INSTRUCTIONS FOR COMPLETING THE NRSD

No.

Title

Description

Example

N/A

NRSD Type

Enter an “X” next to the type of NRSD that is being submitted.  If you select Amendment or Supplement enter Remarks (the reason and or data that has created the need for an Amendment/Supplement.  For an Initial NRSD include all sections, unless they will be blank (i.e. other contact if there isn’t one).  For an Amendment include the employee’s name, DOL case number, NIOSH tracking number, the tables that include changed information, and the DOL information (including the SrCE’ or journey level CE signature).  For Supplements, include the DOL case number, NIOSH tracking number, and employee’s name.

1

DOL Case Number

Enter the 9 digit case number/social security number

123-45-6789

2

Energy Employee (EE)

The employee as listed on the EE-1/EE-2.

 

a

Name

Enter the Employee’s name as it is listed in ECMS/Claim Form (First, Middle Initial, Last, Suffix)

Fred R. Flintstone, III

 

b

Gender

Enter Male or Female as indicated in ECMS/Claim Form

Male, Female

 

c

Date of Birth

Enter the date of birth in MM/DD/YYYY format

01/31/1964

 

d

Date of Death

If applicable, enter the date of death in MM/DD/YYYY format

11/01/2006

 

e

Address

If applicable, enter the full address of the EE(Street, City, State, and zip code)

Helpful Hint: Adding the +4 zip code may speed up mail delivery by several days (visit www.usps.com to find an address’ +4 zip code).

 
 

 

 


710 Bedrock Dr., Aiken, SC 26175-0454

 

f

Phone Number and Type

If available/applicable, enter the employee’s 10 digit phone number.  Refer to ECMS for the EE-2.  Type can include home, work, cell, day, evening, vacation home, etc.

865-123-9870

Home

3

Survivor(s) Data

If applicable, enter the survivor’s data for each survivor that has filed a Claim for Benefits, Form EE-2.  If not applicable (the employee is living), delete these tables.  If there are more than 3 survivors, copy and paste one table and add to the bottom, be sure to include a space between them.

 

a

Name

Enter the Survivor’s name (First, Middle Initial, Last, Suffix).  Refer to ECMS for the EE-2

Betty D. Flintstone

 

b

Address

Enter the full address of the survivor (Street, City, State, and zip code).  Refer to ECMS or the EE-2.

710 Bedrock Dr., Aiken, SC 26175-0454

 

c

Phone Number and type

If available, enter the survivor’s 10 digit phone number. Refer to ECMS or the EE-2. Type can include home, work, cell, day, evening, vacation home, etc.

703-999-8000

Other

 

d

Relationship to Employee

Enter the survivor’s relationship to the employee as selected on the EE-2

Spouse, Child, Grandchild

 

e

Currently eligible survivor (Yes or No)

Enter Yes or No.  Entering “Yes” means the survivor has met all the requirements to establish survivorship.  Also note if the survivor is a “Part E Only” survivor (i.e. a non-spousal child).  In cases of multiple survivors, indicate which survivor would prefer to be contacted by entering “Primary Contact” in the space provided.

Yes (Part E Only/Non-spousal Child)/Primary Contact

4

Other Contact

If applicable, enter the Authorized Representative/Power of Attorney (POA) data.  If not, delete this table.  If there is more than one contact, copy and paste the table and add to the bottom, be sure to include a space between them.

 

a

Name

Enter the Contact’s name (First, Middle Initial, Last, Suffix)

Ira M. Lawyer, Jr.

 

b

Address

Enter the full address of the survivor (Street, City, State, and zip code)

710 Bedrock Dr., Aiken, SC 26175-0454

 

c

Phone Number and Type

If available, enter the survivor’s 10 digit phone number.  Type can include home, work, cell, day, evening, vacation home, etc.

703-999-8000

Work

 

d

Relationship to employee

If known, enter the contact’s relationship to the EE

Lawyer

5

EE Covered Cancer Information

Enter the EEs verified diagnosed cancer(s).  Create a table (copy, cut, paste); for each primary cancer or secondary cancer for which there is an unknown primary.

 

a

Primary or Secondary

Place an “X” (by clicking) in the box that best describes the cancer (Primary or Secondary)

 

 

b

Cancer Description/Type

Enter the cancer description from the pathology/operative report, etc.

Chronic monocytic leukemia, in remission

 

c

Associated ICD-9 Code

Enter the ICD-9 code that best describes the cancer

206.11

 

d

Date of Cancer Diagnosis

Enter the date of cancer diagnosis from pathology report, operative report, death certificate, etc. in MM/DD/YYYY format.  The entire date is not required but preferred.  List the month and year if the full date is not available.  The year of diagnosis is required.

