SEC Class Screening Worksheet

 

1)Employee Name:________________________________________________

 

2)Case ID: _____________________________________________________

 

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(s)?   Y/N

 

If yes, identify SEC site(s) and employment period(s):

 

___________________________________________________________

___________________________________________________________

 

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:  The results of the initial screening are recorded in ECS at the case level via the SEC Screening Navigation Panel: 

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

□  Select “Unlikely” (#5 is No)

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

□  Select “No Action Necessary” 

 

 

 ________________      _____________________________________

Date                         Signature