Oak Ridge Hospital 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 250 workdays of covered employment between May 15, 1950 and December 31, 1959?  Y/N

 

If yes, identify employment period at the Oak Ridge Hospital.

 

_______________________________________________________________

 

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