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 one full year of covered employment between August 13, 1942 and June 30, 1946? Y/N

If yes, identify employment period at Met Lab

_______________________________________________________________

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 may be needed” (#5 is a Yes)

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

______________________________ _______________________________________

Date Signature