Statement of Accepted Facts (SOAF)

 

 

1.       Employee Information

a.       Name:

b.       Case File Number:

c.       Date of Birth:

d.       Date of Death:

                                                   i.      If deceased, list Cause(s) of Death from Death Certificate

 

2.      Medical Information  

a.       Has an Occupational Health Questionnaire (OHQ) been completed? (Provide date)

b.       Diagnosed Condition(s):  (Provide date of diagnosis for each, if possible; if diagnosed condition is skin cancer, provide body location)

c.       Other medical information/conditions available for review by referral personnel (if appropriate):  (Provide dates of Former Worker Protection (FWPP) Interview, authorized home health care periods, etc.)

 

3.      Employment Information - If Relevant - (Provide a detailed description of the employee’s verified and covered employment history – include where employee worked, date(s) of employment, job title(s), job duty(ies)) 

 

4.      Occupational Toxic Exposure - If Relevant - (Provide the occupational toxic substance exposures encountered by the employee and shown to have a potential health effect to the diagnosed condition; provide relevant information on the nature, extent and duration of such exposures)

 

5.      Claim History – If Relevant - (Provide significant events such as date of filing of Part B and/or Part E, date submitted to NIOSH for dose reconstruction, Probability of Causation %,  date of denial/acceptance, date of remanded claim, etc.)

 

6.      Other Information -  (Include any other information that may be useful to those conducting the referral evaluation)

 

7.      Claims Examiner Information

a.       Submitting District Office:

b.       Claims Manager:

c.       Unit designation:

d.       Telephone Number:

e.       E-mail address:

f.        Date of referral:

 

8.      Verification of Review – (Should be signed by District Office Director indicating that the referral information has been reviewed and meets minimum criteria for submittal)