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U.S. DEPARTMENT OF LABOR

+ + + + +

ADVISORY BOARD ON TOXIC SUBSTANCES 

AND WORKER HEALTH

+ + + + +

WEDNESDAY

MAY 17, 2023

+ + + + +

The Advisory Board met at the Holiday 

Inn and Suites Idaho Falls, Snake River Room, 

3005 South Fork Boulevard, Idaho Falls, ID, at 

9:00 a.m. MDT, Steven Markowitz, Chair, 

presiding.

SCIENTIFIC COMMUNITY

AARON BOWMAN

MARK CATLIN*

GEORGE FRIEDMAN-JIMENEZ*

MIKE VAN DYKE

MEDICAL COMMUNITY

MARIANNE CLOEREN

STEVEN MARKOWITZ, Chair

MAREK MIKULSKI*

KEVIN VLAHOVICH*

CLAIMANT COMMUNITY

JIM H. KEY

GAIL SPLETT

DIANNE WHITTEN

DESIGNATED FEDERAL OFFICIAL

RYAN JANSEN
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ALSO PRESENT

KEVIN BIRD, SIDEM

KEVIN DRESSMAN, DOE

CHRIS GODFREY, DOL

GREG LEWIS, DOE

CARRIE RHOADS, DOL

JOHN VANCE, DOL*

*Present via video teleconference
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P-R-O-C-E-E-D-I-N-G-S

(9:00 a.m.)

MR. JANSEN: All right, let's get 

started. Good morning, everyone. My name is Ryan 

Jansen and I'm the Designated Federal Officer for 

the Department of Labor's Advisory Board on Toxic 

Substances and Worker Health.

I'd like to welcome you to today's 

meeting of the Advisory Board here in Idaho 

Falls, Idaho. Today is Wednesday, May 17, 2023. 

We are scheduled to meet from 9:00 a.m. to 5:00 

p.m. Mountain Time.

At the outset, I'd like to express my 

appreciation for the hard work of the Board 

members in preparing for this meeting and their 

forthcoming deliberations. I'd also like to thank 

Kevin Dressman, Director of the Office of Health 

and Safety at the Department of Energy and Chris 

Godfrey, Director of the Office of Workers' 

Compensation Programs at the Department of Labor 

for being here today. 

I'd also like to thank John Vance, 
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Policy Chief with the Energy Program at the 

Department of Labor for joining the discussion 

virtually. Finally, I'd like to thank Carrie 

Rhoads from the Department of Labor and Kevin 

Bird, our logistics contractor, who are both with 

me here today for their work organizing the 

meeting.

The Board's website, which can be 

found at dol. gov / owcp / energy / regs / 

compliance/advisoryboard.htm has a page dedicated 

to this meeting. The page contains all materials 

submitted to us in advance of the meeting and 

will include any materials that are provided by 

our presenters throughout the next day and a 

half. There, you can also find today's agenda as 

well as instructions for participating remotely 

in both the meeting and the public comment period 

later today.

If any of the virtual participants 

have technical difficulties during this meeting, 

please email us at energyadvisoryboard@dol.gov. 

If you are joining by Webex, please note that 
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outside of the public comment period this 

afternoon, this session is for viewing only and 

microphones will be muted for non-Advisory Board 

members. So the public may listen in, but not 

participate in the Board's discussion during the 

meeting. 

If you are participating remotely and 

wish to provide a public comment, please email 

energyadvisoryboard@dol.gov and request to make a 

comment. Be sure to include your name in the 

request. If you are participating remotely and 

need to provide your public comment via 

telephone, not Webex, please include the phone 

number that you will be dialing in from so that 

we can unmute your line when it is your turn to 

make a public comment. 

The public comment period opens at 

4:15 p.m. Mountain Time this afternoon. Please 

note that the public comment period isn't a 

question and answer session, but rather an 

opportunity for the public to provide comments 

about topics being discussed and considered by 
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the Board. If for any reason the Board members 

require clarification on an issue that requires 

participation from the public, the Board may 

request such information through the Chair or 

myself.

A transcript and minutes will be 

prepared from today's meeting. As DFO, I see that 

the minutes are prepared and ensure that they are 

certified by the Chair. The minutes of today's 

meeting will be available on the Board's website 

no later than 90 calendar days from today, but if 

they're available sooner, they'll be posted 

sooner. Although formal minutes will be prepared 

according to the regulations, we also prepare 

verbatim transcripts and they should be available 

on the Board's website within 30 days.

During the discussions today, please 

speak clearly enough for the transcriber to 

understand. When you begin speaking, especially 

at the start of the meeting, make sure that you 

state your name so it's clear who is saying what. 

Also, I would like to ask that our transcriber 
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please let us know if you have trouble hearing 

anyone or any of the information that is being 

provided. 

I'd also like to mention that there is 

currently one vacant position on the Board. As 

such, we have invited interested parties to 

submit nominations for individuals to serve on 

the Board. The selected nominee will serve as a 

member from the claimant community under the 

Board's statute and charter. Nominations for 

individuals to serve on the Board must be 

submitted by May 27, 2023. For further 

information, including details about how to 

submit nominations, please visit the Board's 

website.

As always, I would like to remind the 

Advisory Board members that there are some 

materials that have been provided to you in your 

capacity as special government employees and 

members of the Board which are not suitable for 

public disclosure and cannot be shared or 

discussed publicly including during this meeting. 
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Please be aware of this throughout the 

discussions today. The materials can be discussed 

in a general way which does not include any 

personally identifiable information or PII, such 

as names, addresses, specific facilities if we 

are discussing a case, or a doctor's name.

I'm looking forward to working with 

everyone at this meeting and hearing the 

discussions over the next day and a half and with 

that, I convene this meeting of the Advisory 

Board on Toxic Substances and Worker Health and I 

will turn it now over to Dr. Markowitz for 

introductions.

CHAIR MARKOWITZ: Thank you, Mr. 

Jansen. And I want to just echo his welcome to 

everyone who is attending either virtually or in 

person. We're going to have a really interesting 

meeting, I can assure you of that. It's hybrid, 

so we have four Board members who are online, 

actually we can see you, but I'm not sure we'll 

be able to see if you indicate that you want to 

speak. I'm speaking to those online. If you 
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indicate that you want to speak and we, for some 

reason, don't see that on the screen, then just 

jump in at any point when you want to raise some 

topic.

A thank you to Mr. Jansen and to Ms. 

Rhodes for all the arrangements and especially to 

Mr. Bird for all the detailed arrangements for 

today's meeting.

I want to go over the agenda in a bit, 

but first we do introductions, which includes 

everybody in the room and also the Board members 

online. I will start. Steven Markowitz, I'm an 

occupational medicine physician epidemiologist. I 

run the largest Former Worker Medical Screening 

Program at 14 sites in seven states, DOE sites, 

and have done so since 1997. Ms. Whitten.

MEMBER WHITTEN: Hi, Dianne Whitten. I 

am the Hanford Atomic Metal Trades health 

advocate. I work at Hanford. I've been there 

since 1988 as a radcon tech and I'm happy to be 

here.

MEMBER BOWMAN: Good morning, my name 
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is Aaron Bowman. I am a professor and head of the 

School of Health Sciences at Perdue University. I 

am a toxicologist by training.

MEMBER VAN DYKE: Good morning, Mike 

Van Dyke. I am an associate professor at the 

Colorado School of Public Health and an 

Industrial Hygienist.

MEMBER SPLETT: My name is Gail Splett. 

I worked at the Hanford site for 45 years. I am 

now retired.

MEMBER KEY: Good morning. I'm Jim Key, 

representing the labor community on the Board. I 

am also President of the United Steel Workers 

International Union Atomic Energy Workers Council 

in Washington, D.C. As a Cold War veteran and 

having served 48 years at the Paducah Gaseous 

Diffusion and Uranium Enrichment Facility, I look 

forward to the Board's interactions, discussions 

and recommendations today.

MEMBER CLOEREN: Hi, I'm Marianne 

Cloeren. I'm an occupational medicine physician 

and internal medicine. I'm associate professor of 
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medicine at the University of Maryland School of 

Medicine. I've been the Medical Director for the 

Building Trades Medical Screening Program, one of 

the former worker programs that works with 

construction trade workers, and I've been on the 

Board just for the last year.

CHAIR MARKOWITZ: Thanks, Mr. Catlin?

MEMBER CATLIN: Thank you, Dr. 

Markowitz. My name is Mark Catlin. I'm an 

Industrial Hygienist, currently retired. I spent 

40 years in the field and over the years have 

worked both at Hanford and Los Alamos, and happy 

to be here.

CHAIR MARKOWITZ: Thank you. Dr. 

Vlahovich?

MEMBER VLAHOVICH: Good morning, I'm 

Kevin Vlahovich. I'm an assistant professor at 

the University of New Mexico and a physician.

CHAIR MARKOWITZ: You look like you're 

in a nice place, Kevin. Dr. Friedman-Jimenez? 

You're on mute, George.

MEMBER FRIEDMAN-JIMENEZ: Okay, I tried 
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to unmute. Can you hear me now?

CHAIR MARKOWITZ: Yes.

MEMBER FRIEDMAN-JIMENEZ: Hi, I'm 

George Friedman-Jimenez. I'm an occupational 

medicine physician, Director of the Bellevue/NYU 

Occupational Medicine Clinic and I'm also an 

occupational epidemiologist. I've been on the 

Board almost since the beginning, I think. 

CHAIR MARKOWITZ: And, Dr. Mikulski?

MEMBER MIKULSKI: Good morning, this is 

Marek Mikulski. I'm an occupational 

epidemiologist with the University of Iowa 

Occupational and Environmental Health. I also run 

a former worker program for the former DOE 

workers from the state of Iowa.

CHAIR MARKOWITZ: Okay, thank you. 

We're going to do members of the audience here, 

members of the public and also leadership from 

the Department of Energy and Department of Labor, 

so, if you could start, Kirk.

MR. DOMINA: I'm Kirk Domina. I'm a 

retired Hanford worker.
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MS. HUNT: I'm Annette Hunt. I work 

with United Energy Workers, I'm a benefits 

specialist.

MR. TEBAY: Calin Tebay, Hanford Work 

Force Engagement Center representative.

MR. ARTZER: Josh Artzer, Hanford Work 

Force Engagement Center representative.

MR. MARCINKO: I'm Bob Marcinko. I'm 

retired from the INL for 31 years. I was 

essentially the first Industrial Hygienist that 

was hired at the INL.

MR. LEWIS: I'm Greg Lewis with the 

Department of Energy, Office of Worker Screening 

and Compensation Support, which is part of the 

Office of Health and Safety at DOE.

