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 between January 1, 1963 and February 28, 1970? Y / N If yes, identify employment period at Idaho National Laboratory.
_______________________________________________________________________
5) Does the employee have at least one film badge or TLD dosimetry from CPP between January 1, 1963 and February 28, 1970? Y/N
6) If either question 3, 4 or 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 and #4 both Yes)
□ Select “Unlikely” (#5 is a No)
□ Select “Development Needed” (#5 is a Yes)
______________________________ _______________________________________
Date Signature