Screening Application

Marital Status
I would like to participate in

Describe how or where you lived, worked or played in Lincoln County, MT for a total of at least six months at least 10 years ago. Please attach written proof of your below stated presence in Lincoln County, MT. No application will be approved until proof of presence is received.

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 have to be consecutive. For example, an individual may have lived, worked, or vacationed in Lincoln County, Montana for short periods of time 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.

Primary reason for my visit is:

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, 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.