Piqua Organic Moderated Reactor Site SEC Class Screening Worksheet

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 May 2, 1966 and February 28, 1969? Y/N

If yes, identify employment period at the Piqua Organic Moderated Reactor site.

_______________________________________________________________

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