Vitro Manufacturing

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 January 1, 1960 and September 30, 1965?  Y / N

 

If yes, identify employment period at Vitro Manufacturing.

 

_______________________________________________________________________

 

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