Canoga Avenue Facility

 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 workdays of covered employment between January 1, 1955 and December 31, 1960?     Y / N

 

If yes, identify employment period at the Canoga Avenue Facility.

 

_______________________________________________________________________

 

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