VICP Registry Case Source Bundle
Canonical URL: https://vicp-registry.org/case/USCOURTS-cofc-1_18-vv-00471
Package ID: USCOURTS-cofc-1_18-vv-00471
Petitioner: Rita Czyzewski
Filed: 2018-03-30
Decided: 2019-08-07
Vaccine: influenza
Vaccination date: 2016-09-13
Condition: shoulder injury related to vaccine administration (SIRVA)
Outcome: compensated
Award amount USD: 124069

AI-assisted case summary:
Rita Czyzewski filed a petition for compensation under the National Vaccine Injury Compensation Program, alleging she suffered a shoulder injury related to vaccine administration (SIRVA) from an influenza vaccination on September 13, 2016. The respondent, the Secretary of Health and Human Services, conceded entitlement to compensation in a Rule 4(c) report, agreeing that the claim met the criteria for SIRVA and that petitioner met the statutory and jurisdictional requirements. A ruling on entitlement was issued on March 21, 2019, finding her entitled to compensation. Subsequently, on April 30, 2019, the respondent filed a proffer on award of compensation, proposing an award of $112,500.00 for all damages and an additional $11,569.44 to satisfy a New Jersey Medicaid lien. Petitioner agreed with the proffered award. The Chief Special Master issued a decision awarding damages on August 7, 2019, granting a lump sum payment of $112,500.00 to Rita Czyzewski and a separate lump sum payment of $11,569.44 to satisfy the Medicaid lien. The case was treated as a Table injury claim, and entitlement was conceded by the respondent.

Theory of causation field:
Table

Public staged source text:

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DOCUMENT 1: USCOURTS-cofc-1_18-vv-00471-0
Date issued/filed: 2019-06-20
Pages: 2
Docket text: PUBLIC ORDER/RULING (Originally filed: 03/21/2019) regarding 26 Ruling on Entitlement ( Signed by Chief Special Master Nora Beth Dorsey. )(mpj) Service on parties made.
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Case 1:18-vv-00471-UNJ Document 43 Filed 06/20/19 Page 1 of 2
In the United States Court of Federal Claims
OFFICE OF SPECIAL MASTERS
No. 18-471V
Filed: March 21, 2019
UNPUBLISHED
RITA CZYZEWSKI,
Petitioner, Special Processing Unit (SPU);
v. Ruling on Entitlement; Concession;
Table Injury; Influenza (Flu) Vaccine;
SECRETARY OF HEALTH AND Shoulder Injury Related to Vaccine
HUMAN SERVICES, Administration (SIRVA)
Respondent.
Jeffrey S. Pop, Jeffrey S. Pop & Associates, Beverly Hills, CA, for petitioner.
Ashley Monique Simpson, U.S. Department of Justice, Washington, DC, for respondent.
RULING ON ENTITLEMENT1
Dorsey, Chief Special Master:
On March 30, 2018, petitioner filed a petition for compensation under the
National Vaccine Injury Compensation Program, 42 U.S.C. §300aa-10, et seq.,2 (the
“Vaccine Act”). Petitioner alleges that she suffered a shoulder injury related to vaccine
administration (“SIRVA”) as a result of an influenza (“flu”) vaccination administered on
September 13, 2016. Petition at 1. The case was assigned to the Special Processing
Unit of the Office of Special Masters.
1 The undersigned intends to post this ruling on the United States Court of Federal Claims' website. This
means the ruling will be available to anyone with access to the internet. In accordance with Vaccine
Rule 18(b), petitioner has 14 days to identify and move to redact medical or other information, the
disclosure of which would constitute an unwarranted invasion of privacy. If, upon review, the undersigned
agrees that the identified material fits within this definition, the undersigned will redact such material from
public access. Because this unpublished ruling contains a reasoned explanation for the action in this
case, undersigned is required to post it on the United States Court of Federal Claims' website in
accordance with the E-Government Act of 2002. 44 U.S.C. § 3501 note (2012) (Federal Management
and Promotion of Electronic Government Services).
2 National Childhood Vaccine Injury Act of 1986, Pub. L. No. 99-660, 100 Stat. 3755. Hereinafter, for
ease of citation, all “§” references to the Vaccine Act will be to the pertinent subparagraph of 42 U.S.C. §
300aa (2012).

