Bladder Cancer
Part E Comprehensive Review Screening Worksheet
1) Employee Name _______________________________________________________
2) SS#__________________________________________________________________
3) List Part E Diagnosis(Dx) which are in denial status and Dx Date for each Dx:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
4) Conduct a new SEM search. Be sure to check every Dx for new links.
Attach that search.
5) Review case file, OHQ, DAR, new material for evidence of exposures not previously considered. Note that here:
_______________________________________________________________________
________________________________________________________________________
_______________________________________________________________________
6) Using existing procedures for establishing toxic exposure to a substance, is there now evidence of substantial (at least a year of routine, regular) exposure to a toxic substance based upon the employee’s labor category(ies) now linked to one of the employee’s diagnosed Part E conditions?
If yes, □ Select “ISL” (Exposure Established)
– Obtain medical opinion on causation.
If no, □ Select “ISU” (No new exposure to toxins linked to Dx)
– Note to file with date. Review complete.
If SEM indicates some exposure, but significance in doubt,
□ Select “ISD” (Development needed)
– Prepare IH referral.
______________________________ _______________________________________
Date Signature