1) Employee Name _______________________________________________________
2) Case ID#__________________________________________________________________
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 (monitored for external radiation at INL e.g., having at least one film badge or TLD dosimeter) between March 1, 1970 and December 31, 1974? Y / N
If yes, identify employment period at the Idaho National Laboratory (INL).
_______________________________________________________________________
5) For a claim with a deceased employee, is there an eligible survivor who has filed a claim?
Y / N
6) If either question 3, 4, 5 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, #4, and #5 are Yes)
□ Select “Unlikely” (#6 is a No)
□ Select “Development Needed” (#6 is a Yes)
______________________________ _______________________________________
Date Signature