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|   **U. S.           |                         |                      |
| DEPARTMENT OF       |                         |                      |
| ENERGY**            |                         |                      |
|                     |                         |                      |
| **Employee Concerns |                         |                      |
| Reporting Form**    |                         |                      |
+---------------------+-------------------------+----------------------+
| If you have a       |                         |                      |
| concern to report,  |                         |                      |
| please complete     |                         |                      |
| this form and mail  |                         |                      |
| it to the           |                         |                      |
| appropriate         |                         |                      |
| address.  You may   |                         |                      |
| also report your    |                         |                      |
| concern verbally to |                         |                      |
| the site            |                         |                      |
| representative.     |                         |                      |
|                     |                         |                      |
| **NOTE:**  You are  |                         |                      |
| encouraged to       |                         |                      |
| attempt resolution  |                         |                      |
| of your concern or  |                         |                      |
| problem initially   |                         |                      |
| with your           |                         |                      |
| supervisor and/or   |                         |                      |
| in accordance with  |                         |                      |
| your employer's     |                         |                      |
| established         |                         |                      |
| Concerns Program    |                         |                      |
| reporting           |                         |                      |
| procedures.         |                         |                      |
+---------------------+-------------------------+----------------------+
| **This Report Must  |                         |                      |
| Not Contain any     |                         |                      |
| Classified          |                         |                      |
| Information.**      |                         |                      |
+---------------------+-------------------------+----------------------+
| In order for the    |                         |                      |
| Employee Concerns   |                         |                      |
| Program (ECP)       |                         |                      |
| Representative to   |                         |                      |
| thoroughly          |                         |                      |
| investigate your    |                         |                      |
| concern, you are    |                         |                      |
| asked to complete   |                         |                      |
| as much of the      |                         |                      |
| following           |                         |                      |
| information as you  |                         |                      |
| can, including your |                         |                      |
| name and work       |                         |                      |
| location.  However, |                         |                      |
| your anonymity will |                         |                      |
| be protected if you |                         |                      |
| so indicate.        |                         |                      |
+---------------------+-------------------------+----------------------+
| 1.  Does your       |                         |                      |
|     concern involve |                         |                      |
|     an immediate    |                         |                      |
|     danger to       |                         |                      |
|     employees, the  |                         |                      |
|     environment, or |                         |                      |
|     the public?     |                         |                      |
|     \_\_ Yes        |                         |                      |
|     \_\_ No    \_\_ |                         |                      |
|     Unknown         |                         |                      |
|                     |                         |                      |
|                     |                         |                      |
|                     |                         |                      |
|                     |                         |                      |
|                     |                         |                      |
|                     |                         |                      |
|                     |                         |                      |
|                     |                         |                      |
|                     |                         |                      |
|                     |                         |                      |
|                     |                         |                      |
|                     |                         |                      |
|                     |                         |                      |
|                     |                         |                      |
|                     |                         |                      |
| 2.  Nature of       |                         |                      |
|     Concern:        |                         |                      |
|                     |                         |                      |
|    \_\_Violation    |                         |                      |
|     \_\_Hazard      |                         |                      |
|     \_\_Other       |                         |                      |
|     (Speci          |                         |                      |
| fy):\_\_\_\_\_\_\_\ |                         |                      |
| _\_\_\_\_\_\_\_\_\_ |                         |                      |
| \_\_\_\_\_\_\_\_\_\ |                         |                      |
| _\_\_\_\_\_\_\_\_\_ |                         |                      |
| \_\_\_\_\_\_\_\_\_\ |                         |                      |
| _\_\_\_\_\_\_\_\_\_ |                         |                      |
| \_\_\_\_\_\_\_\_\_\ |                         |                      |
| _\_\_\_\_\_\_\_\_\_ |                         |                      |
| \_\_\_\_\_\_\_\_\_\ |                         |                      |
| _\_\_\_\_\_\_\_\_\_ |                         |                      |
| \_\_\_\_\_\_\_\_\_\ |                         |                      |
| _\_\_\_\_\_\_\_\_\_ |                         |                      |
| \_\_\_\_\_\_\_\_\_\ |                         |                      |
