Ovarian Cancer

Part E Comprehensive Review Screening Worksheet

 

1) Employee Name _______________________________________________________

 

2) Last four SSN________________________

 

3) Ovarian Cancer Dx Date:___________

 

4) What is the first date of DOE contractor employment? ________

 

5) Review the case file and SEM to determine whether there are 250 days of significant exposure.  To decide this – decide whether the case evidence shows:

 

1) asbestos exposure was significant and how we know this, note specific labor categories and/or job tasks from Attachment 2 and/or scenarios associated with exposure

 

2) period of employment during which it is established that the employee experienced significant asbestos exposure at a DOE facility and

 

3) calculate whether such exposure was at least 250 days in duration

 

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Does the case evidence establish at least 250 days of significant asbestos exposure at a DOE facility?   Y – N  (If development is needed, mark N)

 

6)  Are there at least 20 years between first date of asbestos exposure associated with DOE employment (use date from #4) and ovarian cancer diagnosis?   Y -- N   (If development is needed, mark N)

 

7)         If YES to both 5 and 6, update ECS to reflect “ISL” for the circular assessment and continue to review any other denied Part E diagnosis.

If NO to either #5 and/or #6, and it is felt that additional development should be undertaken update ECS to reflect “ISD” for the circular assessment.  Initiate additional development of the case including potential IH referral to ascertain level/extent or duration of asbestos exposure.

 

8) Conduct a new assessment on any other denied Part E condition in accordance with the guidance  listed in bulletin No. 13-02 to ascertain whether there is new exposure data (via new SEM search, evaluation of DAR/OHQ/case evidence) or medical evidence that could potentially alter the denial outcome.  Note the outcome of that assessment here:

 

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Be sure to check each denied condition.  Attach/image for the file record any new SEM search result.  Depending on the outcome of analysis, additional development may be required.  If sufficient evidence exists or is obtained via development to warrant reopening a previously denied claim under Part E appropriate action is taken to initiate such action. 

 

 

 

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Date                                                           Signature