FOGELSTROM v. SECRETARY OF HEALTH AND HUMAN SERVICES

In the United States Court of Federal Claims
OFFICE OF SPECIAL MASTERS
No. 23-2050V
DONNA FOGELSTROM,
Petitioner,
v.
SECRETARY OF HEALTH AND
HUMAN SERVICES,
Respondent.
Chief Special Master Corcoran
Filed: December 10, 2025
Jered Medlock, Medlock & Gramlich LLP, Fort Smith, AR, for Petitioner.
Joseph Douglas Leavitt, U.S. Department of Justice, Washington, DC, for Respondent.
DECISION ON JOINT STIPULATION1
On November 30, 2023, Donna Fogelstrom 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 Table shoulder injury related to
vaccine administration (“SIRVA”) as a result of her September 7, 2022 pneumococcal
conjugate vaccination. Petition at ¶¶ 2-3, 11; Stipulation at ¶¶ 2, 4. Petitioner further
alleges that she received her vaccination in the United States, that she suffered the
residual effects of her injury for more than six months, and that there has been no prior
award or settlement of a civil action on her behalf as a result of her injury. Petition at ¶¶
2, 7-8, 10; Stipulation at ¶¶ 3-5. “Respondent denies that [P]etitioner sustained a SIRVA
Table Injury and denies that the vaccine caused her alleged shoulder injury, any other
injury.” Stipulation at ¶ 6.
Nevertheless, on December 8, 2025, the parties filed the attached joint stipulation,
stating that a decision should be entered awarding compensation. I find the stipulation
reasonable and adopt it as my decision awarding damages, on the terms set forth therein.
1 Because this Decision contains a reasoned explanation for the action taken in this case, it must be made
publicly accessible and will be posted on the United States Court of Federal Claims' website, and/or
at https://www.govinfo.gov/app/collection/uscourts/national/cofc, in accordance with the E-Government
Act of 2002. 44 U.S.C. § 3501 note (2018) (Federal Management and Promotion of Electronic Government
Services). 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, I
agree that the identified material fits within this definition, I will redact such material from public access.
2 National Childhood Vaccine Injury Act of 1986, Pub. L. No. 99-660, 100 Stat. 3755. Hereinafter, for ease
of citation, all section references to the Vaccine Act will be to the pertinent subparagraph of 42 U.S.C. §
300aa (2018).
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2
Pursuant to the terms stated in the attached Stipulation, I award the following
compensation:
A lump sum of $45,000.00, to be paid through an ACH deposit to Petitioner’s
counsel’s IOLTA account for prompt disbursement to Petitioner. Stipulation
at ¶ 8. This amount represents compensation for all items of damages that would
be available under Section 15(a). Id.
I approve the requested amount for Petitioner’s compensation. In the absence of
a motion for review filed pursuant to RCFC Appendix B, the Clerk of Court is directed to
enter judgment in accordance with this decision.3
IT IS SO ORDERED.
s/Brian H. Corcoran
Brian H. Corcoran
Chief Special Master
3 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.
Case 1:23-vv-02050-UNJ Document 25 Filed 01/09/26 Page 2 of 7

IN THE UNITED STATES COURT OF FEDERAL CLAIMS
OFFICE OF SPECIAL MASTERS
DONNA FOGELSTROM,
Petitioner,
V. 	No. 23-2050V (ECF)
Chief Special Master Corcoran
SECRETARY OF HEALTH AND
HUMAN SERVICES,
Respondent.
STIPULATION
The parties hereby stipulate to the following matters:
I. 	On November 30 , 2023, petitioner filed a petition for vaccine compensation under the
National Vaccine Injury Compensation Program , 42 U.S.C. § 300aa-l Oto -34 (the " Program " ).
The petition seeks compensation for an injury allegedly related to petitioner' s receipt of the
pneumococcal conjugate (" Prevnar 20 ") vaccine , which vaccine is contained in the Vaccine
Injury Table, 42 C.F.R. § I 00.3(a) (the "Table" ).
2. 	Petitioner received a Prevnar 20 vaccine on September 7, 2022.
3. 	The vaccine was administered within the United States.
4. 	Petitioner alleges that she suffered a left-sided shoulder injury related to vaccine
administration (" SIRVA") as a result of her vaccination. Petitioner further alleges that she
experienced the residual effects of this injury for more than six months.
5. 	Petitioner represents that there has been no prior award or settlement of a civil action for
damages as a result of her alleged injury.
Case 1:23-vv-02050-UNJ Document 25 Filed 01/09/26 Page 3 of 7