MR. DRESSMAN: Good morning, my name is 

Kevin Dressman. I'm the Director of the DOE 

Office of Health and Safety.

MR. FISHER: Good morning, I'm Miles 

Fisher, the Assistant Director of the Building 

Trades National Medical Screening Program, one of 

the former worker programs that screens 
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construction workers that worked on DOE 

facilities, as Marianne pointed out.

MR. GODFREY: Good morning, I'm Chris 

Godfrey. I'm the Director of the Office of 

Workers' Compensation Programs at the United 

States Department of Labor.

MR. HANSON: Gaylon Hanson, local 

coordinator, Worker Health Protection Program. I 

worked 35 years at the INL.

CHAIR MARKOWITZ: Okay, thank you. 

Hopefully there are members of the public who are 

online, we're not going to ask you to introduce 

yourselves, but let me ask Ms. Rhoads, how many 

public commenters so far do we have for this 

afternoon?

MS. RHOADS: Four.

CHAIR MARKOWITZ: Four. So, let me 

encourage people who are both present here and 

those online, if you wish to make a public 

comment, you're free to do so, that begins at 

4:15 today. Those of you who are online if you 

could email Ms. Rhoads at 
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energyadvisoryboard@dol.gov, did I get that 

right? Yes. We always welcome comments from the 

public. We read those comments, we listen to 

those comments, and we try to integrate those 

issues into our discussion.

So, the agenda. We're going to get 

welcomes from Mr. Dressman and Mr. Godfrey and 

then we're going to get an update from Mr. Vance, 

who is online. He's the policy chief at the 

Energy Compensation Program. Then we're going to 

discuss a couple of different topics that working 

groups have worked on since the last meeting. One 

on the issue of significance and the other on the 

issue of Site Exposure Matrices. We're probably 

going to rearrange the agenda a little bit in the 

afternoon to see how this discussion is following 

this morning in order not to break up the flow, 

but we will have on the agenda review of cases 

that the Board has gone over, review of past 

requests for information that the Board has made 

to the Department, feedback on a recommendation 

that we made at the previous meeting, a new topic 
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that Mr. Key has raised on hearing loss and 

dementia. Then, a public comment period from 4:15 

until 5:00. 

Tomorrow, we'll continue the 

discussion with additional case review. We may 

move the issue of the quality of the contract 

medical consultants, the CMC reports, we may move 

that to today depending on the flow of the 

discussion. But we'll see how it goes.

Any questions, comments on the agenda? 

Any additions that the Board members would like 

to propose? Okay. So, let's move on to the next, 

which is we welcome Mr. Dressman, who is Office 

of Health and Safety Director at the Department 

of Energy, who has a few words for us. You're 

welcome to sit up at the table with the 

microphone.

MR. DRESSMAN: Good morning and thank 

you for the opportunity to share some remarks 

with the Advisory Board. As Dr. Markowitz 

mentioned, my name is Kevin Dressman. I'm the 

Director of the DOE Office of Health and Safety. 
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Among many different programs and 

responsibilities, we administer the Department's 

Former Worker Program as well as fulfilling DOE's 

statutory obligations under the EEOICPA statute. 

I am relatively new to this 

organization and this role, having been in this 

position for about 18 months, but I have spent 

the better part of my 15 years in DOE working in 

the Office of Enforcement, more specifically 

spending a significant amount of time in the 

Office of Worker Safety and Health Enforcement. 

So I am quite familiar with many of the health 

and safety challenges that both our current 

workers as well as our former workers have faced 

as part of the work that they've done for the 

Department of Energy.

I and the organization are fully 

committed to fulfilling DOE's statutory 

obligations for providing information and access 

to records to the Department of Labor as part of 

this process, but I think more importantly is DOE 

is committed to providing the services and 
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support that's necessary to help workers who may 

have faced health concerns or health issues as a 

result of their service to our country. We feel 

that there is a moral and ethical obligation to 

those workers and so we are fully committed to 

providing the information necessary for DOE to 

make a fully informed decision regarding claims 

that are submitted.

We also recognize the partnership that 

we have with the Department of Labor and OWCP in 

this program. We have regular communications on 

issues to make sure the process flows as smoothly 

as possible and our office also regularly 

monitors DOE's response rate for records requests 

that come to us. As you may know, the records are 

provided through DOE's sites. We have points of 

contact. We have agreements with all DOE sites to 

ensure that whatever records are needed or 

required for this process, that our contractors 

that we use are providing those records as 

expeditiously as possible.

I look forward to the discussion 
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today. This is my first public Board meeting for 

this particular Board and so still in the 

learning mode, but I appreciate the opportunity 

to talk with you this morning and I will be 

available all day to discuss anything that I can 

from DOE's perspective. 

The last thing I'd like to do is thank 

Greg Lewis and his team for the outstanding work 

that they've done for many years in support of 

this program. Without that team, without that 

commitment, I don't think we would be as 

effective as we are, but we are always looking 

for opportunities to improve, so please feel free 

to share those opportunities with us at any time. 

Thank you.

CHAIR MARKOWITZ: Thank you. I also 

would like to thank Mr. Lewis for the excellent 

site tour that we had yesterday. We went up to 

the lab. They opened up the EBR-1 Museum, I 

guess, for us early and we saw a number of 

different reactors and sites. It was an excellent 

tour so thank you very much for arranging that 
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for us.

The Board recognizes the crucial role 

of the Department of Energy in providing really 

the underlying data for the exposure information 

that's used in claims evaluation and 

establishing, modifying, improving the Site 

Exposure Matrices, so we understand the critical 

role of the Department of Energy. 

Next, we would like to welcome Mr. 

Chris Godfrey, who is the Director of the Office 

of Workers' Compensation Programs, who would like 

to say a few things.

MR. GODFREY: Good morning, I'm Chris 

Godfrey. I'm the Director of the Office of 

Workers' Compensation Programs at the United 

States Department of Labor. It's an honor to be 

here to speak with all of you today and to have 

the opportunity to meet with you and to take part 

in this event and also the site tour yesterday. I 

want to thank Kevin and Greg for the opportunity 

yesterday. It was a unique opportunity for me to 

be able to be exposed to the site visit and more 
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importantly, just have the opportunity to meet 

with all of you to establish relationships that I 

wasn't able to create during virtual meetings in 

the past. So, this opportunity to come here today 

and to be with all of you and to meet with you 

and hear from you is really, really important.

At the Office of Workers' Compensation

Programs, the Energy Program is a program that is 

very near and dear to me. It's one of the reasons 

that I'm glad that I'm at OWCP. The program is 

one that someone that I worked with and had a 

real opportunity to engage with, Senator Tom 

Harkin, throughout my early days in Iowa, this 

was a program that was very important to him and 

so I'm just really honored that I can play even a 

small role in the work of this program.

I also want to just thank you for the 

recommendations that you make, for the dedication 

that you have for ill workers through the Energy 

Program. It's obviously something that is a great 

focus to us at OWCP. We have made our claimant 

experience a very important part of the work that 
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we do and hopefully we can make sure that we take 

the recommendations that you make back to the 

program and really make life changing 

improvements within the program.

Lastly, I want to thank the Department 

of Energy for their continued cooperation with 

us. It's a unique opportunity for us to work 

together to make sure that we can make positive 

improvements for the lives of those who have been 

impacted through the work at the Energy Program. 

So, thank you again for the opportunity to be 

here and I look forward to the discussion today.

CHAIR MARKOWITZ: Thank you. So, next 

we're going to hear from Mr. Vance, who is the 

Policy Chief of the DEEOIC. Are you on the phone? 

Oh, you're more than on the phone, you're here on 

video.

MR. VANCE: I'm right here on video.

CHAIR MARKOWITZ: Welcome.

MR. VANCE: Welcome to the post-COVID 

video reality, I think. Hopefully everyone can 

hear me. Good morning to you folks out in Idaho 
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and everybody joining on line. 

Again, my name is John Vance. I'm the 

Policy Branch Chief. I have participated in these 

in the past and it's always exciting to sit and 

listen to the conversations the Board has and to 

work very hard in responding to some of the 

recommendations and the input that we do get from 

the Board.

I do want to say that the Director 

regrets not being able to attend today, but she 

was attending an outreach event and so I get the 

honor of getting all of our program updates to 

everyone. We've got a lot that I sort of put 

together as a summary to review. I'm just going 

to march right through some updates. I sort of 

cherry picked information I thought the Board 

might be interested in. I know that as we go 

throughout the meeting, there might be topics 

that we will cover and I will be certainly 

available throughout the entire meeting today and 

tomorrow to help answer questions or provide any 

clarifications of issues that the Board is 
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discussing.

I think the first thing that I always 

want to do is just talk a little bit about the 

production of the program. The Board is well 

aware that we deal with a lot of very interesting 

cases, but our first quarter data from January to 

March 2023, I'm just going to run through some 

highlight numbers here. We received during that 

period, 2,902 claims. We did 1,252 NIOSH 

referrals, that's for the dose reconstruction 

process. We have, as Kevin and Greg can tell you, 

we submitted 1,727 requests for employment data 

to the Department of Energy, so this is a 

reflection of the very high workload that we work 

with DOE to try to facilitate and we commend both 

the Department of Energy and Kevin's and Greg's 

team for helping us out with that. It's a very 

large workload and they've been doing very well 

with that and I just thought it would be telling 

to show you how much work the Department of 

Energy is doing to support our program with that 

number of referrals.
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Of special interest to the Board, we 

have done 1,207 industrial hygiene reviews and 

again that's just for the first quarter here of 

the year, so you can sort of forecast out what 

that looks like for the year. We've issued 6,145 

recommended decisions. This would encompass all 

of our decisions under Part B or E, that's 

followed by 5,976 final decisions. 

We've also made 2,336 lump sum 

payments and while it's not on the agenda or my 

notes here, I just wanted to highlight the work 

of our staff in conjunction with making payments 

in certain situations, specific to a circumstance 

that occurred on Friday. Just to show you the 

dedication of the Department of Labor staff in 

facilitating payments, we had a gentleman who had 

filed a claim for inclusion in a Special Exposure 

Cohort. We found out from his attorney that he 

had gone into palliative care, hospice care and 

we were asked to expedite our process to get his 

decision made and hopefully get a payment to him 

and his family on Friday. 
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Just to give you an understanding of 

what was involved, we had staff across the 

country working to make a Part B decision that 

awarded $150,000 to this gentleman. We also did a 

separate decision sequence including all the 

development steps needed to get an impairment 

award to him, all of which occurred on Friday. 

