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