NIOSH Referral Summary Document (NRSD)

_{Enter a “X” where appropriate}

	Initial	Amendment	Supplement
Remarks(if Amendment or Supplement):

1. DOL Case Number: 

Case File Contact Information

2. Energy Employee (EE):

a. Name (First-Middle-Last-Suffix)

b. Gender (Male or Female)

c. Date of Birth (MM/DD/YYYY)

d. Date of Death (MM/DD/YYYY)

e. Address (Street, City, State, Zip)

f. Phone Number and Type

3. Survivor(s) (SV) (If applicable, create a table for each):

a. Name (First-Middle-Last-Suffix)

b. Address (Street, City, State, Zip)

c. Phone Number and Type

d. Relationship to employee

e. Currently eligible survivor (Y/N)

a. Name (First-Middle-Last-Suffix)

b. Address (Street, City, State, Zip)

c. Phone Number and Type

d. Relationship to employee

e. Currently eligible survivor (Y/N)

a. Name (First-Middle-Last-Suffix)

b. Address (Street, City, State, Zip)

c. Phone Number and Type

d. Relationship to employee

e. Currently eligible survivor (Y/N)

4. Other Contact(s)(OC)(If applicable, create a table for each):

a. Name (First-Middle-Last-Suffix)

b. Address (Street, City, State, Zip)

c. Phone Number and Type

d. Relationship to employee

Medical and Employment Information

5. EE Covered Cancer Information (create a table for each cancer):

a. Primary [] or Secondary (metastatic) []

b. Cancer Description/Type

c. Associated ICD-9 Code

d. Date of Cancer Diagnosis

6. Other Covered Condition:

a. SEC Cancer Claim, but filing for Non-SEC cancer medical benefits  []

b. Other claim for benefits scenario  []

c. Explain:

7. Energy Employee Verified Employment History:

(List all breaks in employment at the DOE or AWE Facility):

a. Employer / Facility Name

b. Start Date

c. End Date

d. Employment Badge Number

e. Dosimetry Badge No.

f. Job Title

8. Employment Verification Information Valuable to NIOSH:

a.  DOE could not verify employment

b.  Employment Verification based upon Affidavit or Other

   Credible Evidence.

c.  Worked for a contractor/sub-contractor not listed in DOE

   Office of Worker Advocacy facility online database.

9. Other information relevant to dose reconstruction, if required:

a. If the claim is for skin cancer or a secondary cancer for which skin cancer is a likely primary cancer, list one or more of the following:	American Indian or Alaska Native Asian, Native Hawaiian, or    Pacific Islander  Black  White-Hispanic  White-Non-Hispanic  Not given
b. If the claim is for lung cancer or a secondary cancer for which lung cancer is a likely primary cancer, select one of the following (Note: Currently refers to time of cancer diagnosis):	Never smoked  Former smoker  Current smoker (? cig/day) à <10 cig/day à 10-19 cig/day à 20-39 cig/day à 40+ cig/day

10. DOL Information:

a. District Office

b. Claims Examiner Name

c. Claims Examiner Phone Number

d. Claims Examiner email address

Reviewed by:

Claims Examiner                                                      Date