Enter a “X” where appropriate
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| Initial |
| Amendment |
| Supplement |
| Remarks(if Amendment or Supplement): | |||||
1. DOL Case ID Number:
Case File Contact Information
2. Energy Employee (EE):
| a. Name (First-Middle-Last-Suffix) |
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| b. Gender (Male or Female) |
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| c. Date of Birth (MM/DD/YYYY) |
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| d. Date of Death (MM/DD/YYYY) |
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| e. Address (Street, City, State, Zip) |
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| f. Phone Number and Type |
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3. Survivor(s) (SV) (If applicable, create a table for each):
| a. Name (First-Middle-Last-Suffix) |
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| b. Address (Street, City, State, Zip) |
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| c. Phone Number and Type |
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| d. Relationship to employee |
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| e. Currently eligible survivor (Y/N) |
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| a. Name (First-Middle-Last-Suffix) |
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| b. Address (Street, City, State, Zip) |
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| c. Phone Number and Type |
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| d. Relationship to employee |
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| e. Currently eligible survivor (Y/N) |
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| a. Name (First-Middle-Last-Suffix) |
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| b. Address (Street, City, State, Zip) |
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| c. Phone Number and Type |
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| d. Relationship to employee |
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| e. Currently eligible survivor (Y/N) |
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4. Other Contact(s)(OC)(If applicable, create a table for each):
| a. Name (First-Middle-Last-Suffix) |
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| b. Address (Street, City, State, Zip) |
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| c. Phone Number and Type |
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| d. Relationship to employee |
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Medical and Employment Information
5. EE Covered Cancer Information (create a table for each cancer):
| a. Primary [] or Secondary (metastatic) [] | |
| b. Cancer Description/Type |
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| c. Associated ICD-9 Code |
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| d. Associated ICD-10 Code |
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| e. Date of Cancer Diagnosis |
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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 |
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| b. Start Date |
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| c. End Date |
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| d. Employment Badge Number |
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| e. Dosimetry Badge No. |
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| f. Job Title |
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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 |
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| b. Claims Examiner Name |
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| c. Claims Examiner Phone Number |
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| d. Claims Examiner e-mail address |
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Reviewed by:
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Claims Examiner Date