EEOICPA BULLETIN NO.02-03
Issue
Date:
________________________________________________________________
Effective
Date:
________________________________________________________________
Expiration
Date:
________________________________________________________________
Subject:
NIOSH Referral Summary
Background: The Claims Examiners (CEs) in the
District Offices are required by EEOICPA
Section 7384n(d)(1) (and 20 CFR 30.115(a)) to forward claimant’s
application package to NIOSH for dose reconstruction. The NIOSH
Referral Summary (shown in Attachment 1) replaces the Statement of Accepted
Facts (SOAF), which has been used to transmit case files to NIOSH. The SOAF will now be used primarily for medical
referrals. The NIOSH Referral Summary is
a tabular form containing the medical and employment information accepted by
the CE as factual. This form will
provide NIOSH with the necessary information to proceed with the dose
reconstruction process.
Much of the
information in the NIOSH Referral Summary is entered into ECMS. The intent in the future is to automate the
NIOSH Referral Summary and have most, if not all, of the fields entered
electronically from ECMS.
Reference: Energy Employees Occupational Illness
Compensation Program Act of 2000, As Amended, 42 U.S.C. § 7384 et seq., Section 7384n(d)(1) (and 20 CFR
30.115(a)).
Purpose:
To notify the District Offices of the NIOSH Referral Summary to be used
for sending cases to NIOSH for dose reconstruction.
Applicability: All staff.
Actions:
1. Attached to this bulletin is the NIOSH
Referral Summary (Attachment 1). This tabular
form contains the medical and employment information accepted by the CE as
factual.
2. The NIOSH Referral Summary should include information on the Energy Employee (EE) including the employee’s full name, gender, date of birth, date of death (if applicable), and address and phone number (if applicable). In cases involving survivors (there may be one or more), provide contact information including the full name, address, and phone number. In cases of multiple survivors, indicate which survivor would prefer to be contacted (if known), e.g., because they are the most knowledgeable or accessible by phone. Also, if the CE is aware of other contacts, including other family members, co-workers, representatives, attorneys, and people providing affidavits, the CE should provide the full name, address, and phone number for each person. For all phone numbers discussed above, the phone type should be entered on the form in the block following the phone number, e.g., home, work, cell, day, evening, vacation home. This is helpful when there are multiple contact numbers listed.
3. The NIOSH Referral Summary
should include the findings of the CE concerning medical factors. The medical information should include, for
each cancer: whether it is primary or secondary (use a “X”), cancer description
or type, along with the ICD-9 code, and the date of diagnosis. List all primary cancers, or all secondary
cancers if no primary cancers are determined. It is not necessary to list the
secondary cancers if there are primary cancers established. For
the date of cancer diagnosis, the year of diagnosis is required, but the full
date should be entered, if possible. Other covered conditions should be indicated (by
a “X”) when a SEC cancer claim is submitted, but the claimant is filing for
non-SEC cancer medical benefits, or in case of other claim benefits scenarios
(details can be provided on the form).
4.
The NIOSH Referral Summary should include the findings
of the CE regarding the employee’s verified employment period for each DOE or
AWE employment period. For each
employment period include: employer/facility name, start and end date at the facility,
employee number (if available from EE-3), dosimetry badge number (if available
from EE-3), and the employee’s job title (the description is not
required). Verified employment could
extend beyond the covered employment periods.
It is no longer necessary to provide NIOSH with the covered
periods, as dose reconstruction will be performed for all verified
employment. When applicable, the CE
should select the facility name from the Federal Register Notice of List of
Facilities Covered by the Energy Employees Occupational Illness Compensation
Act of 2000. Also, indicate information
related to the method of employment verification (with a “X”), i.e., DOE could
not verify employment, employment verification based on affidavit or other
credible evidence, or employee worked for a sub/sub contractor not listed in
DOE Office of Worker Advocacy facility online database.
5. Other
information that is relevant to NIOSH dose
reconstruction includes race/ethnicity information (for skin cancer) and
smoking history (for lung cancer). These
cancers may be either primary or secondary cancers (sites to which a malignant
cancer has spread). The CE should develop this information
only for individuals with skin or lung cancers.
