Step 1 of 5 - Who this is for

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Phone

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Who are you completing this for?(Required)

Myself

My Spouse

A Parent

Another Family Member

A Friend or Loved One

Choose one.

Personal information

First name(Required)

Last name(Required)

Phone number(Required)

Email address(Required)

Street address

City

State

ZIP code

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Hanford employment

Approximate answers are fine — we can help fill in the details later.

Were you employed at the Hanford Site?(Required)

Yes

Approximately what years did you work at Hanford?

Before 1950

1950 – 1959

1960 – 1969

1970 – 1979

1980 – 1989

1990 – 1999

2000 – 2009

2010 or later

Employer or contractor

Department, area, or buildings

Primary job title or occupation

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Medical history

Check all that apply. Nothing here is shared outside our care team.

Have you ever been diagnosed with any of the following?

Cancer

Chronic Kidney Disease

COPD

Asthma

Pulmonary Fibrosis

Pleural Plaques

Beryllium Disease

Neuropathy

Skin Cancer

Hearing Loss

None

Other

If diagnosed with cancer, what type?

Other condition (please specify)

Are you currently experiencing any of the following symptoms?

Shortness of breath

Chronic cough

Wheezing

Difficulty walking

Fatigue

Oxygen use

None

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Your White Card status(Required)

I have never applied

Interested in learning if I qualify

My claim is being processed

I have an approved White Card

I have been denied benefits

I'm not sure

Which best describes your current situation?

How can we help you today?

Determine if I qualify

File a new claim

Understand my benefits

Home Health Services

Family Caregiver Program

Skilled Nursing

Medical Equipment (DME)

Case Management

Transportation

Other

Check all that apply.

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Anything else we should know?

Work history, medical details, or how we can help. Optional.

Consent(Required)

I authorize At Home Staffing to contact me about my potential eligibility and services. This form is not a benefits application and is not legal advice.

Your answers stay on this page until you submit.

Hanford Worker Eligibility Questionnaire

Personal information

Hanford employment

Medical history