Case 1:18-vv-00471-UNJ Document 43 Filed 06/20/19 Page 2 of 2
On March 21, 2019, respondent filed his Rule 4(c) report in which he concedes
that petitioner is entitled to compensation in this case. Respondent’s Rule 4(c) Report
at 1. Specifically, respondent has concluded that petitioner’s claim meets the criteria for
a SIRVA Id. at 5. Respondent further agrees that petitioner meets the statutory and
jurisdictional requirements for compensation under the Vaccine Act. Id. at 5-6.
In view of respondent’s position and the evidence of record, the
undersigned finds that petitioner is entitled to compensation.
IT IS SO ORDERED.
s/Nora Beth Dorsey
Nora Beth Dorsey
Chief Special Master

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DOCUMENT 2: USCOURTS-cofc-1_18-vv-00471-1
Date issued/filed: 2019-08-07
Pages: 5
Docket text: PUBLIC DECISION (Originally filed: 05/01/2019) regarding 34 DECISION Stipulation/Proffer ( Signed by Chief Special Master Nora Beth Dorsey. )(mpj) Service on parties made.
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Case 1:18-vv-00471-UNJ Document 44 Filed 08/07/19 Page 1 of 5
In the United States Court of Federal Claims
OFFICE OF SPECIAL MASTERS
No. 18-471V
Filed: May 1, 2019
UNPUBLISHED
RITA CZYZEWSKI,
Petitioner,
Special Processing Unit (SPU);
v.
Damages Decision Based on Proffer;
Influenza (Flu) Vaccine; Shoulder
SECRETARY OF HEALTH AND
Injury Related to Vaccine
HUMAN SERVICES,
Administration (SIRVA)
Respondent.
Jeffrey S. Pop, Jeffrey S. Pop & Associates, Beverly Hills, CA, for petitioner.
Ashley Monique Simpson, U.S. Department of Justice, Washington, DC, for respondent.
DECISION AWARDING DAMAGES1
Dorsey, Chief Special Master:
On March 30, 2018, petitioner filed a petition for compensation under the
National Vaccine Injury Compensation Program, 42 U.S.C. §300aa-10, et seq.,2 (the
“Vaccine Act”). Petitioner alleges that she suffered a shoulder injury related to vaccine
administration (“SIRVA”) as a result of an influenza (“flu”) vaccination administered on
September 13, 2016. Petition at 1. The case was assigned to the Special Processing
Unit of the Office of Special Masters.
On March 21, 2019, a ruling on entitlement was issued, finding petitioner entitled
to compensation for a SIRVA. On April 30, 2019, respondent filed a proffer on award of
compensation (“Proffer”) indicating petitioner should be awarded $112,500.00 and
1 The undersigned intends to post this decision on the United States Court of Federal Claims' website.
This means the decision will be available to anyone with access to the internet. In accordance with
Vaccine Rule 18(b), petitioner has 14 days to identify and move to redact medical or other information,
the disclosure of which would constitute an unwarranted invasion of privacy. If, upon review, the
undersigned agrees that the identified material fits within this definition, the undersigned will redact such
material from public access. Because this unpublished decision contains a reasoned explanation for the
action in this case, undersigned is required to post it on the United States Court of Federal Claims'
website in accordance with the E-Government Act of 2002. 44 U.S.C. § 3501 note (2012) (Federal
Management and Promotion of Electronic Government Services).
2 National Childhood Vaccine Injury Act of 1986, Pub. L. No. 99-660, 100 Stat. 3755. Hereinafter, for
ease of citation, all “§” references to the Vaccine Act will be to the pertinent subparagraph of 42 U.S.C. §
300aa (2012).