The CE should request this information from the claimant early in the
process so that it is available when the case is sent to NIOSH. A sample development letter for skin cancer
claimants is shown in Attachment 2. A
sample development letter for lung cancer claimants is shown in Attachment 3. For the race/ethnicity information, mark one
or more of the five designations shown on the NIOSH Referral Summary
(Attachment 1). For the smoking history,
indicate the smoking level (at the time of cancer diagnosis) using one of the
seven designations shown in the NIOSH Referral Summary (Attachment 1). The smoking categories include: Never Smoked
- employee who smoked no more than 100 cigarettes before the date of
cancer diagnosis; Former Smoker - employee who quit smoking more than five
years before the date of cancer diagnosis; and Current Smoker - employee who
smoked cigarettes at the time of the cancer diagnosis or who quit
smoking fewer than five years before the date of the cancer diagnosis (the
cigarette smoking level should be designated as one of the following: less than
10 per day, 10 – 19 per day, 20 – 39 per day, or 40 or more per day).
6. For pertinent cases already sent to NIOSH
that did not have race/ethnicity or smoking
history information, the CEs must develop that information. The National Office will use ECMS to sort
cases already sent to NIOSH. The
National Office will provide the District Office with a list of cases requiring
race or ethnicity information or smoking history. Once received, the DO should send development
letters to all of those individuals identified.
When the information is received from the claimant, the CE should
complete a new NIOSH Referral Summary with the race/ethnicity and smoking
history sections completed. The new form
should then be forwarded to NIOSH along with the weekly packages.
7. Finally, at the bottom of the NIOSH Referral
Summary, provide the information related to the CE’s completion of this
summary, which includes the District Office, the CE’s name and direct dial
phone number, and the date prepared. On
a temporary basis, a review by the supervisor is required. The reviewer’s name and the date of the
review should be noted.
8. The evidence in file must
support any finding made by the CE and documented in the NIOSH Referral
Summary. The CE should make a copy of
the NIOSH Referral Summary and place it in the case file record.
Disposition:
Retain until incorporated in the Federal (EEOICPA) Procedure Manual.
PETER
M. TURCIC
Director,
Division of Energy Employees
Occupational
Illness Compensation
DOL Case Number: [Energy Employee (EE) SSN]
Case File
Contact Information:
Energy Employee:
EE Full
Name: [First, Middle, Last, Suffix] |
|
|
EE Gender:
[M, F, U] |
|
|
Date of
Birth: [Month, Day, Year] |
|
|
Date of
Death (If applicable): [Month, Day, Year] |
|
|
EE Full
Address (If applicable): [Street Address, City, State, Zip] |
|
|
EE Phone
Number (If applicable): [Phone Number,
Phone Type] |
|
|
Survivor(s) (SV) [Create a table for
each SV]:
SV Full
Name (s) (If applicable): [First, Middle, Last, Suffix] |
|
|
SV Full
Address (If applicable): [Street Address, City, State, Zip] |
|
|
SV Phone
Number (If applicable): [Phone Number,
Phone Type] |
|
|
SV
Relationship (If applicable): [Relationship] |
|
Other Contact(s) (OC) [Create a table
for each OC]:
OC Full
Name (s) (If applicable): |
|
|
OC Full
Address (If applicable): [Street Address, City, State, Zip] |
|
|
OC Phone
Number (If applicable): [Phone Number,
Phone Type] |
|
|
OC
Relationship (If applicable): [Relationship] |
|
Medical and
Employment Information:
EE Covered Cancer Information [For each
cancer, list the following information]:
Primary
[ ] or Secondary (Metastatic)
[ ] |
|
Cancer
Description / Type |
|
Associated
ICD-9 Code |
|
Date of
Cancer Diagnosis |
|
Other Covered Condition:
SEC Cancer
Claim, but filing for Non-SEC cancer medical benefits [
] |
Other
claim for benefits scenario [ ] |
Energy
Employee Verified Employment History:
Verified
Employment Period (List all breaks in employment at the DOE or AWE Facility):
Employer /
Facility Name |
|
Start Date
at the Facility (Full Date if Possible) |
