SEC Class Screening Worksheet for New SEC Cancers
Laryngeal Cancer and Solitary Plasmacytoma (Bone Form)
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 the employment meet the criteria of a SEC class? Y/N
If yes, identify the SEC class
_______________________________________________________________
5) Does there appear to be 250 workdays of covered employment in a SEC class or an aggregate of more than one SEC class? Y/N
If yes, identify the employment period at the SEC class
_______________________________________________________________
6) If either question 3, 4 or 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?
______________________________________________________________________
______________________________________________________________________
Coding Action Taken:
□ Coded ISL “SEC inclusion likely” (#3, #4 and #5 all Yes)
□ Coded ISD “SEC development may be needed” (#6 is a Yes)
□ Coded ISU “SEC inclusion unlikely” (#6 is a No)
______________________________ _______________________________________
Date Signature