Mound Plant

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 from September 1, 1972 through December 31, 1972 or from January 1, 1975 through December 31, 1976?  Y / N

 

If yes, identify employment period at the Mound Plant.

 

_______________________________________________________________________

 

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