Los Alamos National Laboratory

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 work days of covered employment between January 1, 1976 through December 31, 1995?  Y / N

 

If yes, identify employment period at Los Alamos National Laboratory.

 

_______________________________________________________________________

 

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 Screening (SEC/PER/Other) Navigation Panel:

                  Select “Likely” (#3 and #4 both Yes)

      Select “Unlikely” (#5 is a No)

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

 

 

 

______________________________      _______________________________________

Date                                                           Signature