This includes the issuance of a 

recommended decision, our processing to a final 

decision and processing an expedited payment. 

This involved well in excess of a dozen 

individuals throughout our program and it 

reflects the dedication that our staff has in 

making sure that when we are in a position to get 

payments out to terminal individuals, that we are 

able to do that. Unfortunately, this payee passed 

away on Monday. So, a very timely action on our 

part and I just wanted to highlight the work of 

the many Claims Examiners, hearing 

representatives and fiscal folks that were 

contributing to making that happen and I think 

it's important for the Board to understand these 
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are staff with our program that really went out 

of their way to basically stop, drop and get this 

done. So, it's just a reflection of the work 

ethic of our folks. So I thought I'd highlight 

that for the Board.

I also wanted to run through some of 

our outreach activities. We do recurring webinar 

series. They are online kinds of educational 

experiences that we do for the public. Anyone can 

join them. We actually have our staff participate 

in many of these, where our staff are more than 

welcome to join and hear about program updates. 

These are things that any Board member can 

actually register for and they're maintained in 

our outreach calendar online through our main 

website. 

For the past few outreach activities 

that we've done since the start of the year, we 

did a presentation on authorized representative 

services and the expectations of folks providing 

client services for our claimants. We did an 

exposure and causation presumptive standard 
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discussion with the public and just talking a 

little bit about that process and many of those 

things that we're going to be talking about this

week or the Board will be talking about today and 

tomorrow. 

We also provided an update on some 

changes that are occurring with our medical 

pharmacy benefit program. Then we reviewed and 

had a webinar on all the available tools and 

resources that are available to claimants to 

facilitate getting their claims through our 

process. 

We did several interagency joint 

outreach events; we did three. One was held in 

North Las Vegas in February. This was followed by 

another one in Pahrump, Nevada and then we had a 

very large event in Oak Ridge, Tennessee in April 

that I attended. It was a combination of an 

authorized representative workshop, where we're 

talking to authorized representatives about this, 

the processes that are involved with case 

adjudication. That was followed up by an outreach 
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event for claimants to come in and meet with 

staff and facilitate solutions to any case issues 

that they had. 

So again, now that we're sort of postCOVID, we are definitely getting back into the 

outreach process and really trying to work with 

our claimants and their representatives and 

educating those folks about our program and the 

steps needed to get the cases through our case 

adjudication process. 

Just some really quick technology and 

information management updates. As you know, we 

have an energy case management system or energy 

compensation system that sort of is how we track 

case management activities in cases. This is 

constantly being updated and I've just got a 

couple of bullet points here that we have been 

doing a lot of work in developing out our medical 

benefit adjudication resources in that tool. 

They've made several changes to how we manage and 

track medical benefit claims and that's been a 

major part of the effort of our ECS development 
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team.

Some other things that have occurred 

with regard to our electronic document portal, we 

used to have a file size limitation that has been 

removed. We can now take much larger electronic 

submissions and upload that documentation in the 

case file. We've really been pushing hard to 

integrate digital submissions for different kinds 

of forms. We now have the ability to have 

claimants and their attorneys or authorized 

representatives filing our EE-1 which is the 

initiated claim form for employees or EE-2 for 

survivors. Our employment history form is now 

digitally able to be submitted. We work on adding 

the ability to complete medical reimbursement 

forms, the 915 and the 957 forms. We're also 

seeing a lot of use and a lot of uptick in our 

EN-20, which is our payment processing form. That 

was added last year, but we are seeing a really 

good use of that process and that capability by 

claimants. 

Just some real quick numbers. Since 
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the beginning of the quarter, we've had over 900 

electronically submitted EN-20s, which is 

fabulous because that enables us to make payments 

much more quickly and much more securely. So, 

we're really trying to promote the use of these 

digitally submitted forms. It just makes our 

process a lot more productive and efficient and 

it also is producing good effects for our 

claimants because we're able to move things along 

much more quickly.

Moving on to my usual presentation on 

policy and procedural updates. I saw on the 

agenda that there will be a discussion about our 

latest Procedure Manual update, so I'll just 

cover some of the highlights here. Now that we 

have moved to this new post-COVID world, we have 

restricted or eliminated a process that used to 

require face-to-face examinations. We allow for 

some telemedicine opportunities, but we feel that 

with the end of COVID, we need to return back to 

that face-to-face requirement for medical 

benefits. 
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The allowance for telemedicine 

appointments was granted through May 11th. That's 

when the COVID public health emergency ended 

officially. I think there was some preemptive 

elimination of those restrictions going back with 

some announcements from the President's office, 

but as far as the program is concerned, we've now 

gone back to what existed previously, whereby if 

individuals are seeking medical benefits, such as 

home and residential healthcare, they really do 

need to have that face-to-face engagement with 

their physicians to assess the extent of their 

medical need for those types of services. That 

was published in a directive put out by the 

program so that was made available to the public.

We've also issued a Circular, this is 

just an update that was required by OWCP or it 

was affiliated with some things that were going 

on with regard to making sure that we have a 

process for notifying the public about any kinds 

of prescription medications that the program has 

determined to have no medical efficacy. While 
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this process exists, we have not actually 

identified any of these prescription medications, 

but we now have the platform to exclude those 

kinds of medications that are found to not have 

any kind of medical purpose or efficacy.

That Circular, 2301, actually 

describes the process by which we would evaluate 

and make those kinds of public notifications on 

excluded medications.

Our Procedure Manual update, our last 

one, I'm certain you guys are going to take some 

time to talk about this. It's on the agenda, but 

just some things that I think are important for 

the Board to be aware of. We did incorporate 

changes to our industrial hygiene reporting on 

exposure levels language. That was something that 

was actually issued as a bulletin, but was 

incorporated into the last publication of the 

Procedure Manual. 

We also had some changes to our 

standards for evaluating silicosis claims under 

Part B. We used to have a restriction with regard 
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to when mining of tunnels stopped at facilities 

in Nevada, specific to the Nevada Test Site, but 

through some feedback from the Board and, I 

think, some other feedback that we received from 

stakeholders, we went back and took a look at 

whether or not there was continuing mining of 

tunnels related to experiments involving atomic 

weapons at the Nevada Test Site after 1992. We 

did find that that was the case so that date was 

removed from our procedures and we have gone back 

and reevaluated many cases impacted by that, are 

in the process right now of evaluating those 

cases and reopening any cases that we think are 

potentially impacted by that change. 

There is a whole series of other 

changes that we made to the Procedure Manual, but 

most of those are primarily administrative in 

nature and if there are any other questions, I'm 

certain that those will come up during the 

Board's agenda item, talking about the Procedure 

Manual.

I also saw that the Board is going to 
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be talking about the Department of Labor's 

response to recommendations, so I'm going to hold 

off on discussing that until the Board has had an 

opportunity to take a look at that and ask any 

questions that they have. Specific to this 

question of individuals that had reason to be 

working throughout a facility and the Department 

of Labor had gotten questions about this in the 

past and we responded a few times on that, I 

think it's going to be a topic of discussion 

later that we can certainly cover.

With regard to the Site Exposure 

Matrices, just some very quick highlights from 

our Paragon and Site Exposure Matrices team. 

They've received over 28 SEM email inquiries and 

eight public internet accessible inquiries. That 

information is generally going to be speaking to 

any kind of questions that our staff has about

site issues or questions or submissions from the 

public about different kinds of Site Profile 

changes or issues and that demonstrates that we 

have this mechanism for the public to submit 
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information that they would like Paragon to 

consider in changing information that's available 

in the Site Exposure Matrices or adding new 

information to the Site Exposure Matrices.

We've had in the past, I think this is 

from November until April of 2023, some of the 

big sites that we have had a lot of updates, 

major site profile updates included the S-50 

facility in Oak Ridge, the Thermal Diffusion 

Plant, Savannah River, the uranium mill in 

Lakeview, Oregon, I think, Connecticut Aircraft 

Nuclear Engine Laboratory, Canoga Avenue Facility 

and the Portsmouth Gaseous Diffusion Plant.

As the Board is aware, we do these 

freezes where we have to basically freeze our 

internal Site Exposure Matrices and have it go 

through an evaluation by the Department of Energy 

to ensure there are no classification issues. 

Freeze 24 occurred in November 2022 and was 

available the following month. The next freeze 

was just conducted in May of this year, this 

month, and we're getting ready to publish that 
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for the public.

Our current inventory in the Site 

Exposure Matrices as far as toxic substances are 

concerned, we now have information on 16,741 

toxic substances used at 139 DOE sites. So, as 

you can imagine, that's a pretty extensive amount 

of information about the types of materials that 

were being used at these sites that are currently 

maintained in the Site Exposure Matrices and I'm 

sure there will be further discussion about that 

by the Working Group on that.

At the end of April 2023, the SEM 

Library contained over 27,000 documents related 

to the information that is communicated out in 

the Site Exposure Matrices. The SEM library 

contains records which include documents not 

stored electronically, such as classified 

documents and other material that is used to 

provide and inform the site exposure information 

that's available to the public.

I will highlight just that Paragon was 

a major contributor to that change in our 
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procedure with regard to information about the 

mining of tunnels at the Nevada Test Site, so 

they did a lot of the leg work and looking at 

information that is available about the type of 

activities that are going on. The type of 

experimentation and tunneling that's going on 

actually relates to non-critical kinds of testing 

that's going on, but it basically is affiliated 

with the stewardship program that's being run by 

the Department of Energy just to ensure that the 

components of atomic weapons are usable. So, 

that's why that change occurred. 

We also made a change to our SEM data 

that I thought the Board would be interested in 

hearing about. We have updated information about 

how information is reported out on silicosis. We 

changed the way that that information is reported 

to make it a little less complicated. We took it 

and basically changed how it was presented. There 

were different classifications of types of 

silicosis in the Site Exposure Matrices. They 

were all listed out distinctly. We combined all 
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of those under the health effect of silicosis so 

that would reduce the likelihood of any kind of 

improper search outcomes by our staff and it 

would hopefully allow for the public to have a

better understanding of silicosis and the 

different types of aliases for that disease. So, 

a lot of work going on with regard to our Site 

Exposure Matrices.

Again, I've already mentioned this, 

but we did eliminate this telemedicine allowance 

that existed during the COVID emergency. We have 

returned back to the face-to-face medical 

assessment requirement for medical benefits and 

residential healthcare. We've gone back to that, 

that's actually in place now and our Medical 

Benefit Examiners are now in response to cases 

expecting that claimants will now have to go in 

to meet with their physicians so that we can get 

a good understanding of the extent of healthcare 

needs by our claimants.

