DTRA Form 150-F (Nov 2022) 1 

 

DEFENSE THREAT REDUCTION AGENCY

Atomic Veterans Service Recognition Program

Atomic Veterans Commemorative Service Medal and/or

Atomic Veterans Service Certificate Application

PLEASE RETURN YOUR RESPONSE TO THE ADDRESS BELOW. 

Responses should be sent to: Defense Threat Reduction Agency, Attn: RD-NTS (NTPR), 8725 John J. Kingman 

Road, Stop 6201, Fort Belvoir, VA 22060-6201. For assistance, please either call the NTPR toll-free helpline: 

(1-800-462-3683), email us at dtra-ntpr@mail.mil, or write us at the address above. 

SECTION I. AGENCY DISCLOSURE NOTICE

The public reporting burden for this collection of information should average 15 minutes per response, including the time 

for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing 

and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this 

collection of information, including suggestions for reducing the burden, to whs.mc-alex.esd.mbx.dd-dod-informationcollections@mail.mil. Respondents should be aware that notwithstanding any other provision of law, no person shall be 

subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB 

control number. 

SECTION II. PRIVACY ACT STATEMENT

AUTHORITY: 42 U.S.C. 2013 (Atomic Energy), Pub. L. 117-81, section 583 (FY22 NDAA), Pub. L. 93-579 (Privacy 

Act), and E.O. 9397 (SSN).

PURPOSE(S): For use by agency officials and employees, or authorized contractors, and other DoD components to 

provide data or documentation relevant to the processing of administrative claims or litigation; to conduct scientific 

studies or medical follow-up programs; and in the preparation of the histories of nuclear programs.

ROUTINE USES: Disclosure of records permitted outside DoD under 5 U.S.C. 552a(b) (Privacy Act) to the Department 

of Veterans Affairs and Department of Justices for identifying and processing claims by individuals who allege jobrelated disabilities as a result of participation in nuclear test programs and for litigation actions, Veterans Advisory Board 

on Dose Reconstruction for the purpose of reviewing and overseeing the DoD Radiation Dose Reconstruction Program 

audits of dose reconstructions and to the Department of Health and Human Services, National Council on Radiation 

Protection & Measurements, and Vanderbilt University for the purpose of conducting epidemiological studies on the

effects of ionizing radiation on participants of nuclear test programs. The DoD 'Blanket Routine Uses' also apply.

DISCLOSURE: Voluntary. However, failure to provide the requested information and authorization may delay or 

preclude DTRA from providing or releasing information.

OMB No. 0704-0447

Expiration: 29 Feb 2024
DTRA Form 150-F (Nov 2022) 2 

SECTION III. PARTICIPANT PERSONAL DATA (please print)

1. Last Name 2. First Name 3. Middle Name 4. Sex

M F 

5. SSN 6. Branch of Service 7. Rank 8. Service Number

9. Date of Birth (mm/dd/yy) 10. Place of Birth 11. Deceased

Yes No

12. Date of Death (mm/dd/yy)

SECTION IV. PARTICIPATION DATA (please print)

If you directly participated in the detonation of an atomic weapon or device, or you were exposed to ionizing radiation 

resulting from the operational use of atomic weapons during World War II (e.g., Occupation of Hiroshima or Nagasaki, 

Japan), please complete blocks 13-16. 

13. Detonation or Japanese Occupation Location(s) 14. Associated Date(s) (mm/dd/yy)

15. Participating Unit Assigned During Test or Occupation

16. Remarks

If you directly participated in the cleanup of radioactive material resulting from an atmospheric atomic weapon or device

detonation (e.g., Bikini or Enewetak Atoll cleanup), or directly participated in the cleanup of radioactive material resulting 

from an accident associated with an atomic weapon (e.g., Palomares or Thule accidents), please complete blocks 17-20. 

__________________________________________________________________________________________________

17. Cleanup or Accident Location(s) 18. Associated Date(s) (mm/dd/yy)

19. Participating Unit Assigned During Cleanup or Accident

20. Remarks
DTRA Form 150-F (Nov 2022) 3 

SECTION V. IDENTITY OF THE REQUESTER (please print)

21. Requester is (check one):

 Participant identified in Section III, above

 

 Next of kin, if participant is deceased (specify name/relationship) ______________________________________

 Legal guardian (must submit copy of court appointment)

 Other (specify relationship AND obtain signed authorization from participant per Authorization Statement below)

Relationship:___________________________ 

22. How did you hear of the Atomic Veterans Commemorative Service Medal: 

_______________________________________________________________________________________________

23. Your Mailing Address

___________________________________________________________ 

City____________________________State ___________Zip___________ 

24. Telephone

Home ( ) ____________________ 

Other ( ) ____________________ 

SECTION VI. SIGNATURE AND AUTHORIZATION

I certify under penalty of perjury under the laws of the United States of America that the information in Section III is true

and correct. Violations of the provisions of the Privacy Act are enforceable through legal action, and criminal and civil 

penalties may apply. It is a crime to knowingly and willfully request or obtain records concerning an individual from a 

Government agency under false pretenses.

Signature of Requester _______________________________________ Date _____________________ 

AUTHORIZATION STATEMENT

(Must be completed if requester is not the participant, next of kin of a deceased participant, or legal guardian)

Pursuant to the Privacy Act of 1974, I authorize the Defense Threat Reduction Agency to release information to:

____________________________________________________ 

(Print name of authorized individual) 

Signature of Participant ______________________________________ Date _____________________ 

If you have any questions regarding this form, please call the NTPR toll-free helpline:

1-800-462-3683