Lawrence Livermore National Laboratory (LLNL)

SEC Class Screening Worksheet

1) Employee Name _______________________________________________________

2) Case ID#__________________________________________________________________

3) Is there proof of a diagnosis of a specified cancer? Y / N

If yes, (list cancer type and diagnosis date)

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4) Does there appear to be 250 workdays of covered employment between Janaury1, 1974 and December 31, 1989? Y / N

If yes, identify employment period at the Lawrence Livermore National Laboratory in Livermore, CA:

_______________________________________________________________________

5) For a claim with a deceased employee, is there an eligible survivor who has filed a claim? Y/N

6) If either question 3, 4, 5 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 on SEC Screening Navigation Panel:

Select “Likely” (#3, #4, and #5 are Yes)

Select “Unlikely” (#6 is a No)

Select “Development Needed” (#6 is a Yes)

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Date Signature