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AFFF Claim Application Form
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Diseases with strong association with exposure to AFFF:
Kidney cancer
Testicular cancer
Prostate cancer
Pancreatic cancer
Liver cancer
Bladder cancer
Thyroid disease
Ulcerative colitis
Other cancer:
Other disease associated with AFFF exposure:
Non-Hodgkin's Lymphoma
Colorectal cancer
Leukemia
Breast cancer
Ovarian cancer
Endometrial cancer
Other non-cancer condition:
Diagnosing/treating doctor:
Hospital or medical facility name
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Military/Work exposure:
Are you a current or former member of the U.S. Military?
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No
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Dates served:
Type of work in the military:
List all ships/bases you were on/stationed:
Are you a current or former firefighter or closely associated personnel?
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Employer
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Started
Ended
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Did you use AFFF during your time in the military?
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No
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Frequency of use
Time period
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Did you use AFFF during your career?
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No
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Frequency of use
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