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necessity

necessity
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intake form


COLD WAR ENERGY WORKERS. . . . . . .INTAKE INFORMATION 1 Please complete and return to COLD WAR ENERGY WORKERS (formerly Nuclear Workers of Florida) c/o______________________________ Please Print Neatly Full Name of Worker____________________________________________________________________ Worker Date of Birth___________________________ Worker SS#_______________________________ Living________ Deceased___________ deceased date_____________ survivor claim________________ FACILITY____________________________________________________________________ Employment begin__________________________ employment end______________________________ JOB Titles/duties Date:_____________________ COLD WAR ENERGY WORKERS. . . . . . .INTAKE INFORMATION 2 WORKING CONDITIONS WORK involved accidents, spills, incidents, etc. Monitored______ Not Monitored___________ CANCERS: ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ __________________________________________________ ILLNESSES/DISEASES_________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ____________________________________________________ FILED a claim _____________________________ status of claim_______________________________ Other Information: Name:_____________________; Date:_________________
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