Another big change that has occurred 

is that we are moving to a Prescription Benefit 
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Manager for handling and processing of 

prescription medications. Existing claimant 

beneficiaries are going to be receiving a new 

medical benefit card that has updated pharmacy 

benefit manager numbers, so that information is 

going to be really helpful for claimants. We're 

hoping that this new process, and I think it will 

produce really good efficiencies for making sure 

that folks are getting timely authorizations and 

quick reimbursements for prescription 

medications.

So those are the updates that I am 

providing for the program. Again, I will be 

available throughout the week to answer any 

questions or issues that come up from the Board. 

I'm looking forward to hearing and listening in 

on the discussions. Dr. Markowitz, I am sending 

it back to you.

CHAIR MARKOWITZ: Thank you.

MR. VANCE: Unless there are any 

questions or comments.

CHAIR MARKOWITZ: Great, thank you, Mr. 
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Vance. To the Board members, any comments or 

questions for Mr. Vance? I have some, but I'll 

let other people go first. Online, anybody? No? 

Okay, Mr. Vance, just a couple of questions. A 

lot of claims in the first three months of this 

year, about a thousand a month, have I got that 

right, 2,902, I think in three months? And a lot 

--

(Simultaneous speaking.) 

MR. VANCE: -- from our Resource 

Centers alone it's been in excess of 200 claims a 

week, so it's been a lot.

CHAIR MARKOWITZ: And a lot of 

referrals to the Industrial Hygienist for 

analysis of exposure --

MR. VANCE: Yes.

CHAIR MARKOWITZ: About 1,200. Of the 

roughly 3,000 claims in the first three months, 

how many of them were radiation only as opposed 

to involving Part B, Part E within the 

jurisdiction of the Board?

MR. VANCE: Well, I don't have that 
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information right in front of me, but we can 

certainly take a look at getting that 

information, but you can see by the, if anybody 

jotted it down, for that same period we had 1,252 

NIOSH referrals, so those would be specific to 

Part B radiation cancer claims, if you wanted to 

take a look at that portion compared to the 2,900 

cases in total we received. But, Dr. Markowitz, 

we'd have to get that specific information for 

you. 

CHAIR MARKOWITZ: No, no, that's good 

enough because that lets us know there were 

roughly 1,800 claims that would come in for Part 

E or Part B, but non-radiation related. Of those 

1,800, there were about 1,200 referrals to the 

Industrial Hygienist so that means just crudely 

about two out of every three claims that came in 

earlier this year were referred to the Industrial 

Hygienist for reports, which I think is useful to 

know in terms of our discussion about the 

industrial hygiene work.

A note on the silicosis clarification 
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at the Nevada Test Site, actually the issue of 

the post '92 exposure and eligibility for 

silicosis claims was raised by a public commenter 

to this Board at or just prior to the last 

meeting. And --

MR. VANCE: All I can say is that's why 

I listen in because that was a question that I 

had raised with my staff when I saw that and we 

took the initiative based on that public comment 

to take a harder look at that and I think the 

Board did ask a question of the Department about 

it. So, that was what motivated us to take a look 

at that and that just is a reflection of our 

participation during these meetings, so that we 

can hear any issues that we think are relevant

and important for us to take a look at from the 

public comments.

CHAIR MARKOWITZ: Thank you, so that 

really sends a message to the public commenters 

that we listen, that the Department of Labor 

listens and by all means, add your comments.

I have a question about -- we're going 
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to talk more about the Site Exposure Matrices, 

but it's obviously a dynamic process, right, 

where the SEM is updated periodically across the 

complex. I'm sure it's a challenging process. As 

you learn new things about exposures at various 

sites, you add toxins or add certain links within 

the SEM, then you have claims that were submitted 

previously, perhaps years previously, that were 

in some cases declined because there wasn't an 

exposure-disease link found. But now with the new 

information, actually it's conceivable that you 

might or those links might be reversed and that 

with the new information those claims might be 

accepted, might have been accepted, if that 

information was known earlier. 

So, the question is then how to 

develop a system whereby those earlier declined 

claims can be looked at once again for the 

validity of the claim. I know it's a challenging 

question and I'm just wondering what the current 

Department's thinking is about that.

MR. VANCE: Yes, we provided a written 
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response to that question and I know that the 

Board had presented a series of questions about 

the Site Exposure Matrices, and we responded in 

writing to this particular question. I can just 

sort of summarize and say that that kind of 

comparative analysis would require information to 

be captured during case adjudication that would 

allow us to identify those types of circumstances 

and, unfortunately, that kind of data capture or 

that information about the rationale or the 

information that is reported in the Site Exposure 

Matrices that's applied in a case file that could 

potentially change in the future, that 

information is just not available in the way that 

we manage our case adjudication process. So, it 

is a very difficult challenge. We don't have a 

system in place right now where we can go back 

and do that type of robust evaluation of the 

impact that changes have within the Site Exposure 

Matrices on case files. 

Where it is possible for us to do some 

sort of backfill operation where we go back and 
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take a look at cases potentially impacted by 

different policies and procedures, we do do that. 

For example, we were able to do that for denied 

cases on silicosis because we were looking for 

any case that had employment after or on 1992. We 

were looking at the impact, potentially looking 

at that for reopening that case to revisit that 

and potentially look at whether that case could 

be found compensable. We were concurrently 

looking at silicosis cases because we were also 

looking at changes that we had done last year 

with regard to a change to our presumptive 

standard. 

So, the Department of Labor will 

initiate reviews of previously denied cases where 

we have the information that allows us to do 

that, unfortunately the information that we have 

for the Site Exposure Matrices changes just is 

not something that we maintain that kind of data 

in ECS that would allow for us to do that kind of 

comparative analysis.

CHAIR MARKOWITZ: Right, I remember 
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that written response actually. By the way, I 

just want to thank you for those responses. The 

Board submitted an information request around the 

SEM with essentially a series of questions two 

weeks ago or less than two weeks ago and the 

Department produced detailed written responses in 

a very timely way. Thank you very much for that. 

It seems to me though that it's at a 

minimum unfortunate, maybe even unfair, that 

claimants, as the SEM has improved and new 

information is acquired, that claimants whose 

claims were previously denied because in part 

that information wasn't available, that it is now 

up to them to somehow track the improvements in 

the SEM and to consider whether their claim might 

now be accepted and resubmit a claim. The onus 

being on the claimant to do that seems burdensome 

and unrealistic. 

I understand that the data of the 

claims system is not set up in a way that allows 

you to do that, and I don't have an answer for 

this because I know it's a complicated problem, 
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but I just wonder whether it's a problem that 

deserves additional thinking and maybe some 

creativity to figure out how claimants who may 

now have a valid claim because new information 

has been obtained can be informed about that 

possibility and their claim be reconsidered in a 

way that doesn't leave it entirely up to the 

claimant, if I make myself understandable.

Other comments or questions? Okay, so 

let's move on then. We're ahead of schedule, 

that's good.

We're going to talk about the Working 

Group on "Significance." I just want to take a 

moment if I could to set the stage for this 

discussion, in particular for the public to see 

where this comes from and what it means. So in 

the claims evaluation process, the claimant 

submits information about what they did at the 

DOE complex. They submit a form that details 

their jobs, the years, the tasks, what exposures 

they recall and then they undergo a 

questionnaire, an Occupational Health 
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Questionnaire. You may hear that summarized by us 

as the OHQ, which is done that obtains additional 

information about their exposures. 

That is sent along to the Claims 

Examiner who, together having reviewed medical 

information, medical records also obtained for 

the claim, then does an analysis or evaluation 

through the Site Exposure Matrix to learn more 

about what that person might have been exposed to 

and quite commonly now that information is sent 

to an Industrial Hygienist for their analysis 

about the meaning of that, of what's know about 

exposure for that person in that claim. 

That Industrial Hygienist produces a 

report that is often sent then by the claim 

examiner along with a series of questions and 

accepted facts to a contract medical consultant, 

a CMC, a physician consultant who then weighs in 

on the issue of causation. 

So, this issue of causation we're 

going to discuss is did this person's exposures 

at the complex cause, contribute or aggravate 
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their disease and there's a standard set out by 

the Act, which we'll go over. So this discussion 

is how the industrial hygiene and the medical 

input, how that is obtained, how it's assembled, 

how it's interpreted in terms of making causation 

decisions, which ultimately determine, in large 

part, whether the claim is accepted or not. So 

with that, let me turn it over to Dr. Cloeren, 

who's going to lead this discussion. 

MEMBER CLOEREN: Thank you. So, a small 

group of us met to discuss this and came up with 

the following slides to just sort of help guide 

our discussion. Next slide.

I think the first thing is the word 

significant is not insignificant. It's a really 

important word. It's actually used in the Act and 

so you can see from the definition from the Act 

itself that it's at least as likely as not that 

an exposure to a toxic substance at a DOE 

facility was a significant factor in aggravating, 

contributing to or causing the death of such 

employee.
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We're not proposing getting rid of the 

word. The word is just really important, but it 

is important to understand the meaning of it and 

there are multiple different meanings of it. Next 

slide. 

So in the newest version of the 

Procedure Manual, the word appears 99 times, but 

there are two different technical contexts in the 

Manual. One of them relates to the assessment of 

exposure which is typically done by the 

Industrial Hygienist and then the second use of 

it relates to the determination of causation. So, 

there are two different meanings and the use of 

the word can be misinterpreted kind of depending 

on your role and your perspective. Next slide.

We thought looking it up in the 

dictionary might help and so what Merriam-Webster 

says about significant, one of the definitions is 

of a noticeably or measurably large amount. We 

think that this kind of correlates with the 

industrial hygiene definition, right? So, this is 

related to exposure, high amount. Next.
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But the word also can mean having or 

likely to have influence or effect, important. So 

that definition relates to causation 

determinations. Then finally, the last definition 

kind of goes along with the Act definition, 

right? Probably caused by something more than 

mere chance. So, you can see there are three 

different definitions and so when somebody's 

reading the word, they may have in their head one 

of these definitions which may not be meant by 

the person that is using the word. Next slide.

The current procedural guidance tells 

the Industrial Hygienist to review various 

factors related to exposure and then to 

characterize the exposure as significant high, 

significant moderate, significant low, incidental 

and then elsewhere there's a category of 

somewhere between incidental and significant so 

not incidental, but not quite significant low, 

and then no exposure. So, these are the six 

different characterizations that the Industrial 

Hygienist may apply to their exposure 
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determination. Next.

