Clarksville Modification Center, Ft. Campbell
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 August 1, 1949 through December 31, 1967? Y / N
If yes, identify employment period at the Clarksville Modification Center, Ft. Campbell.
_______________________________________________________________________
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