|
End Date at the Facility (Full Date if Possible) |
|
Employment
Badge Number (If available) |
|
Dosimetry
Badge Number (If available) |
|
Job Title
(Description not required) |
|
Employer /
Facility Name |
|
Start Date
at the Facility (Full Date if Possible) |
|
End Date at the Facility (Full Date if Possible) |
|
Employment
Badge Number (If available) |
|
Dosimetry
Badge Number (If available) |
|
Job Title
(Description not required) |
|
Employer /
Facility Name |
|
Start Date
at the Facility (Full Date if Possible) |
|
End Date at the Facility (Full Date if Possible) |
|
Employment
Badge Number (If available) |
|
Dosimetry
Badge Number (If available) |
|
Job Title
(Description not required) |
|
[ ]
DOE could not verify employment |
[ ] Employment Verification based upon Affidavit or Other Credible Evidence. |
[ ] EE worked for a sub/sub contractor not
listed in DOE Office of Worker Advocacy facility online database. |
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 or Native Hawaiian or Pacific Islander [ ]
Black [ ]
White-Hispanic [ ]
White-Non-Hispanic [ ]
Not given |
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) [ ]
<10 cig/day (currently) [ ]
0-19 cig/day (currently) [ ]
20-39 cig/day (currently) [ ]
40+ cig/day (currently) |
DOL
Information:
District
Office |
|
Claims
Examiner Name |
|
Claims
Examiner Phone Number |
|
Date
Prepared for NIOSH |
|
Reviewed By |
|
U. S. DEPARTMENT OF LABOR EMPLOYMENT
STANDARDS ADMINISTRATION
OFFICE
OF WORKERS’ COMPENSATION PROGRAMS
DIVISION
OF ENERGY EMPLOYEES’ OCCUPATIONAL
ILLNESS COMPENSATION
200 CONSTITUTION AVE
ROOM C-4511
WASHINGTON DC 20210
TELEPHONE: (202) 693-0081
March 28,
2002 Employee:
File
Number:
JOE CLAIMANT
1234 W. MAIN
STREET
WASHINGTON,
D.C.
Dear Mr.
Claimant:
This
letter concerns your claim for compensation under the Energy Employees
Occupational Illness Compensation Program. We have reviewed the claim and found
that the exposed employee was diagnosed with skin cancer.
The
next step in determining whether you are eligible for benefits is calculating
whether the diagnosed cancer is reasonably related to exposure to radioactive
materials during the course of covered employment. The calculation of probability of causation
is based on many factors, such as the length of exposure and proximity to
radiological sources, safety protection worn, the type of cancer diagnosed,
etc.
We
calculate the probability of causation by using a computer program to determine
whether the diagnosed cancer is reasonably related to exposure during covered
employment. For certain types of cancer,
such as skin cancer or a cancer which has spread to more than one location in
the body, the computer program requires that we include information about the
exposed employee’s race or ethnic identification as an additional factor in
order to complete the calculation.
Therefore,
we are asking you to complete the attached questionnaire in full and return it
to the address that appears at the bottom of the questionnaire. Please return the questionnaire within 30
days to avoid any delay in the claims process.
It
is important that you complete the questionnaire and return it to us so that we
can perform the probability of causation calculation. If we do not receive a
fully completed questionnaire, we will be unable to perform a calculation of
probability. Without a calculation of probability, we will not be able to
determine whether you are entitled to benefits under this program and no award
of benefits will be made.
Remember
as the claimant, it is ultimately your responsibility to submit the necessary
information to establish a claim under the EEOICPA. If you have any questions
or concerns, please contact the District Office at XXX-XXX-XXXX or fax
XXX-XXX-XXXX.
Sincerely,
Claims
Examiner
Employee:
File Number:
The National
Institute for Occupational Safety and Health (NIOSH) has developed a computer
program known as the Interactive Radioepidemiological Program (IREP) that is
used to calculate the probability of causation between a diagnosed cancer and
employment. More information can be
obtained about this program by contacting NIOSH at 1-800-35-NIOSH.
