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