W.R. Grace and Company in Curtis Bay, Maryland
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 from May 1, 1956 through January 31, 1958? Y / N
If yes, identify employment period at W.R. Grace and Company in Curtis Bay, MD.
_______________________________________________________________________
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)
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Date Signature