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