Clinton Engineer Works
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 that meets both A & B below? Y/N
A: The employee worked on the premises of the Clinton Engineer Works for 250 workdays between January 1, 1943 and December 31, 1949
and
B: The employee was employed by either of the following companies in any combination of days totaling at least 250 workdays as follows:
i. Tennessee Eastman Corporation(TEC) between 1/1/1943-12/31/1947
and/or
ii. Carbide and Carbon Chemicals Corporation(C&CCC) between 1/1/1947-12/31/1949.
Identify on the lines below periods of employment by TEC and C&CCC at the CEW that meet the parameters of this question:
TEC: _______________________________________________________________________
C&CCC: ____________________________________________________________________
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?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
ECS Action Taken on NIOSH Causation Path:
□ Select “Likely SEC” (#3 and #4 both Yes)
□ Select “Unlikely SEC” (#5 is a No)
□ Select “SEC Development Needed” (#5 is a Yes)
______________________________ ___________________________________________
Date Signature