = )
[374]Specify Date
[376]Position Title -
[378]Gross Annual Salary*
[380]_ * If emoloyee is a civil service annuitant (includes U.S. House of Representatives), the gross annual salary shown should include the annuity received by the employee
[382]plus the salary received ‘from the employing office.
[384]. (If Committee Employee, complete appropriate item below.)
[386]1. 0 Standing Committee: Staff—C] Clerical or 1 Professional.
[388]2. @ Special (Investigative staff of Standing Committee) or Select Committee: Authority—H. Res. 325 of 234 congress.
[389]3. O Joint Committee.
[391](If Employee of an Officer of the House, complete item below.)
[393]Position Number If applicable, Level
[395]‘| certify that this. authorization is not in violation of 5 U.S.C. 3110(b), prohibiting the employment of
[396]relatives. ’
[398]july 7 73
[399]vuly e
[400]Date_____“=* too pW
[401], (Signature of Authorizing Official)
[402]wave OAL
[404]LOUIS STOKES, CHAGHRAN
[405](if appropriate, signature of Subcommittee Chairman or Ranking Minority Member) ~=~=~S~S*S*S*”~S*:S*Sype ov print nome of Authorizing Offaly)
[406]7 (Type or print name and title of above official). == Fee GFitle=If Member, Districtand State). SSCS
[408]All appointments and. salary adjustments for employees under. the House Classification Act and for Committee em-
[409]ployees, except those of the Committee on Appropriations, the Committee on. the Budget, and the Joint-Committees, must:
[410]be approved by the Committee on House. Administration.
[412]Chairman, Committee on House Administration
[414]APPROVED:
[416]2
[418]‘ Office of Finance use only:
[420]Office Code
[422]W 88326 | ae ae
[424]1d:32244096 Page 8 : vos ;
[426]dataset ante ED
[428]BYaaiGp EICoanics UV CPAINR TORTE NW TOON WUD ENTT SOS SE MURR? YT OTR OS ANUS AUT PRLS AES Oey ER
[430]cee eB Obdee oo LO a bd pba dalek
[432]aiid, ae Mle
[434]each ate tne ata
[436]7 et ny
[437]poalanded «5 Tabet eect
[443]PAYROLL AUTHORIZATION FORM.
[445](Pledse Use Typewriter .
[446]_ or Ballpoint Pen).
[448]~ | hereby authorize the
[450]“
[452]i Employee
[454]f
[456]_ To the Clerk of the House of Representatives:
[460]following payroll-action:
[462]Name (First-Middle-Last)
[464]‘(J Termination (At close of business on. effective date)
[466]A “US: -HOUSE OF: REPRESENTATIVES -.
[467]7 . Washington, D.C: 20515
[469]PALLST? .
[471]«(any erasures, corrections, or changes ~
[472]this form must he initialed by the |. |.
[473]authorizing official.)
[475]Effective Date
[477]&] Appointment
[479], am Salary Adjustment
[481]Type of Action
[483](If Committee Employee, complete appropriate item below.)
[485]1. CJ Standing Committee: Staff—[_] Clerical or [_] Professional.
[487]2. &] Special or Select Committee: Authority— H. Res. ASS of _2
[489]3. (] Joint Committee.
[491](If Employee of an Officer of the House, complete item below.)
[493]Position Number
[495]relatives.
[497]_o ee If applicable; Level
[499]Sahy 22 ; 1977
[501]85
[503]SthCongress.
[505]| certify. that this authorization is not in. violation of 5 U.S.C..3110(b), prohibiting the employment of-- |
[507]All appointments and salary adjustménts for employees. under the House Classification Act and - for Committee em- .
[508]ployees, except those of the Committee on Appropriations; the Committee. on the Budget, and the Joint Committees; ‘must
[509]be- approved by the Committee on House Administration.
[511]_ APPROVED:
[512]Office of Finance use only: ~ °
[513]Office Code
[514]Monthly Annuity $__- 00
[516]Copy for Initiating
[518]Office or Committee
[521]MEMORANDUM
[523]TO: ALL STAFF | | Oo Be |
[525]RE: Payroll Certification . . 7 . : ob
[527]The Regulations and Accounting Procedures for Allowances and _
[528]Expenses of Committees, Members and Employees of the U.S. House of. en |
[529]Representatives require that, among other things, tne Committee's ve |
[531]. monthly payroll certification include the relati onship, if any, of | .
[532]- each employee to any current Member of Congress. This certification
[533]is Signed monthly by our Chairman.
[535]The following: are “the relationships to be “included in the et
[536]certification: .
[538]Father . nephew . brother-in-law
[539]_mother niece - sister-in-law
[540]son . ~ husband stepfatner
[541]daughter wife -. stepmother
[542]brother father-in-law stepbrotner. oo a
[543]sister _ mother-in-law sss Stepsister oo \
[544]uncle _ son-in-law . half-brother \
[545]aunt = . daughter-in-law half-sister . a \
[546]first cousin -
[547]| ‘Piease complete the appropriate portion below, sign and date ete
[548]this form, which will then become a part of your permanent personnel.
[549]| File. if this status changes, you must notify the Committee's Budget
[550]7 Of¥ice Jinmediately of the change.
[551]| Xi I am not related to any current (95th Congress) Member of Congress.
[553]fo /-/ 1 am related to a current (95th Congress} Member of Congress.
[554]I (Please specify.) ee _
[555]4
[556]4
[560]Sate