Case 1:18-vv-00471-UNJ Document 44 Filed 08/07/19 Page 2 of 5
$11,569.44 to satisfy a New Jersey Medicaid lien. Proffer at 1. In the Proffer,
respondent represented that petitioner agrees with the proffered award. Id. Based on
the record as a whole, the undersigned finds that petitioner is entitled to an award as
stated in the Proffer.
Pursuant to the terms stated in the attached Proffer, the undersigned awards
(1) Petitioner a lump sum payment of $112,500.00 in the form of a check
payable to petitioner, Rita Czyzewski. This amount represents compensation
for all damages that would be available under § 300aa-15(a); and
(2) A lump sum payment of $11,569.44, representing compensation for
satisfaction of the State of New Jersey Medicaid lien, payable jointly to
petitioner3 and to:
Treasurer, State of New Jersey
Division of Revenue, Lockbox 656
200 Woolverton Avenue, Bldg. 20 Trenton, NJ 08646
File Number: DMA/57018
The clerk of the court is directed to enter judgment in accordance with this
decision.4
IT IS SO ORDERED.
s/Nora Beth Dorsey
Nora Beth Dorsey
Chief Special Master
3 Petitioner agrees to endorse this payment to Treasurer, State of New Jersey.
4 Pursuant to Vaccine Rule 11(a), entry of judgment can be expedited by the parties’ joint filing of notice
renouncing the right to seek review.
2

Case 1:18-vv-00471-UNJ Document 44 Filed 08/07/19 Page 3 of 5
IN THE UNITED STATES COURT OF FEDERAL CLAIMS
OFFICE OF SPECIAL MASTERS
RITA CZYZEWSKI,
Petitioner,
No. 18-471V
v. Chief Special Master Dorsey
ECF
SECRETARY OF HEALTH AND
HUMAN SERVICES,
Respondent.
RESPONDENT’S PROFFER ON AWARD OF COMPENSATION
On March 21, 2019, respondent conceded that entitlement to compensation was
appropriate under the terms of the Vaccine Act. Thereafter, on March 21, 2019, Chief Special
Master Dorsey issued a Ruling on Entitlement, finding that petitioner was entitled to vaccine
compensation for his Shoulder Injury Related to Vaccine Administration (“SIRVA”).
I. Compensation for Vaccine Injury-Related Items
Based on the evidence of record, respondent proffers that petitioner should be awarded
$112,500.00. This amount represents all elements of compensation to which petitioner would be
entitled under 42 U.S.C. § 300aa-15(a), with the exception of the reimbursement of the Medicaid
lien, below. Petitioner agrees.
Respondent further proffers that petitioner should be awarded funds to satisfy a State of
New Jersey Medicaid lien in the amount of $11,569.44, which represents full satisfaction of any
right of subrogation, assignment, claim, lien, or cause of action the State of New Jersey may
have against any individual as a result of any Medicaid payments that the State of New Jersey
has made to or on behalf of Rita Czyzewski from the date of her eligibility for benefits through

Case 1:18-vv-00471-UNJ Document 44 Filed 08/07/19 Page 4 of 5
the date of judgment in this case as a result of his vaccine-related injury suffered on or about
September 13, 2016, under Title XIX of the Social Security Act. Petitioner agrees.
II. Summary of Recommended Payments
Respondent recommends that the compensation provided to petitioner be made through
two lump sum payments as described below:
(1) A lump sum payment of $112,500.00 in the form of a check payable to
petitioner,1 and
(2) A lump sum payment of $11,569.44, representing compensation for satisfaction
of the State of New Jersey Medicaid lien, payable jointly to petitioner and to:
Treasurer, State of New Jersey
Division of Revenue, Lockbox 656
200 Woolverton Avenue, Bldg. 20 Trenton, NJ 08646
File Number: DMA/57018
Petitioner agrees to endorse this payment to Treasurer, State of New Jersey.
Petitioner is a competent adult. Evidence of guardianship is not required in this case.
Respectfully submitted,
JOSEPH H. HUNT
Assistant Attorney General
C. SALVATORE D’ALESSIO
Acting Director
Torts Branch, Civil Division
CATHARINE E. REEVES
Deputy Director
Torts Branch, Civil Division
GABRIELLE M. FIELDING
Assistant Director
Torts Branch, Civil Division
1 Should petitioner die prior to the entry of judgment, respondent reserves the right to move the
Court for appropriate relief. In particular, respondent would oppose any award for future
medical expenses, future pain and suffering, and future lost wages.

Case 1:18-vv-00471-UNJ Document 44 Filed 08/07/19 Page 5 of 5
S/ ASHLEY SIMPSON
Ashley Simpson
Trial Attorney
Torts Branch, Civil Division
U.S. Department of Justice
P.O. Box 146
Benjamin Franklin Station
Washington D.C. 20044-0146
Tel: (202) 305-0253
Email: Ashley.M.Simpson@usdoj.gov
Dated: April 30, 2019