Clinton Engineer Works

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 that meets both A & B below? Y/N           

A:   The employee worked on the premises of the Clinton Engineer Works for 250 workdays between January 1, 1943 and December 31, 1949

and

B:   The employee was employed by either of the following companies in any combination of days totaling at least 250 workdays as follows:

i.         Tennessee Eastman Corporation(TEC) between 1/1/1943-12/31/1947

and/or

ii.       Carbide and Carbon Chemicals Corporation(C&CCC) between 1/1/1947-12/31/1949.

 

Identify on the lines below periods of employment by TEC and C&CCC at the CEW that meet the parameters of this question:

 

TEC:  _______________________________________________________________________

C&CCC: ____________________________________________________________________

 

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 “Likely SEC” (#3 and #4 both Yes)

      Select “Unlikely SEC” (#5 is a No)

      Select “SEC Development Needed” (#5 is a Yes)

 

______________________________      ___________________________________________

Date                                                           Signature