Qualification form for Downwinder program, onsite participant, uranium worker

First Name*:	A value is required.	Last Name*:	A value is required.
Address:		City:
Zip Code:		State:
Daytime Phone*:	A value is required.	Evening Phone:
E-mail Address*:	A value is required.	Type of claim	Downwinder Onsite Uranium worker

Downwinder Claim
County of Residence at Time of Exposure
Dates of Exposure:
Pick one of the covered illnesses corresponding to the type of claim:
Leukemia Chronic Lymphocytic leukemia Multiple myeloma Lymphomas(other than Hodgkin's Disease)
Primary cancer of the:
Pharynx Thyroid Female Breast Male Breast Pancreas Ovary Salivary Gland Lung Esophagus Stomach Brain Urinary Bladder Bile ducts Liver (except if cirrhosis or hepatitis B is indicated) Colon Gall Bladder

Onsite Participant:
Dates of participation in testing
Name of test site:
Pick one of the covered illnesses corresponding to the type of claim
Leukemia Chronic Lymphocytic leukemia Multiple myeloma Lymphomas (other than Hodgkin’s Disease)
Primary cancer of the:
Pharynx Thyroid Female Breast Male Breast Pancreas Ovary Salivary Gland Lung Esophagus Stomach Brain Urinary Bladder Bile ducts Liver (except if cirrhosis or hepatitis B is indicated) Colon Gall Bladder

Uranium Worker:
URANIUM MINER
Nonmalignant Respiratory Disease:
Pulmonary Fibrosis Silicosis Cor pulmonale, related to fibrosis of the lung Pneumoconiosis Lung Cancer
URANIUM MILLER or ORE TRANSPORTER
Lung cancer Renal cancer Chronic renal disease (including nephritis and kidney tubal tissue injury)
Nonmalignant Respiratory Disease:
Pulmonary Fibrosis Silicosis Cor pulmonale, related to fibrosis of the lung Pneumoconiosis