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 October 1, 1943 and June 30, 1972? Y / N
If yes, identify employment period at Hanford.
_______________________________________________________________
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