SEC Class Screening Worksheet for New SEC Cancers

Laryngeal Cancer and Solitary Plasmacytoma (Bone Form)

 

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 the employment meet the criteria of a SEC class?  Y/N

 

If yes, identify the SEC class 

_______________________________________________________________

 

5)  Does there appear to be 250 workdays of covered employment in a SEC class or an aggregate of more than one SEC class?  Y/N

 

If yes, identify the employment period at the SEC class

 

_______________________________________________________________

 

6)  If either question 3, 4 or 5 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, #4 and #5 all Yes)

□   Coded ISD “SEC development may be needed” (#6 is a Yes)

□   Coded ISU “SEC inclusion unlikely” (#6 is a No)

 

______________________________      _______________________________________

Date                                                                                        Signature