| _\_\_\_\_\_\_\_\_\_ |                         |                      |
| \_\_\_\_\_\_\_\_\_\ |                         |                      |
| _\_\_\_\_\_\_\_\_\_ |                         |                      |
| \_\_\_\_\_\_\_\_\_\ |                         |                      |
| _\_\_\_\_\_\_\_\_\_ |                         |                      |
| \_\_\_\_\_\_\_\_\_\ |                         |                      |
| _\_\_\_\_\_\_\_\_\_ |                         |                      |
| \_\_\_\_\_\_\_\_\_\ |                         |                      |
| _\_\_\_\_\_\_\_\_\_ |                         |                      |
| \_\_\_\_\_\_\_\_\_\ |                         |                      |
| _\_\_\_\_\_\_\_\_\_ |                         |                      |
| \_\_\_\_\_\_\_\_\_\ |                         |                      |
| _\_\_\_\_\_\_\_\_\_ |                         |                      |
| \_\_\_\_\_\_\_\_\_\ |                         |                      |
| _\_\_\_\_\_\_\_\_\_ |                         |                      |
| \_\_\_\_\_\_\_\_\_\ |                         |                      |
| _\_\_\_\_\_\_\_\_\_ |                         |                      |
| \_\_\_\_\_\_\_\_\_\ |                         |                      |
| _\_\_\_\_\_\_\_\_\_ |                         |                      |
| \_\_\_\_\_\_\_\_\_\ |                         |                      |
| _\_\_\_\_\_\_\_\_\_ |                         |                      |
| \_\_\_\_\_\_\_\_\_\ |                         |                      |
| _\_\_\_\_\_\_\_\_\_ |                         |                      |
| \_\_\_\_\_\_\_\_\_\ |                         |                      |
| _\_\_\_\_\_\_\_\_\_ |                         |                      |
| \_\_\_\_\_\_\_\_\_\ |                         |                      |
| _\_\_\_\_\_\_\_\_\_ |                         |                      |
| \_\_\_\_\_\_(Attach |                         |                      |
|     additional      |                         |                      |
|     sheets if       |                         |                      |
|     necessary).     |                         |                      |
|                     |                         |                      |
| 3.  What Do You     |                         |                      |
|     Believe May Be  |                         |                      |
|     The             |                         |                      |
|     Consequence(s)  |                         |                      |
|     If Your Concern |                         |                      |
|     Remains         |                         |                      |
|     Unaddressed?    |                         |                      |
|                     |                         |                      |
|              \_\_   |                         |                      |
| Loss of life or     |                         |                      |
| injury              |                         |                      |
|                     |                         |                      |
|                     |                         |                      |
|                \_\_ |                         |                      |
| Damage or loss of   |                         |                      |
| to                  |                         |                      |
| environmental       |                         |                      |
|                     |                         |                      |
|              \_\_   |                         |                      |
| Damage or loss of   |                         |                      |
| safety-related      |                         |                      |
| faci                |                         |                      |
| lities              |                         |                      |
| \_\_                |                         |                      |
| Other**:\_          |                         |                      |
| \_\_\_\_\_\_\_\_\_\ |                         |                      |
| _\_\_\_\_\_\_\_\_\_ |                         |                      |
| \_\_\_\_\_\_\_\_\_\ |                         |                      |
| _\_\_\_\_\_\_\_\_** |                         |                      |
|                     |                         |                      |
| 4.  Who is your     |                         |                      |
|     Employer?       |                         |                      |
|     \_\_DOE         |                         |                      |
|                     |                         |                      |
|  \_\_Contractor     |                         |                      |
|     \_              |                         |                      |
| \_Subcontractor     |                         |                      |
|     \_\_Other       |                         |                      |
|     (Specify        |                         |                      |
| ):\_\_\_\_\_\_\_\_\ |                         |                      |
| _\_\_\_\_\_\_\_\_\_ |                         |                      |
|                     |                         |                      |
| 5.  Have you        |                         |                      |
|     reported your   |                         |                      |
|     concern to any  |                         |                      |
|     other source?   |                         |                      |
|     \_\_Yes         |                         |                      |
|     \_\_No  (If     |                         |                      |
|     Yes, to         |                         |                      |
|     whom)\_\_\_\_\  |                         |                      |
| _\_\_\_\_\_\_\_\_\_ |                         |                      |
| \_\_\_\_\_\_\_\_\_\ |                         |                      |
| _\_\_\_\_\_\_\_\_\_ |                         |                      |
| \_\_\_\_\_\_\_\_\_\ |                         |                      |
| _\_\_\_\_\_\_\_\_\_ |                         |                      |
| \_\_\_\_\_\_\_\_\_\ |                         |                      |
| _\_\_\_\_\_\_\_\_\_ |                         |                      |
| \_\_\_\_\_\_\_\_\_\ |                         |                      |
| _\_\_\_\_\_\_\_\_\_ |                         |                      |
| \_\_\_\_\_\_\_\_\_\ |                         |                      |
| _\_\_\_\_\_\_\_\_\_ |                         |                      |
| \_\_\_\_\_\_\_\_\_\ |                         |                      |
| _\_\_\_\_\_\_\_\_\_ |                         |                      |
|                     |                         |                      |
| 6.  Identify any    |                         |                      |
|     individuals     |                         |                      |
|     (name and       |                         |                      |
|     phone) you      |                         |                      |
|     believe should  |                         |                      |
|     be contacted    |                         |                      |
