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 at least one full year of covered employment between January 1, 1958 and December 31, 1965 ? Y/N
If yes, identify employment period at CANEL
_______________________________________________________________
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