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 workdays of covered employment between May 15, 1950 and December 31, 1959? Y/N

If yes, identify employment period at the Oak Ridge Hospital.


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