Screening Application

Legal Name

Date of Birth

Other Names Used

Mailing Address

Street Address City State ZIP Code

Different Physical Address?*

Yes
No

Physical Address

Street Address City State ZIP Code

Home Phone

Day Phone

Cell Phone

Email

Gender

Male
Female

Marital Status

Ethnicity

Hispanic/Latino
Not Hispanic/Latino
Prefer Not to Disclose

Race

Language

I would like to participate in:

Traditional Screening at CARD
Long Distance Screening (available if you live >100 miles from Libby, MT or if other circumstances prevent you from traveling to CARD)

Describe how or where you lived, worked or played in Lincoln County, MT for a total of at least six months at least ten years ago. Please attach written proof of your below stated presence in Lincoln County, MT. For further detail on documenting proof of presence, see the reverse side of this application. No application will be approved until proof of presence is received.

Lived/Worked/Played

Date From:

Date To:

Primary reason for my visit is:

PROOF OF PRESENCE

All CARD Screening applicants are required to prove their presence in Lincoln County, Montana for a total of six months at least ten years ago. Residency is not required, and the six-month period does not need to be continuous. For example, an individual may have lived, worked, or vacationed in Lincoln County, Montana for short periods over several years. CARD can accept the following documentation as proof of presence:

Records on file at CARD which were completed before March 23, 2010 or,
Medical Records from previous screenings (MASSA or ATSDR)

Any ONE of the following documents with your name, a Lincoln County address, and a date at least ten years ago:

Medical Records from any other medical office
Title or deed to real estate
Rent receipts, rental lease
Unemployment records
Utility bill
Montana driver’s license or ID card
Mail
Telephone directory listing
Tax assessment notice
Marriage certificate
Divorce papers
Summer camp or campground registration
Fishing, hunting or boating license
Birth certificate of claimant’s child
School records
Records that show participation in a social program
Local bank record or check cashing card
Record of volunteer activity
Religious, fraternal, or social organization records

If none of the above documents are available, CARD will accept two signed affidavits from individuals other than the applicant or his/her immediate family attesting to knowledge of the individual’s presence in Lincoln County, MT for at least 6 months at least 10 years ago. Affidavits must include contact information and contain convincing detail.

Proof of stated presence:

Accepted file types: jpg, pdf, Max. file size: 1 MB.

JPG or PDF no larger than 1MB

Card ID#

Official Use Only

Approved By:

Official Use Only

Approved Date

Official Use Only

Sent to Swift Current

Official Use Only

Diagnosis Code V15.84

Official Use Only

I certify that to the best of my knowledge, the statements made within this application are complete and true. I understand that by completing and submitting this application, CARD Screening, funded by the Center for Disease Control only provides screening benefits for asbestos related diseases. Screening participation is voluntary and includes a chest x-ray, spirometry, ANA (autoimmune) blood screening, exposure interview, and visit with a medical provider as well as a FOBT and CT scan if medically warranted. CARD Screening benefits are intended for individuals who are not diagnosed with asbestos related disease but who have potential exposure to asbestos in Lincoln County, MT. These benefits may be used more than once based on medical provider’s recommendation of recall, but may not be used more frequently than annually. I understand that submission of this application does not guarantee benefits under the CARD Screening Program.

Screening Application

PROOF OF PRESENCE

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