Savannah River Site

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, 1953 and September 30, 1972?  Y / N

 

If yes, identify employment period at the Savannah River Site

 

_______________________________________________________________________

 

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?

______________________________________________________________________

 

______________________________________________________________________

 

______________________________________________________________________

 

ECS Action Taken on NIOSH Causation Path:

                  Select ISL “SEC inclusion likely” (#3 and #4 both Yes)

      Select ISD “SEC development may be needed” (#5 is a Yes)

      Select ISU “SEC inclusion unlikely” (#5 is a No)

 

 

______________________________      _______________________________________

Date                                                           Signature