Dow Chemical Company, Pittsburg, CA
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 from October 1, 1947 through June 30, 1957? Y / N
If yes, identify employment period at the Dow Chemical Company in Pittsburg, CA:
_______________________________________________________________________
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 SEC Screening Navigation Panel:
□ Select “Likely” (#3 and #4 both Yes)
□ Select “Unlikely” (#5 is a No)
□ Select “Development Needed” (#5 is a Yes)
______________________________ _______________________________________
Date Signature