Lawrence Livermore National Laboratory

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 at least 250 workdays of covered employment between January 1, 1950 and December 31, 1973? Y / N

If yes, identify employment period at Lawrence Livermore National Laboratory.

_______________________________________________________________________

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