Kidney Cancer
Part E Comprehensive Review Screening Worksheet
1) Employee Name _______________________________________________________
2) Last 4 SSN_______________________ Case ID #______________________________
3) Kidney Cancer Diagnosis Date ____________________________________________
4) What is the first date of DOE contractor employment? ________________________
5) Exposure Determination: Review the case file and SEM to determine whether there are 5 or more consecutive years of TCE exposure prior to 1990. Decide whether the case evidence shows:
a. Did the employee work at a facility on Attachment 2 for more than 5 consecutive years prior to 1990? (Y/N)
(List facilities here) _______________________________________________
_________________________________________________________________
b. Does a SEM search based upon the employee’s labor category(ies) indicate a potential for TCE exposure for 5 consecutive years? (Y/N)
(List labor categories here) ________________________________________
________________________________________________________________
c. If “yes” to 5a and 5b, significant exposure can be presumed. Move on to #6. If no potential for TCE exposure, code “ISU,” and go to #7. If some potential, but not meeting the threshold, confer with IH on whether an IH referral is appropriate and proceed accordingly.
6) Causation Determination: Is there a 20-year latency period between first exposure (date noted in #4) and kidney cancer diagnosis noted in #3? (Y/N)
a. If “yes,” code “ISL” and go to #7.
b. If there is not a 20-year latency period, obtain medical opinion and code “ISD.”
7) Conduct a new assessment on any other denied Part E condition in accordance with the guidance listed in Bulletin No. 13-02 to ascertain whether there is new exposure data (via new SEM search, evaluation of DAR/OHQ/case evidence) or medical evidence that could potentially alter the denial outcome. Note the outcome of that assessment here:
____________________________________________________________________________
____________________________________________________________________________
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Be sure to check each denied condition. Attach/image for the file any new SEM search result. Depending on the outcome of analysis, additional development may be required. If sufficient evidence exists or is obtained via development to warrant reopening a previously denied claim under Part E, appropriate action is taken to initiate such action.
______________________________ _______________________________________
Date Signature