Oak Ridge Hospital SEC Class Screening Worksheet


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