SEC Class Screening Worksheet
1) Employee Name:________________________________________________
2) Case ID: _____________________________________________________
3) Is there proof of a diagnosis of 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 at the SEC site(s)? Y/N
If yes, identify SEC site(s) and employment period(s):
___________________________________________________________
___________________________________________________________
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, 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?
________________________________________________________________
________________________________________________________________
________________________________________________________________
Action Taken on the ECS Screening Navigation Panel:
□ Select “Likely” (#3, #4, and #5 are Yes)
□ Select “Unlikely” (#6 is No)
□ Select “Development Needed” (#6 is Yes)
________________ _____________________________________
Date Signature