Hood Building SEC Class Screening Worksheet

 

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 one full year of covered employment between May 9, 1946 and December 31, 1963?  Y/N

 

If yes, identify employment period in the Hood Building

 

_______________________________________________________________

 

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