But the complexity of characterizing 

an exposure needs to account for and honestly in 

the industrial hygiene reports, a lot of this is 

often captured. The type of exposure, you know, 

whether it's a direct exposure to the person 

doing the work, if the person was a bystander and 

so near something that they were exposed to or 

that the exposure happened regularly in their 

work area. The route of exposure, is it by 

inhalation, ingestion or skin absorption. The 

intensity of exposure, so the concentration, the 

level if you will. How often is it happening? How 

long does it happen? So, is it every day but just 

for a minute or is it every day for six hours out 

of the day. Then, how long during the period of 

the person's work did it happen? If they worked 

there 10 years, was this ongoing during that 

time? 

It's also important to document for 

some diseases the calendar timing between the 

exposure and the disease diagnosis because of the 
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concept of latency. Some diseases take a while 

for the exposure to have the disease effect and 

cancer is the classic example of that. And then 

also, use of personal protective equipment, 

engineering controls and other mitigating 

factors. 

The Procedure Manual advises the 

Industrial Hygienist to take into account these 

things when making a decision about significant 

high versus incidental, et cetera, but these 

details are not always presented in a way that 

the next consumer of the industrial hygiene 

report can see. So, the details can be important 

to determining causation but they may be obscured 

when applying this determination of significant 

high, moderate, low, et cetera. Next slide. 

Our proposed recommendations are that 

the industrial hygiene reports more clearly 

include the basic metrics of exposure signs, 

which include intensity, route, frequency and 

duration, that they can be divided by facility 

and job because that's important too. People have 
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different jobs in different facilities as 

relevant to the claim. And that we need some help 

understanding what is meant by the six different 

exposure categories in the context of these, and 

we're going to give you some examples of what we 

mean here. 

We also think it's important to 

clarify how a single metric of exposure, for 

example, significant low can be applied when 

somebody has multiple medical conditions that may 

be related to different exposures. Next slide. 

We're proposing something along these 

lines, it doesn't have to be this, but this is an 

example of an Exposure Assessment Form, could be 

used that would help the next consumer of the 

information, which would include in most cases a 

CMC, in all cases the Claims Examiner, in some 

cases the claimant, the treating doctor, et 

cetera, the Former Worker Program sometimes, but 

that the exposures be characterized with some 

precision, as much precision as the data allow, 

the type of exposure, route, intensity, et cetera 
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and we have on the right kind of a key for what 

we mean here. And also, it would be really 

helpful if the Industrial Hygienist included 

where in the claim file they found the 

information, so that others can look at that and 

refer back to that information.

The next slide actually shows a 

fictional case, kind of an example, and I think 

it could be helpful to kind of go through this. 

In this case, I do a lot of work for the Former 

Worker Program dealing with construction workers, 

so this is a case of a pipefitter, which is a 

construction job, at Hanford claiming COPD and to 

show you how this type of form could be used to 

provide more information. Also, where it gets 

kind of challenging applying the grouped 

categories without the details. 

Asbestos in this case would have been 

direct. Inhalation is the route. The Industrial 

Hygienist in this case may have said that the 

intensity was low during the time period '87 to 

'97, that the frequency was a few times a month, 
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but for 10 years and that the person usually wore 

protective equipment and you can see that in this 

fictional case, there's information in the claim 

file on page 180 about that. Exposure two would 

be cement dust. So, you can go through here, the 

intensity would be medium, daily during the same 

time period, but never using PPE. Exposure three 

would be silica and it wouldn't be very often. 

The exposure would be low, et cetera and you can 

see welding fumes, the same.

So for each of these, they may have a 

different characterization of whether it's 

significant high, significant moderate, et 

cetera. So if we take just cement as an example, 

the fact that the intensity is medium, somebody 

might say that that's significant moderate, 

right? But it was daily and so others of us might 

say that that's significant high and we don't 

know how those categories are being applied right 

not. One of our recommendations is that we get 

some clarity about how significant high, 

significant moderate, et cetera, are applied in 
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relation to these and that there be, if needed, 

some instructions that include how do you 

incorporate the frequency, the duration, the 

intensity in making those decisions.

That's it, the end of the slides. Time 

for discussion.

CHAIR MARKOWITZ: Okay, Board 

discussion. Anybody want to make a comment or 

pursue this discussion? Oh, by the way, if you're 

present if you wouldn't mind just putting up your 

name card so I can see who wants to speak and for 

those of you online just indicate somehow or jump 

in. Dr. Bowman?

MEMBER BOWMAN: Yes, thank you. I just 

want to echo and affirm the message. The slides

sort of went over the long discussion that we had 

as a Working Group relating to the importance of 

having reports that are going to those that are 

eventually going to be making the decision of 

causation of having the information of these 

various specific individual metrics of exposure. 

Basically, it comes back to the potential that 
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individual metrics can have importance in whether 

or not they are contributing to a disease that 

relates to these individual metrics. For example, 

if the route, even if it's high, if the route is 

wrong, it may not be ever associated with the 

disease, but you could have an exposure that is 

very low, but in the correct route would be 

deemed highly associated with that disease. The 

concern of applying a significance overall that 

doesn't divide this out could lead to inaccuracy 

in the decisions of the medical professionals if 

they are just looking at that terminology. So, 

that, I think, rests back to the importance of 

that.

I don't think we're saying as a group 

that the word, significance, isn't important to 

be used at all and I think, Marianne, you 

addressed that in your remarks already, but as 

divided into the routes of exposure because I can 

just imagine someone assessing the 

epidemiological data of disease risk related to 

exposures, they'll know routes. They'll know 
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levels. They'll know durations that are 

associated with these risks in making a final 

decision at least on their recommendation about 

an association. Without that kind of information, 

there could be decisions that are not right and 

so this is why I definitely support this idea of 

keeping these metrics. These are the basic 

metrics that IH, Industrial Hygienists, would use 

anyway. These is how exposure science is done. I 

do find this to be very important so I just 

wanted to affirm what you were saying.

CHAIR MARKOWITZ: I have a comment. 

Actually, this slide portrays something really 

interesting. Suppose the claimant had submitted a 

claim for two conditions asbestosis and scarring 

of the lungs due to asbestos and separately for 

COPD, two distinct, mostly distinct, pulmonary 

conditions. Usually we're looking at a slide 

which hopefully contains the Industrial 

Hygienist's best version of the facts of the 

case, right, the exposure facts. For asbestosis, 

frankly there's only one of these columns which 
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is relevant which is exposure number one that 

column. We see this pipefitter during that period 

'87 to '97 had low exposure inhalation a few 

times a month and the duration for 10 years. So, 

if you were to attach then an interpretation of 

how significant that is, you might not call that 

moderate or high significant. You might call that 

significant low because it was only a few times a 

month and it was consider low intensity during 

that era. With reference to asbestosis, if the IH 

takes these facts a step further and assigns it a 

significance description, that's likely where 

they'd end up.

On the other hand if COPD is the 

condition being claimed, then you'd probably not 

look so much at the asbestos column, you'd look 

at cement, you'd look at welding fumes. Cement 

was daily, it was moderate exposure over a 10-

year period, or you have welding which was two to 

three times per week so pretty frequent at a 

moderate level, so clearly that would end up at a 

moderate significance or maybe even significant 
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high. The point is that these facts are 

condition-dependent, whatever the claimant is 

submitting for, they aren't universal across 

conditions, the interpretation of those depends 

on what condition that is being examined in terms 

of the claim. So, that significance description 

is going to vary depending on what the condition 

being claimed is, so that's one aspect of, I 

think, a problematic aspect in terms of 

translating these facts into a significance 

description. Yes?

MEMBER SPLETT: Gail Splett. One of the 

things that I really like about this is as a 

layperson reading through some of the files, it 

sometimes was very difficult to follow the IHs' 

thought processes and the documentation seemed to 

say, yes, I think, or, no, I don't, I'm sure that 

there's a process behind that, but this documents 

that process and makes it easy. Again, I liked 

the comment about for the follow on folks who are 

reviewing that file whether it's a CMC or the 

Claims Examiner or the FAB, they've got this all 
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out in writing.

The other question is who would fill 

out this form? Would this be the Claims Examiner 

filling out the top with the overall exposure 

then the types filled out by the IH? Would the 

claimant be consulted on any of this? Is there an 

interview to get all of these or is this 

something the Claims Examiner would fill out or 

the IH or all of the above?

CHAIR MARKOWITZ: Dr. Bowman?

MEMBER BOWMAN: Sure, I'll take a stab 

at that. I think others within the Working Group 

could contribute to that as well. The basic 

premise of the recommendation is that these 

metrics of exposure are what all the IH's should 

be doing anyway and they're just being obscured 

by this pulling together. So, these should all be 

coming in anyway so I would think this would be 

done by the IH in that context, but I'll let 

others chime in if there's something I'm missing 

about that.

MEMBER CLOEREN: I think, Gail, the top 
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information would come from the statement of 

accepted facts that would go from the CE to the 

IH, I think. 

That's what would make sense. The 

actual exposures of those top four that you're 

showing here are the ones that right now that the 

Claims Examiner is sending the top seven over 

that they would identify that from their review. 

Then, the IH would fill in the specific data, but 

again, I really like your comment about that 

thought process being available for follow on 

reviewers. It's very well done, very impressive.

CHAIR MARKOWITZ: Let me just add one 

before we move on. The IH has to take an 

independent look at the EE-3, the Occupational 

History Report, from the claimant and a look at 

the Occupational Health Questionnaire and not 

rely entirely on the Claims Examiner's 

interpretation or distillation of the exposure 

because it's the IH who understands best what 

those forms and what that questionnaire contains, 

not the Claims Examiner, however good they might 
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be, it's not their training. So yes, the 

statement of accepted facts can send along 

whatever number of toxins, but the IH really 

needs to take a look at the primary information 

in order to get it right. Mr. Key?

MEMBER KEY: Yes, I agree with your 

statement, Dr. Markowitz. The Claims Examiners by 

and large have no historical knowledge of these 

jobs at these sites. And also I appreciate Gail's 

comment; an interview process with the claimant 

needs to be incorporated simply because at a lot 

of the SCC's and it was the intent of Congress, 

who came up with the language. It is as likely as 

not that that exposure was the reason for 

causation of the illness or disease because at 

many sites, records and documentation and 

personal monitoring was never performed up until 

mid-1990's going into 2000.

CHAIR MARKOWITZ: Dr. Van Dyke?

MEMBER VAN DYKE: Mike Van Dyke. Adding 

onto Dr. Bowman's comments, you know, this is how 

the Industrial Hygienist is thinking about this. 
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I don't think this is a significant change to how 

an Industrial Hygienist is doing things. I really 

think this is just a language thing that 

Industrial Hygienists and occupational medicine 

physicians don't necessarily speak exactly the 

same language, so really making sure that the 

Industrial Hygienist is getting across what they 

mean to the occupational medicine physician. 

