SEC Class Screening Worksheet

 

1) Employee Name:________________________________________________

 

2) Case ID: _____________________________________________________

 

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

 

     If yes, list cancer type and diagnosis date:

___________________________________________________________

 

4) Does there appear to be at least 250 workdays of covered employment at the SEC site(s)?   Y/N

 

If yes, identify SEC site(s) and employment period(s):

___________________________________________________________

___________________________________________________________

 

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, 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?

 

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

            

Action Taken on the ECS Screening Navigation Panel: 

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

□  Select “Unlikely” (#6 is No)

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

 

 

 

 ________________      _____________________________________

Date                         Signature