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
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4) Does there appear to be at least one full year of covered employment between August 13, 1942 and December 31, 1957? Y/N
If yes, identify employment period at Vitro Manufacturing (Canonsburg)
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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?
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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)
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Date
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Signature