We see these words in the reports from 

the IHs, but then it gets distilled down into 

those significant low, significant medium, 

significant high sort of words that make less 

sense. I think it's just a clarification of the 

language more than anything else.

Now, if I was to really go a bridge 

too far, I would say we also don't know what low, 

medium and high necessarily mean, but I think 

that's a conversation for a different day.

CHAIR MARKOWITZ: Oh, you mean 

tomorrow? Maybe not, we'll see. Just a quick 

comment on that and then we'll move on. The fact 

is, the industrial hygiene reports currently 
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generally contain a table of data about their 

understanding of the exposure and what we're 

proposing or what this slide proposes is just an 

amplification of that table. It's considers a 

broader set of varieties, more systemically and 

perhaps more clearly. There are some people in 

the room who want to speak, but I do want to give 

the opportunity for board members online if 

anybody wants to say something, now's a good 

time. 

MEMBER FRIEDMAN-JIMENEZ: This is 

George Friedman-Jimenez. One comment. The 

question of the work flow, how does the work flow 

occur? Who fills in what part of the table, I 

think is an important one and we may want to 

distinguish the different fields in the table by 

who should fill them out. For example, maybe the 

Claims Examiner or even a clerical person can 

fill out all of the demographic information, the 

name of the condition that we're considering and 

we need to discuss if a separate exposure 

assessment needs to be done for each medical 
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condition. Spoiler, I would say yes it does, but 

I think we can discuss that. The point is that I 

think it needs to be an iterative process and the 

people that know the toxicology and the causation 

fill out part of the form, but people that are 

doing the administrative set up can fill out a 

good part of the form also. I think it would be 

useful to define what order the fields should be 

filled out and by whom.

CHAIR MARKOWITZ: Dr. Cloeren?

MEMBER CLOEREN: Thanks. I have a 

couple of followup thoughts. One is, I believe, 

I'd have to check the Procedure Manual, but I 

believe that there is flexibility for the 

Industrial Hygienist to identify additional 

exposures that were not included in the Claims 

Examiner's statement of accepted facts. If that's 

not the case, then that definitely should be 

something that is permitted for the Industrial 

Hygienist to use their knowledge to identify 

things that maybe were not identified by the 

claimant or included. So, that's comment one.
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CHAIR MARKOWITZ: Okay, so that's a 

factual question and, Mr. Vance, if you could 

weigh in on that. I'm not sure whether you heard 

it, but the Industrial Hygienist gets the 

statement of accepted facts from the Claims 

Examiner, includes a number of toxins for which 

some research in the SEM has been done. Is the 

Industrial Hygienist allowed to modify or add to 

the list of toxins that are looked at in terms of 

their IH report?

MR. VANCE: Yeah, I'm going to start by 

saying generally speaking the Industrial 

Hygienists are going to be responding to 

questions about individual exposures identified 

by the Claims Examiner. Now there is a process 

that we have that allows a Claims Examiner to 

reach out to an Industrial Hygienist when they 

have a multitude of exposures that they have to 

sort of prioritize or identify in order to sort 

of filter it down to something of the best 

targeted toxins to evaluate and that's a prescreening process. But, if the Claims Examiner is 
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looking at information in a case file and they're 

pretty confident that they've targeted two, 

three, four, five or whatever number of toxins 

and they're the ones that decide these are the 

ones that I want the Industrial Hygienist to 

profile, then the Industrial Hygienist is going 

to profile those toxins. They're not going to go 

back and reassess the case file to determine are 

there other ones in there.

Is it possible that an Industrial 

Hygienist would identify some glaring anomaly 

that really should be brought to the attention of 

the Claims Examiner? Yes, that mechanism does 

exist where the contract Industrial Hygienist 

would reach out to our federal IH person and then 

that person would feed comments or questions back 

to the Claims Examiner. But I would say generally 

speaking if there is no pre-screen, or if the 

Claims Examiner asks the IH to do sort of a 

preliminary review of what toxins to profile, the 

Claims Examiner has the authority and the 

discretion to identify the toxins that they want 
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profiled and then the Industrial Hygienist will 

respond to those referrals that identify the 

toxins the CE is exploring.

One other quick comment from the 

slides, our Industrial Hygienists would not 

classify somebody as having no exposure. Their 

lowest level of profiling that they would do is 

generally going to be incidental levels of 

exposure. I think that that might be getting 

confused a little bit about the initial screening 

process that the Claims Examiner goes through, 

because if they cannot identify any targeted 

toxins that are related to a particular disease, 

that's where it could possibly stop, but the 

Industrial Hygienists are never going to be in a 

position to say no exposure. I've talked with our 

Industrial Hygienists team and they would never 

do that. The lowest they can ever go is 

incidental. Hopefully that answers your question 

and I just wanted to make that extra comment as 

well.

CHAIR MARKOWITZ: Thank you. Ms. 
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Splett?

MEMBER SPLETT: One of the things, and 

not foregoing the conversation on claimants, I 

reviewed a file where the Industrial Hygienist 

responded to the elements that the Claims 

Examiner sent, but did not respond to any of the 

exposures that the claimant had identified. So, 

it could even be some sort of subset those toxins 

or exposures that the Claims Examiner in the 

statement of accepted facts, plus an interview or 

even reviewing the OHQ, which in this particular 

claimant, was not. They didn't look at any of 

those elements, neither did the IH. The IH was 

not requested to do so. It was only requested to 

look at the ones that the Claims Examiner 

identified.

CHAIR MARKOWITZ: Ms. Whitten?

MEMBER WHITTEN: Thank you. The few 

claims that I have reviewed for respiratory, the 

IH reports to me and to a claimant might seem 

confusing and vague. Usually they'll just say 

they had incidental significant exposures, but I 
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like this because if, in fact, they do get 

denied, they can request their complete case 

file. This will be in it and then they can have 

it reviewed to see if it's actual factual for 

their job that they did back in the '80s and 

'90s.

CHAIR MARKOWITZ: Okay, Dr. Cloeren?

MEMBER CLOEREN: I have an interesting 

example of a case. I don't actually remember the 

claim condition, it might have been COPD, but the 

job title of this person did not match with 

welding fumes at all in the SEM and the claimant 

identified welding fumes. The doctor identified 

welding fumes, but the job title didn't show 

welding as part of the job. So that was kind of 

dismissed and when I talked with the claimant, 

whatever their job title was, it wasn't what they 

did and they actually had documentation. They 

kept documentation of 10,000 welds or something 

like that and so they were able to follow up with 

documentation of that and get acceptance, but if 

the Industrial Hygienist had reviewed the OHQ or 
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interviewed the person, then that probably would 

not have been denied. That would have been an 

opportunity for the IH to let the Claims Examiner 

know that there may be something missing in the 

SOAF. That's just sort of a concrete example of a 

real case.

CHAIR MARKOWITZ: Other comments or 

questions? Steve Markowitz, I'd be surprised if 

the Industrial Hygienist didn't look at the OHQ 

and the EE-3 when writing their report. I'd be 

surprised if they relied wholly on the statement 

of accepted facts by the Claims Examiner. I don't 

know what actually happens, but it strikes me if 

you're a professional and you're weighing in on 

an important issue to people, in terms of 

understanding their exposures, that you'd want to 

and you'd need to look at what very limited 

primary data you have, which is the EE-3 and the 

OHQ, in order to do that. It would be nice in the 

IH report if in the listed references, things 

they looked at, if they included whether they 

looked at the EE-3 or the OHQ, because I don't 
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think that's currently done that listing and I 

think it would be helpful to understand the 

process. Dr. Van Dyke?

MEMBER VAN DYKE: To respond to that 

question, in the cases that I reviewed, I do 

think that the Industrial Hygienists look at that 

EE-3 and OHQ, in terms of describing the nature, 

extent and duration of the exposure, but I don't 

think they're going to add exposures from that, 

that they weren't asked to classify. I think the 

reason is because they rely on, and this is just 

my interpretation, they rely on the Claims 

Examiner to really identify those exposures that 

kind of fit that intersection of their job and 

their disease. I think the Claims Examiner 

identifies those and forwards those on to the IH. 

So, the IH, I don't think they're going to add 

too many exposures because they're not asked to.

MEMBER FRIEDMAN-JIMENEZ: This is 

George Friedman-Jimenez. I have a question, how 

is it determined which exposures to focus on? For
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example, does the Claims Examiner review, given 

the medical condition that is being requested for 

compensation, does the Claims Examiner review the 

SEM for listed substances that may cause that 

medical condition or do they respond to the 

exposures that the treating physician thinks may 

be related or are related or do they review the 

OHQ and look for exposures that may be toxic and 

see if they are related to the condition? What is 

the general process that actually happens? What 

is the work flow here and how does this list of 

exposure one, exposure two, exposure three, 

exposure four get generated? Because I think 

that's a key element in the overall process of 

determining causation and this is the first step 

that sounds to me that it doesn't really get 

reconsidered very often if something is missed on 

the first step. I've reviewed a number of cases 

in the past that a critical exposure was missed 

and wasn't listed and wasn't assessed and then 

when you go back and look for it, it's actually 

there sometimes. So, I'm asking the question what 
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is the reality, how does this list get generated? 

The list of exposures that get assessed.

CHAIR MARKOWITZ: Well, so for reality 

questions, we turn those over to Mr. Vance, so if 

you could address that.

MR. VANCE: That's a good way to put 

it. Let me put everybody in the shoes of a Claims 

Examiner. Let's start by saying, Dr. FriedmanJimenez, the answer is all of the above. I'm a 

claims adjudicator, we have 1,207 cases that are 

going to an Industrial Hygienist, but the role of 

the Claims Examiner is to facilitate the 

adjudication of a case and we have to maintain 

some expectation of pursuing these cases in a 

timely manner. 

The Procedure Manual lays out a 

process by which the Claims Examiner is going to 

start looking at this and say okay, what is my 

condition that I'm evaluating here? Has it been 

established as a diagnosed condition? So, for the 

case on the form in front of you, it's COPD. One 

of the most common kinds of diseases that we 
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actually encounter.

The Claims Examiner begins by 

evaluating all the available information about 

the type of activities, work processes, labor, 

whatever information is available about that 

individual in the case. They're going to look at 

the EE-1. They're going to look at the EE-3 which 

is the employment history data. They're going to 

look at the Occupational History Questionnaire 

and hopefully get a feeling of the framework of 

the case. They're going to look at the document 

acquisition information, that's the information 

coming in from the site.