6. 	Respondent denies that petitioner sustained a SIRVA Table injury and denies that the
vaccine caused her alleged shoulder injury , or any other injury.
7. 	Maintaining their above -stated positions, the parties nevertheless now agree that the
issues between them shall be settled and that a decision should be entered awarding the
compensation described in paragraph eight of this Stipulation.
8. As soon as practicable after an entry of judgment reflecting a decision consistent with the
terms of this Stipulation, and after petitioner has filed an election to receive compensation
pursuant to 42 U.S.C. § 300aa-21 (a)(]) , the Secretary of Health and Human Services will issue
the following vaccine compensation payment:
A lump sum payment of $45,000.00 to be paid through an ACH deposit to
petitioner 's counsel's IOLTA account for prompt disbursement to petitioner. This
amount represents compensation for all damages that would be available under 42
U.S.C. § 300aa-15(a).
9. 	As soon as practicable after the entry of judgment on entitlement in this case, and after
petitioner has filed both a proper and timely election to receive compensation pursuant to 42
U .S.C. § 300aa-2 l (a)(!), and an application, the parties will submit to further proceedings before
the special master to award reasonable attorneys' fees and costs incurred in proceeding upon this
petition.
10. Petitioner and her attorney represent that the compensation to be provided pursuant to
this Stipulation is not for any items or services for which the Program is not primarily liable
under42 U.S.C. § 300aa-15(g), to the extent that payment has been made or can reasonably be
expected to be made under any State compensation programs, insurance policies, Federal or
State health benefits programs (other than Title XIX of the Social Security Act (42 U.S.C.
§ 1396 et seq.)), or by entities that provide health services on a pre-paid basis .
2
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11. Payment made pursuant to paragraph eight and any amounts awarded pursuant to
paragraph nine of this Stipulation will be made in accordance with 42 U.S.C. § 300aa-l 5(i),
subject to the availability of sufficient statutory funds.
12. The parties and their attorneys further agree and stipulate that , except for any award for
attorneys' fees and litigation costs, the money provided pursuant to this Stipulation will be used
solely for the benefit of petitioner as contemplated by a strict construction of 42 U .S.C. § 300aa-
l 5(a) and (d), and subject to the conditions of 42 U.S.C. § 300aa-l 5(g) and (h).
13. In return for the compensation described in paragraphs eight and nine, petitioner, in her
individual capacity, and on behalf of her heirs, executors, administrators, successors , or assigns,
does forever and in-evocably and unconditionally release, acquit , and discharge the United States
and the Secretary of Health and Human Services from any and all actions or causes of action
(including agreements, judgments , claims, damages, loss of services, expenses, and all demands
of whatever kind or nature) that have been brought , could have been brought, or could be timely
brought in the Court of Federal Claims, under the National Vaccine Injury Compensation
Program , 42 U .S.C. § 300aa-l 0 et seq. , on account of, or in any way growing out of, any and all
known or unknown, suspected or unsuspected personal injuries to or death of petitioner resulting
from , or alleged to have resulted from, the Prevnar20 vaccination administered on September 7,
2022 , as alleged in a petition for vaccine compensation filed on or about November 30 , 2023 , in
the United States Court of Federal Claims as petition No. 23-2050V.
14. If petitioner should die prior to entry of judgment , this agreement shall be voidable upon
proper notice to the Court on behalf of either or both of the parties.
15. If the Chief Special Master fails to issue a decision in complete conformity with the
terms of this Stipulation or if the Court of Federal Claims fails to enter judgment in conformity
3
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with a decision that is in complete conformity with the terms of this Stipulation, then the parties '
settlement and this Stipulation sha ll be vo idable at the so le discretion of either party.
16. This Stipulation expresses a full and comp lete negotiated settlement of li abi li ty and
damages c laimed under the National Childhood Vaccine Injury Act of 1986, as amended , expect
as otherwise noted in paragraph nine above. There is abso lutely no agreement on the part of the
parties hereto to make any payment or to do any act or thing other than as herein expressly stated
and clearly agreed to. The parties further agree and understand that the award described in this
Stipu lation may reflect a comprom ise of the parties ' respective positions as to liability and / or
amount of damages, and further, that a change in the nature of th e inju ry or condition or in the
items of compensation sought , is not grounds to modify or revise this agreement.
17. This Stipu lation shall not be construed as an admission by the United States or the
Secretary of Health and Human Serv ices that the Prevnar 20 vacc in e caused petitioner's a ll eged
shou ld er injury or any other injury , or that she suffered an injury contained in the Vaccine Injury
Tab le.
18. Al l rights and ob li gations of petitioner hereunder sha ll apply equally to petitioner' s heirs,
executors , admin istrators, successors , and / or assign s.
END OF STIPULATION
4
Case 1:23-vv-02050-UNJ Document 25 Filed 01/09/26 Page 6 of 7

Respectfully submitted,
PETITIONE R:
~Ol'Vle 	J 	-:cJ,,Jl ft.o/K..DO NNA FOGELSTRO
ATTORNEY OF RECORD FOR
PETITIONER:
~M. J 	D 	LOCK 	'-.....:...._
Mlock&Grarn lich~
105 N. 14th
Fort Smith , AR 72901
Telepho ne: (479) 494-56 14
jmedlock@fortsmithlawfirm.com
AUTHORIZED REPRESENTATIVE OF
THE SECRET ARY OF HEALTH AND
HUMAN SERVICES:
Jeffrey 5. 	Digitally signed by
Jeffreys. Beach -5
B 	h S Date: 2025 .11. 21
ea C 	- 	_ 	11 :13:01 -os ·oo · 	for
CAPT GEO RGE REED GRIMES, MD, MPH
Director, Division of Inju ry
Compensation Programs
Health Systems Bureau
Hea lt h Reso urces and Services
Adm inistration
U.S. Depa rtm ent of Health
and Human Se rvi ces
5600 Fishers Lane, I4W-l 8
Rockville, MD 20857
Dated : 'Dtt.ttv\'ae.r 	t; 1
1.01...<;
5
AUTHORIZED REPRESENTATIVE
OF THE ATTORNEY GENERAL:
/uah~~- ?0:v1l~
h0 	Vl-U:' hlo #, 	~~
HEATHER L. PEARLMAN
Deputy Director
Torts Branch
C ivil Division
U.S . Department of Just ic e
P.O. Box 146
Benjam in Fra nkl in Station
Washington, D.C. 20044-0146
ATTORNEY OF RECORD FOR
RESPONDENT:
Civil Div ision
U.S . Department of Justice
P.O. Box 146
Benjam in Franklin Station
Washington, D.C. 20044-0 146
(202) 616-0515
joseph.leavitt@usdoj.gov
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