|     regarding your  |                         |                      |
|     concern (e.g.   |                         |                      |
|     to provide      |                         |                      |
|     additional      |                         |                      |
|     information):   |                         |                      |
| \_\_\_\_\_\_\_\_\_\ |                         |                      |
| _\_\_\_\_\_\_\_\_\_ |                         |                      |
| \_\_\_\_\_\_\_\_\_\ |                         |                      |
| _\_\_\_\_\_\_\_\_\_ |                         |                      |
| \_\_\_\_\_\_\_\_\_\ |                         |                      |
| _\_\_\_\_\_\_\_\_\_ |                         |                      |
| \_\_\_\_\_\_\_\_\_\ |                         |                      |
| _\_\_\_\_\_\_\_\_\_ |                         |                      |
|                     |                         |                      |
| 7.  Do you want     |                         |                      |
|     your name kept  |                         |                      |
|     confidential?:  |                         |                      |
|     \_\_Yes         |                         |                      |
|     \_\_No     ­­­\_\_ |                         |                      |
| \_\_\_\_\_\_\_\_\_\ |                         |                      |
| _\_\_\_\_\_\_\_\_   |                         |                      |
|     \_\_\_\_\_\     |                         |                      |
| _\_\_\_\_\_\_\_\_\_ |                         |                      |
|                     |                         |                      |
|                     |                         |                      |
|                     |                         |                      |
|                     |                         |                      |
|                     |                         |                      |
|                     |                         |                      |
|                     |                         |                      |
|           Name      |                         |                      |
|                     |                         |                      |
|                     |                         |                      |
| Date                |                         |                      |
+---------------------+-------------------------+----------------------+
| **Mail to:  DOE     |                         |                      |
| Employee Concerns   |                         |                      |
| Program at the      |                         |                      |
| Respective Site or  |                         |                      |
| Call:**             |                         |                      |
+---------------------+-------------------------+----------------------+
| Bartley A.  Fain,   | Gary Stegner, Ohio      | Gary Stegner,        |
| EMCBC               | Field Office --         | Fernald Closure      |
|                     | Springdale              | Project              |
| U. S. Department of |                         |                      |
| Energy              | U. S. Department of     | U. S. Department of  |
|                     | Energy                  | Energy               |
| 250 East 5^th^      |                         |                      |
| Street, Suite 500   | 175 Tri-County Parkway  | 175 Tri-County       |
|                     |                         | Parkway              |
| Cincinnati, Ohio    | Cincinnati, Ohio 45246  |                      |
| 45202               |                         | Cincinnati, Ohio     |
|                     | 513-246-0074            | 45246                |
| 513-246-0468        |                         |                      |
|                     |                         | 513-246-0074         |
+---------------------+-------------------------+----------------------+
| Gary Stegner,       | Daniel Sullivan, West   | Mike Rose, Carlsbad  |
| Miamisburg Closure  | Valley Demonstration    | Field Office         |
| Project             | Project                 |                      |
|                     |                         | U. S. Department of  |
| U. S. Department of | U. S Department of      | Energy               |
| Energy              | Energy                  |                      |
|                     |                         | P.O. Box 3090        |
| 175 Tri-County      | 10282 Rock Springs Road |                      |
| Parkway             |                         | Carlsbad, NM         |
|                     | West Valley,  NY 14171  | 88221-3090           |
| Cincinnati, Ohio    |                         |                      |
| 45246               | 716-942-4016            | 505-234-7319         |
|                     |                         |                      |
| 513-246-0074        |                         |                      |
+---------------------+-------------------------+----------------------+
| Simon  Lipstein,    | Susan Sparks,           | John Sattler,        |
| Rocky Flats Closure | Portsmouth/Paducah      | Columbus Closure     |
| Project             | Project Office          | Project              |
|                     |                         |                      |
| U. S. Department of | U. S. Department of     | U. S. Department of  |
| Energy              | Energy                  | Energy               |
|                     |                         |                      |
| 12101 Airport Way,  | 1017 Majestic Drive,    | 1425 Plain           |
| Unit A              | Suite 200               | City--Georgesville,  |
|                     |                         | State Rt.142         |
| Broomfield, CO      | Lexington, KY  40513    |                      |
| 80021-2583          |                         | West Jefferson, OH   |
|                     | 859-219-4016            | 43162                |
| 303-966-4948        |                         |                      |
|                     |                         | 513-246-0603         |
+---------------------+-------------------------+----------------------+
| Lynette Chafin- EM  | Lisa Maul -- Ashtabula  |                      |
| Small Sites         | Office                  |                      |
|                     |                         |                      |
| US Department of    | U. S Department of      |                      |
| Energy              | Energy                  |                      |
|                     |                         |                      |
| 250 East 5^th^      | West Valley             |                      |
| Street,  Suite 500  | Demonstration Project   |                      |
|                     |                         |                      |
| Cincinnati, Ohio    | 10282 Rock Springs Road |                      |
| 45202               |                         |                      |
|                     | West Valley,  NY 14171  |                      |
| 513-246-0461        |                         |                      |
|                     | 716-942-4690            |                      |
+---------------------+-------------------------+----------------------+