01/10/2001

6

Other Covered Condition

If applicable, place and “X” (by clicking) in the box(es).

 

a

SEC Cancer Claim, but filing for Non-SEC cancer medical benefits

Select this box if the claim is an employee claim or a survivor claim where the employee filed initially, that is being or has been accepted for an SEC cancer; and there is a claim for a non-SEC Cancer.

Employee is accepted for SEC lung cancer; and now is filing for a non-SEC skin cancer.

 

b

Other claim for benefits scenario

If there is any scenario not “typical” (i.e., non SEC cancer/employment) and not covered in 6.a, select this box by clicking.

Part B survivor case accepted for CBD. Under Part E, cannot establish death link relating to CBD; death certificate lists lung cancer as cause of death.

 

c

Explain

Provide a detailed/specific explanation for the reason box 6.b was selected

For the example above: “Survivor already compensated under Part B, Dose Reconstruction will be to establish death link for Part E only.”

7

Energy Employee Verified Employment History

Complete this section for all verified employment.  Any breaks in employment seven days or more must be reported separately.  Create another table by using copy, paste; remember to leave a space between them.  It is not necessary to verify employment beyond the date of cancer diagnosis for the purposes of submitting the NRSD; however, once submitted, continue to complete employment verification for toxic exposure and other claimed illnesses.  Remember that the verified employment may extend beyond the covered employment at a particular site.  The CE must verify the covered dates for a site by going to the DOE Office of Worker Advocacy Covered Facility List (http://www.hss.energy.gov/healthsafety/fwsp/advocacy/faclist/findfacility.cfm).

 

a

Employer/Facility Name

Enter the employer and Facility Name

Union Carbide/K-25

 

b

Start Date

Enter the start date in MM/DD/YYYY Format

01/01/1956

 

c

End Date

Enter the end date in MM/DD/YYYY Format

12/31/1959

 

d

Employment badge number

If available, list the EEs employment badge number from the EE-3 or DAR.

10349

 

e

Dosimetry Badge No.

If available, list the EEs dosimetry badge number from the EE-3, DAR, or ORISE

10949

 

f

Job Title

If available, list the EEs job title (for the specific employment period) using information from the EE-3, DAR, or ORISE

Pipefitter

8

Employment verification information valuable to NIOSH

Select these boxes, by clicking, if applicable.

 

a

DOE could not verify employment

Select this box if employment wasn’t verified

 

 

b

Employment verification based on affidavit or other credible evidence

 

 

 

c

Worked for a contractor/sub-contractor not listed

If the employee worked for a contractor/subcontractor not listed on the DOE Office of Worker Advocacy Covered Facility List, select this box.

F.H. McGraw

9

Other information relevant to dose reconstruction

For skin cancer and lung cancer cases additional information regarding the following must be provided.

 

a

Ethnicity selection

For skin cancers, it is required that the District Office supply NIOSH with the EEs race/ethnicity.  The method used to gather this information is EE/EN-9  (Attachment 4).  If the claimant does not return the questionnaire within 60 days, the case will be administratively closed.  However, if the CE can obtain the information from the EE’s medical information or other credible source (i.e. DAR), the NRSD may be completed using that information and forwarded to NIOSH with an explanation of where the information was acquired.

 

b

Smoking History

For lung cancer or a secondary cancer with an unknown primary cancer that includes lung cancer as a possible primary cancer , the CE must request the EEs smoking history using the EE/EN-8 (Exhibit 3).  If the claimant does not return the questionnaire within 60 days, the case will be administratively closed.  However, if the CE can obtain the information from the EE’s medical information or other credible source (i.e. DAR), the NRSD may be completed using that information and forwarded to NIOSH with an explanation of where the information was acquired.  If the employee is a current smoker (currently refers to time of cancer diagnosis), then the CE must select an additional box, which indicates the amount (per day) the employee smoked at the time of cancer diagnosis.

10

DOL Information

Enter the requested information

 

a

District Office

Enter the CE’s District Office

Cleveland, Denver, Jacksonville, Seattle

 

b

Claims Examiner Name

Enter the CE’s full name

Fred C. Flintstone

 

c

Claims Examiner Phone No.

Enter the CE’s direct dial phone number (not the toll free number)

(904)357-4795 x74307

 

d

Claims Examiner email address

Enter the CE’s DOL email address

flinstone.fred@dol.gov

Reviewed by

A SrCE or journey level CE must review the NRSD, sign, and date; affirming that to the best of her/his ability, they have reviewed the information provided and believe it to be accurate and correct.

Note: A complete copy of the case file (including the Part D if available) will be duplicated and sent with the NRSD to NIOSH.