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