For
skin cancer claims, racial or ethnic identification is necessary to accurately
perform the IREP calculation. It is a
required element of the computer program.
In order to proceed with a determination of causation, please mark the
box(es) that best match(es) the racial or ethnic identification of the
employee named above:
American Indian or Alaskan Native
Asian, or Native Hawaiian or Other Pacific
Islander
Any person who knowingly
makes any false statement, misrepresentation, concealment of fact or any other
act of fraud to obtain compensation as provided under the EEOICPA or who
knowingly accepts compensation to which that person is not entitled is subject
to civil or administrative remedies as well as felony criminal prosecution and
may, under appropriate criminal provisions, be punished by a fine or
imprisonment or both.
I certify that the
information provided is accurate and true.
Print Name
_______________________________________________
Signature
________________________________________________
Date ____________________________
U. S. DEPARTMENT OF LABOR EMPLOYMENT
STANDARDS ADMINISTRATION
OFFICE
OF WORKERS’ COMPENSATION PROGRAMS
DIVISION
OF ENERGY EMPLOYEES’ OCCUPATIONAL
ILLNESS COMPENSATION
200 CONSTITUTION AVE
ROOM C-4511
WASHINGTON DC 20210
TELEPHONE: (202) 693-0081
March 28, 2002 Employee:
File Number:
JOE CLAIMANT
1234 W. MAIN
STREET
WASHINGTON,
D.C.
Dear Mr.
Claimant:
This
letter concerns your claim for compensation under the Energy Employees
Occupational Illness Compensation Program.
We
have reviewed the claim and found that the exposed employee was diagnosed with
one of the following:
§
Primary
Trachea
§
Bronchus
§
Lung
The
next step in determining whether you are eligible for benefits is calculating
whether the diagnosed cancer is reasonably related to exposure to radioactive
materials during the course of covered employment. The calculation of probability of causation
is based on many factors, such as the length of exposure and proximity to
radiological sources, safety protection worn, the type of cancer diagnosed,
etc.
We
calculate the probability of causation by using a computer program to determine
whether the diagnosed cancer is reasonably related to exposure during covered
employment. For a claim involving
primary trachea, bronchus, or lung cancer or cancers that have spread to more
than one location in the body, the computer program requires that we include
information about the employee’s smoking history prior to the diagnosis of
cancer.
Therefore,
we are asking you to complete the attached questionnaire in full and return it
to the address that appears at the bottom of the questionnaire. Please return the questionnaire within 30
days to avoid any delay in the claims process.
It
is important that you complete the questionnaire in full and return it to us so
that we can perform the probability of causation calculation. If we do not receive a fully completed
questionnaire, we will be unable to perform a calculation of probability. Without a calculation of probability, we will
not be able to determine whether you are entitled to benefits under this
program and no award of benefits will be made.
Remember
as the claimant, it is ultimately your responsibility to submit the necessary
information to establish a claim under the EEOICPA. If you have any questions
or concerns, please contact the District Office at XXX-XXX-XXXX or fax
202-693-1465.
Sincerely,
Claims
Examiner
Employee:
File Number:
1. Check the box that best describes the smoking
history of the employee named above.
Never Smoked – Employee who smoked no more than 100 cigarettes
before the date of cancer diagnosis.
Former Smoker - Employee who quit smoking more than five years
before the date of cancer diagnosis
Current Cigarette Smoker - Employee who smoked cigarettes at the
time of the cancer diagnosis or who quit smoking fewer than five years
before the date of the cancer diagnosis
2. If you checked Current Cigarette Smoker above, please check the box below that
corresponds with the number of cigarettes smoked per day at the time of the
cancer diagnosis:
* Generally
20 Cigarettes Per Pack
Any person who knowingly
makes any false statement, misrepresentation, concealment of fact or any other
act of fraud to obtain compensation as provided under the EEOICPA or who
knowingly accepts compensation to which that person is not entitled is subject
to civil or administrative remedies as well as felony criminal prosecution and
may, under appropriate criminal provisions, be punished by a fine or
imprisonment or both.
I certify that the
information provided is accurate and true.
Print Name
_______________________________________________
Signature
________________________________________________
Date ____________________________