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SCORE-Bench

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2. Social Security Number
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864-29-731
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3. Date of Birth
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5
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Month
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2
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Day
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1987
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Year
4. Sex [] Male
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[x]
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Female
5. Dependents [] Spouse [] Children [] Other ___
6. Address (Street, Apt. #, P.O. Box)
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42 9ᵗʰ St
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7. Telephone Number(s) a. Home: (
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872
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)
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555
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-
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4444
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b. Other: ( ___ ) ___ - ___
(City, State, ZIP Code)
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Georgetown AZ 85701
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8. Identify the Diagnosed Condition(s) Being Claimed as Work-Related (check box and list specific diagnosis)
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[] Cancer (List Specific Diagnosis Below) 9. Date of Diagnosis
Month Day Year
a. ___ ___ ___ ___
b. ___ ___ ___ ___
c. ___ ___ ___ ___
[] Beryllium Sensitivity ___ ___ ___
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[x]
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Chronic Beryllium Disease (CBD)
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01
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09
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19
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[] Chronic Silicosis ___ ___ ___
[] Other Work-Related Condition(s) due to exposure to toxic substances or radiation (List Specific Diagnosis Below)
a. ___ ___ ___ ___
b. ___ ___ ___ ___
c. ___ ___ ___ ___
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Awards and Other Information
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10. Have you filed a lawsuit based on exposure to radiation, beryllium, asbestos or any other toxic substance?
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[x]
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Yes [] No
11. Have you filed any state workers’ compensation claims in connection with any condition(s) you claim in Item 8?
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[x]
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Yes [] No
12. Have you or another person received a settlement or other award in connection with a lawsuit or state workers’ compensation claim described in Questions 10 or 11? [] Yes
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[x]
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No
13. Have you either pled guilty to or been convicted of any charges connected with an application for or receipt of federal or state workers’ compensation? [] Yes
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[x]
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