SEC Class Screening Worksheet

1)Employee Name:______________________________________________________

2)SS#______________________________________________________

3) Is there proof of a diagnosis of specified cancer?   Y/N

     If yes,(list cancer type and diagnosis date)

___________________________________________________________

4) Does there appear to be at least 250 days of employment at the SEC site?   Y/N

If yes, identify employment period:

______________________________________________________

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?

___________________________________________________________

___________________________________________________________

___________________________________________________________

Coding Action Taken:

□  Coded ISL “SEC inclusion likely” (#3 and #4 both Yes)

□  Coded ISD “SEC development needed” (#5 is a Yes)

□  Coded ISU “SEC inclusion unlikely” (#5 is a No)

________________      _____________________________________

Date                         Signature