Westinghouse Electric Corporation 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 at least 250 days of covered employment between August 13, 1942 and December 31, 1949? Y/N

 

If yes, identify employment period at Westinghouse Electric Corp..

 

_______________________________________________________________________

 

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)

 

 

 

 

 

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Date                                                           Signature