1) Employee Name ___________________________________________________________
2) Case ID___________________________________________________________________
3) Is there a diagnosis of Non-Hodgkin’s lymphoma? Y / N
If yes, (provide diagnosis date).
_____________________________________________________________________________
4) Review the DAR and conduct SEM searches based upon the employee’s DOE facility and labor category. Is there any evidence of potential exposure to lindane (1,2,3,4,5,6-Hexachlorocyclohexane) or pentachlorophenol? Y/N
If yes to either, or both, describe evidence that indicates potential for exposure to either/both lindane and/or pentachlorophenol.
_____________________________________________________________________________
5) What are the dates of employment that correspond to the potential lindane or pentachlorophenol exposure, noted above?
____________________________________________________________________________
6) Period of Exposure
For lindane, is the work period with the potential for exposure at least 56 days? Y/N
For pentachlorophenol, is the work period with the potential for exposure at least 2 years? Y/N
7) Latency:
For lindane, is the date of diagnosis 20 years or more after first potential exposure? Y/N
For pentachlorophenol, is the date of diagnosis 10 or more years after first potential exposure? Y/N
8) If question 4 is answered “no,” is there anything in the file to suggest that additional development might change the answer to “yes?” Y / N
If so, what development is needed?
______________________________________________________________________
______________________________________________________________________
ECS Action Taken on SEC Screening Navigation Panel:
□ Select “Likely” (#6 and #7 both Yes for lindane or pentachlorophenol)
□ Select “Unlikely” (#3, #6 or #7 is a No and #8 is a No)
□ Select “Development Needed” (#8 is a Yes)
______________________________ _______________________________________
Date Signature