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. List any accepted conditions (if applicable).
d. 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, or designee, indicating that the referral information has been reviewed and meets minimum criteria for submittal