1) Employee Name _______________________________________________________

 

2) SS#__________________________________________________________________

 

3) Is there proof of a diagnosis of a specified cancer? Y/N If yes, list cancer type and diagnosis date

 

_______________________________________________________________________

 

4) Does there appear to be at least one full year of covered employment between August 13, 1942 and December 31, 1957? Y/N

 

If yes, identify employment period at Vitro Manufacturing (Canonsburg)

 

_______________________________________________________________________

 

5) If either question 3 or 4 is answered “no,” is there anything in the file to suggest that additional development might change the answers to “yes?” Y/N

 

If so, what development is needed?

______________________________________________________________________

 

______________________________________________________________________

 

______________________________________________________________________

 

Coding Action Taken:

Coded ISL “SEC inclusion likely” (#3 and #4 both Yes)

Coded ISD “SEC development may be needed” (#5 is a Yes)

Coded ISU “SEC inclusion unlikely” (#5 is a No)

 

 

 

______________________________

Date

_______________________________________

Signature