Once they have a good, robust 

understanding of the picture of this employee 

then they begin looking at what can I tell about 

COPD and this employee. So, we know that they are 

a pipefitter at Hanford. The first thing they're 

going to look for is what do we know about 

exposures that are linked to the pipefitting 

labor category at Hanford. They're going to go to 

the Site Exposure Matrices. The Site Exposure 
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Matrices is going to start identifying 

information that creates that relational 

connection to specific types of labor, work 

activities, and specific substances related to 

COPD. More than likely for a pipefitter, you're 

going to come up with this complement of 

exposures. You're going to see asbestos, cement, 

silicon dioxide and maybe welding fumes.

The next thing that they're going to 

do, is they're going to say okay, do I have an 

abundance of exposures for a pipefitter related 

to COPD? Because what we have to do is try to 

prioritize these cases, because each one of these 

represents a time commitment. The more work that 

you're asking to be done by the Industrial 

Hygienists, the slower it goes. We try to 

maintain this seven toxins or this framework of 

seven toxins, but we can go beyond that. The 

Claims Examiner in this particular case would 

probably get these identified and targeted toxins 

from the Site Exposure Matrices. More than 

likely, a lot of this information may be 
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complementary to information from the employment 

records. In other words, the employee could be 

reporting incidents that involve asbestos or they 

could be talking about activities relating to 

cement dust or silicon dioxide or just dust and 

other types of materials that they were working 

on. All of this information gets fed into that 

exposure profile worksheet that the Claims 

Examiners try to construct to frame out what they 

want the Industrial Hygienist to look at. 

It really is a matter of filtering 

down to try to prioritize the targeted toxins, 

that's the role of the Claims Examiner. This 

information for COPD is generally going to be 

reliant on the Site Exposure Matrices, but we 

could have situations where you're dealing with a 

unique disease, a unique circumstance where we 

have nothing in the Site Exposure Matrices, so 

then the Claims Examiner will turn to other 

resources, such as like what is in the 

occupational history records that we're getting 

from DOE? What is that a physician is saying is 
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an exposure that the doctor feels is a concern 

for this particular disease? 

For example, one that I was looking at 

last week was degenerative disk disease. A 

physician was arguing that lead exposure is 

contributing to this arthritic kind of process. 

Because the physician is identifying lead as your 

targeted toxic substance, that's the one that the 

CE would go to the Industrial Hygienist and say 

what was the extent of this individual's exposure 

to lead? So that when we go back to the 

physician, we can say here's better, more 

accurate data for you to inform your opinion 

because that's the function of this proposal that 

the Board is making, is you're trying to make 

sure that the physician who is looking at the 

question of significance is accurately informed 

so that their opinion can be weighed as 

probative. 

So the function of the Industrial 

Hygienist process is to give that physician a 

good clear understanding of what it is that's 
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going on so just keep that in mind. A physician 

can look at this in 30 seconds and say okay, this 

is what I get from this and here's my take on it, 

but other physicians will spend more time looking 

at it, but our process is set up to give that 

physician, whoever it may be, either the 

claimant's physician or an internal CMC, the 

opportunity to see that accurate characterization 

of exposure. So hopefully that answered your 

question.

CHAIR MARKOWITZ: Thank you. There 

seems to be a general agreement among the Board 

members about this form that we're looking at, 

about the contents, how it represents some 

improvement from what's being done presently. 

There are questions about who exactly fills out 

what part of the form. There's a question on

intensity about what low, medium, high actually 

means. We might refer to these elements here as 

facts, but in fact, they are really the IH 

interpretations of what the record shows. 

Having general agreement on this, then 
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the next question becomes the translation of 

these metrics, these findings into question of 

significant exposure. This is the incidental, 

more than incidental but less than significant, 

significant low, medium, high and we've sort of 

acknowledged that if that additional step, 

perhaps a bridge too far as Dr. Van Dyke says, is 

made that it at least should be medical 

condition-specific because the same metrics mean 

different things for different claimed 

conditions. 

But setting that aside for the moment, 

what do we think of this moving to the next step 

and then sorting this into levels of 

significance? That process, whether it needs to 

be altered in any sense, defined better or the 

like. Can we focus on that for a couple of 

minutes? I'm sure we can. Dr. Bowman?

MEMBER BOWMAN: Thank you. I'll kick 

this off. This will be a lively conversation I am 

sure. I think there is value if these 

terminologies are mapped onto the context of the 
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metrics that we identified that are sort of the 

key metrics in exposure science. At this point I 

don't have any strong objection to the use of the 

word significant if it's broken down by these key 

metrics. If an IH says that the intensity is 

significantly high or significantly low, I think 

that can have meaning and value to the next step. 

Where I think that meaning and value goes away is 

when it's all collapsed into a single assessment, 

where then the consideration by the physician is 

then not informed by those important metrics. So, 

I'll start there.

CHAIR MARKOWITZ: Dr. Van Dyke?

MEMBER VAN DYKE: I have significant 

concerns about that, yeah, lively. I mean we just 

broke it down into something that was more 

interpretable and now we're talking about rolling 

it back up into a word that we already said was 

not very interpretable. I think it can be done if 

that's what we have to do based on language in 

the Procedure Manual, language in the law, if we 

have to stick with these terms, but I think that 
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we've identified that these terms themselves 

cause a problem. I don't know if it's -- it's not 

as useful. I think this is more useful than 

significant high, medium or low, but that's just 

me being precise.

CHAIR MARKOWITZ: Dr. Bowman?

MEMBER BOWMAN: I'm sorry, just a point 

of clarity, Dr. Van Dyke. What I was saying is 

that under the category say intensity, what does 

low mean? Is it significant? I was not suggesting 

to roll it back up, I was just suggesting within 

the context of some of these metrics like 

frequency. In intensity, it makes some sense 

because you can apply the word low, medium and 

high, it sort of implies intensity and it 

actually gets away from and doesn't really imply 

route. 

Is that route a significant route? 

That's more of a determination from a physician 

not a determination from an IH. I guess I was 

just saying that you could apply that term to the 

intensity at least and maybe one could talk about 
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if the frequency was very high and this is a 

significant frequency, it makes less sense once 

you pull away from that. 

I think that's part of the problem 

with the terminology, is when you force 

significance to low, medium, high, it seems to 

focus all on just that one metric, intensity, 

where sometimes the other metrics are far more 

important.

CHAIR MARKOWITZ: Mr. Key?

MEMBER KEY: Yeah, to go along with 

what Dr. Bowman was saying, on the line of 

intensity, how are these captured? By the CE, by 

the Industrial Hygienist, or is this in fact 

information that the claimant has provided? If 

the claimant is not interviewed and provided an 

opportunity to express the intensity of each of 

these jobs, then clearly the other players are 

going to miss his/her actual exposure.

CHAIR MARKOWITZ: Just at least a 

partial response to that, I think what happens 

now and what we're proposing or what we're 
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looking at doesn't disagree with that, which is 

it's the Industrial Hygienist who assigns it as 

low, medium, high in terms of intensity, how 

intense was the exposure. 

That's drawn from whatever the Claims 

Examiner provides. It's drawn hopefully from a 

reading of the OHQ and the EE-3, but it's the IH 

who is assigning that word, if that answers your 

question. Board members on the phone, anyone want 

to make a comment here?

MEMBER FRIEDMAN-JIMENEZ: Yes, George 

Friedman-Jimenez. I have a concern about the use 

of the words significant and incidental, that 

they really do depend on the disease that we're 

talking about. They carry some implication of 

causation, so let's take for example, isocyanate 

exposure, inhalation exposure and let's say we're 

considering two diseases, say work-related 

asthma. So you have isocyanate exposure two or 

three times in a five-year employment period at 

let's say a medium intensity level. That would be 

generally considered an incidental exposure, in 
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passing, something that is about as low as you 

could practically imagine. 

However, it certainly could be a 

causal exposure for work-related asthma because 

we're talking about a sensitization process that 

causes someone to develop a new disease that they 

didn't have before and it can be caused by one or 

a few medium level exposures to isocyanate. 

Whereas if we're talking about let's say dementia 

or some kind of longstanding neurotoxic disorder 

and considering isocyanate as a solvent or a 

neurotoxin, that would be an incidental exposure 

that there's just no way that it would be enough 

to be causal for that outcome. 

So, incidental exposure could be a 

causal exposure for one disease and not a causal 

exposure for another disease, so that kind of 

breaks the one-to-one mapping between these four 

metrics and the significance level. 

And that's my concern, that what is a 

significant exposure for one outcome for a given 

toxin may not be a significant level of exposure 
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for a different outcome. So in that case, I think 

it's better for the CMC or the people who are 

judging causation to have access to essentially 

the raw data or a summary of the raw data like 

there is in this table that they can see just 

what kind of exposure occurred, when did it occur 

and at what levels. 

And then they use their own knowledge 

of that particular disease and causation process 

to determine whether it's likely or not that it 

could have been causal in the question of 

determining work-related causation. So, that's my 

concern with keeping the use of the words 

significant and incidental as part of strictly 

the exposure assessment process.

CHAIR MARKOWITZ: Steve Markowitz. So, 

that I think, is an argument for recommending 

that what we're looking at now and those of you 

who can't see it, we're looking at our proposed 

Exposure Assessment Form that details for a given 

person what their route of exposure was, 

intensity, frequency for a set of toxins. 
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This Industrial Hygienist's version of 

the facts of the case, that their assessment ends 

here and that that information then returns to 

the Claims Examiner ultimately, most likely, sent 

to the physician for them to determine the 

significance of these exposures. That's, I think, 

one argument or one position that we could take. 

Leave it here and move it on, right? An 

alternative position is that we might accept or 

recommend changes in the Procedure Manual in this 

classification of incidental, significant low, 

significant medium, significant high, et cetera. 

So, the question is obviously there is 

some degree of discomfort in the way it currently 

reads, the Procedure Manual, the current process, 

the question is, is there any alternative 

proposal or some modified significance assessment 

that the Board members feel that we ought to 

examine and consider.

MEMBER FRIEDMAN-JIMENEZ: This is 

George Friedman-Jimenez again. Yes, I think there 

is and getting back to what John Vance presented, 
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we're talking about impressive numbers of 

decisions that have to be made every month by a 

very limited number of staff, so we need 

something that works smoothly and can be done 

fairly quickly. So I think the idea of 

presumptions is something that we should talk 

about. 

There are many cases in which there is 

a clear one-to-one mapping, it's sort of a linear 

dose response, right? Where a larger amount of 

exposure leads to a much higher probability of 

causation than a lower level of exposure. It's 

not idiosyncratic like in asthma, for example, 

with allergens. So, there is a subset of 

exposures which is probably a fairly large 

subset, for which I think that the old method 

could work. 

In other words, big exposure, higher 

probability of causation, significant. I just 

think the word significant kind of clouds things, 

but I think that there is room for a presumptionbased decision making system that will work for 
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the majority maybe of exposure-disease pairs and 

will really expedite the decision making for many 

or maybe most of the claimants, but there's an 

important subset of people for which the exposure 

needs to be considered much more carefully and 

there is a lot of room for making mistakes in 

these subtle cases. 

Ad so I think we should talk about 

setting up presumptions for the most obvious 

cases and one by one, case by case evaluations of 

exposure and causation for the ones that don't 

meet the presumptions of the most extreme and 

obvious causal relationships.

CHAIR MARKOWITZ: This is Steve 

Markowitz. Yes, so just a brief history of this 

in terms of the Board work. The Department has 

invited us to assist them with developing 

presumptions between exposure and disease that 

would expedite claims, in particular, claims 

acceptance, but claims decision making and over

the last six years or so, we have helped them 

expand and develop presumptions which I think has 
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been very useful to the Department. I think Mr. 

Vance would agree with that. 

So the presumptions are sort of a 

separate stream of decision making because there 

you're not looking at the individual's exposures 

and their condition, it's a more expedited way. 

So, this separate stream here that we're trying 

to help improve, I think we should try to assist 

in developing further presumptions or expand the 

current presumptions, but for a moment, we're 

looking at the non-presumption stream of decision 

making, right, where the individual facts are 

really seriously considered and looked at. 

MR. VANCE: Dr. Markowitz, can I jump 

in real quick and just add a comment for 

consideration?

CHAIR MARKOWITZ: Sure.

MR. VANCE: So I understand the 

conversation about the definition of 

significance. Now, I'm going to add a complexity 

because that's what I'm really good at here. The 

comment about the presumptions is very good 
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because we struggled with recommendations from 

the Board before about this very question of 

significance and how to characterize exposure. 

Remember that many of the causation presumptions 

require a level of significant exposure, not 

significant low, moderate or high, just 

significant. So the question would be, does this 

document represent significant exposure, because 

you remember as part of our process, you want the 

Claims Examiners looking at any kind of input 

that they're getting and saying this triggers one 

of those causation standards. 

So the comment I will just have is 

just remember however the IH is looking at this, 

you're still going to have to figure out how to 

integrate what the IH is doing in this type of 

scenario to trigger that presumptive standard. So 

you're still going to struggle with this 

significance question because if our presumptions 

are based around significant exposure, what is 

that versus not significant and will this process 

that's being discussed by the Board address that 
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administrative reality that we have with regard 

to those causation presumptions or are you going 

to be changing those presumptions in some way to 

identify that the level of intensity needs to be 

low, moderate or high or whatever you're going to 

use in your characterization. 

So the impact that you are talking 

about on this needs to be considered in 

conjunction with those presumptive standards that 

require that level of significant exposure and 

that's how we characterize all those 

presumptions. So I think this is a good point 

that was discussed, but I wanted to make that and 

highlight that, there is sometimes a bleedover 

from what the Industrial Hygienist is doing in 

their assessments to our application of those 

presumptive standards, so it's just a good point 

I wanted to make.

MEMBER FRIEDMAN-JIMENEZ: Can I 

respond?

CHAIR MARKOWITZ: Sure. Dr. FriedmanJimenez?
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MEMBER FRIEDMAN-JIMENEZ: The 

presumptions often use the word significant, but 

there's a circular logic here because really what 

they mean by significant is sufficient to cause 

the disease. That's the meaning of significant 

that they're using in the presumption. So the 

presumptions I'm thinking about are the ones, for 

example, I think solvents and hearing loss. It 

requires a certain number of years of exposure to 

a particular TCE or whatever the chemical is and 

it's an objectively defined level of exposure 

that doesn't use the word significant, but I 

think using the word significant there's a danger 

that it really means that when you use the word 

significant, you're assigning the possibility 

that that chemical can cause that disease 

implicitly. 

So the question is, who assigns that? 

Who makes that causation judgment? Is it the IH, 

should it be the CMC, should it be someone that 

has training in causation analysis or could it be 

a Claims Examiner that's just looking at the Site 
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Exposure Matrix and seeing the association that 

is summarized there? That's why I'm uncomfortable 

with the word significant because of this dual 

meaning that it has and it's kind of slippery and 

hard to pin down. And if we mean causation or 

probability of causation informally then we 

should be talking about that. 

But we see all the problems of that in 

the Radiation Board. That doesn't entirely solve 

the issue either and we don't have any hope of 

getting that clean as they do with measured level 

of ionizing radiation because we don't have any 

kind of measurements that are anywhere near that 

level of precision for these chemicals. 

So that's my discomfort with using the 

word significant even in the presumptions, but 

most presumptions, I think, could be stated in an 

objective way. The problem is that you're sort of 

skimming off the top of the most obvious causal 

relations and you leave those that are more 

difficult cases and I want to make sure that 

those more difficult cases or that second stream, 
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as Steve Markowitz is calling it, is dealt with 

appropriately and that's where I think this table 

really could be a great tool for the people that 

are judging the causation, which is usually the 

CMC, I think.

CHAIR MARKOWITZ: Dr. Cloeren?

MEMBER CLOEREN: I'd be very interested 

in hearing from the IH contractor, what their 

instructions are to the IHs about how to make the 

determination of the significant categories, if 

they have specific -- we don't know how they make 

their decision whether something is significant 

high, significant moderate, et cetera and if 

there are any kind of written instructions to the 

Industrial Hygienists, I think it would be really 

useful to know what those instructions are.

CHAIR MARKOWITZ: Dr. Bowman?

MEMBER BOWMAN: Just a point of 

clarification if I understood what John Vance was 

saying. Do I understand that our presumptions as 

currently set are based on the IH reporting the 

exposure level as being significant or not and so 
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that is happening at the level of the IH? Do I 

understand that correctly? 

But then if because of what we talked 

about earlier that if this link to causation 

pushes that decision down to the CMC that seems 

to be counter to the idea of trying to have 

presumptions save time, if you then have to go 

one more step in the process before you can meet 

a presumption. Just a little bit of 

clarification, John, did I understand you 

correctly? 

MR. VANCE: Yes, so let me give you an 

example. Let's say I'm a Claims Examiner, I'm 

sitting down looking at this case for COPD. And I 

think that we have a presumptive standard that 

applies for asbestos, so the Claims Examiner 

wants to know can I accept this case knowing what 

I know about COPD and the presumption for 

asbestos exposure? 

The Claims Examiner is going to want 

to have this question answered. Just for this 

table example, if you're in column exposure 
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number one, the Claims Examiner wants to know 

does this mean that this person had a significant 

exposure to asbestos. They need to have that 

answer because if the answer is yes and they meet 

whatever other conditions exist for the 

presumption, they can accept this case. 

Without that kind of understanding, a 

CE could look at this and say do I know that this 

characterization of low exposure, is that 

significant or is it not significant? Because if 

it's not significant, I can't trigger the 

presumption. At that point, I'm going to go 

forward with getting a medical opinion about 

this. That's what I'm trying to get to, is that 

the Claims Examiner has guidance that says for a 

presumption to be triggered, there needs to be a 

finding of significant exposure. 

My point is just that column one, does 

this mean significant exposure or not. The Claims 

Examiner is told yes it does, the presumption 

could likely be triggered and we would approve 

that case. If not, this case is going to a 
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physician to look at everything to make a 

judgment on the causation. Does that explain it a 

little bit better? 

MEMBER BOWMAN: Yes, thank you.

CHAIR MARKOWITZ: Dr. Van Dyke?

MEMBER VAN DYKE: See, I knew the word 

significant was coming back somehow. I mean I 

think if we break it down really simply, all of 

these exposures here are significant according to 

the current guidance, because you really only 

have a choice of significant versus incidental. 

So I think that could be easy to 

provide guidance on that, but I think for the 

CMC, significant is kind of meaningless in this 

context. I think they still need this kind of 

advice to make decisions, but from an 

administrative reason, there's always some reason 

right, from an administrative reason if we need 

to say significant, you only have two choices, 

significant and incidental, then that makes it 

pretty simple.

CHAIR MARKOWITZ: Dr. Bowman?
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MEMBER BOWMAN: I think there are 

three, it's significant, incidental or between 

them.

MEMBER VAN DYKE: Everybody always 

wants a third choice, don't they? 

CHAIR MARKOWITZ: Other comments? Yes, 

Dr. Vlahovich?

MEMBER VLAHOVICH: Kevin Vlahovich. Is 

there consideration of aggravating or mitigating 

factors or is that only done at the CMC level? 

For instance, people have underlying conditions 

that might make them have a different outcome at 

a different level of exposure?

CHAIR MARKOWITZ: I think that's a Mr. 

Vance question.

MR. VANCE: Well, remember you're going 

to always look at what it is that you're being 

told by a physician. So, in other words, let me 

see if I can say this in a way that makes sense. 

Physicians can offer whatever opinion that they 

want in conjunction with the information that 

they're provided by the Department of Labor or 
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just their own understanding of the circumstances 

of what the employee did and exposures that they 

had. The conditions that the physician can 

consider in rendering a causation opinion can 

certainly consider aggravating or contributing 

effects. 

In other words, let's say I'm a doctor 

looking at this form in front of me. The 

presumption was not triggered. The point that 

everybody is making is true, different physicians 

will interpret what this means in their 

professional judgment. I'm a physician and I'm 

going to look at this and say I certainly don't 

think that the level of exposure here caused COPD 

for this employee, but this level of exposure 

over this duration of time certainly could have 

contributed to the development of COPD. 

Now you could also have other 

physicians look at this and in their own 

professional judgment say, I'm not convinced that 

that duration of exposure at these levels could 

have caused, contributed or aggravated the 
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disease. That's the challenge. Different 

physicians are going to look at the same material 

and potentially come back with different 

viewpoints, that's the real challenge. 

No matter how you try to define it, 

it's ultimately up to the physicians' 

interpretation and their understanding of the 

circumstances of the case to reach an opinion of 

contribution, aggravation or cause. So, this is 

where you get to the meat of the challenge with 

this program is that each one of these 

components, whether you're talking about the 

Industrial Hygienist looking at the situation and 

the answer to the question from before was they 

inform their opinions based on the information 

that we provide in the Procedure Manual and the 

application of their own professional judgment. 

The same dynamic exists for a 

physician looking at this. They will look at the 

data. They will interpret it however they feel is 

most appropriate to inform their decision and 

then they will render an opinion as to whether or 
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not they think the data is enough to trigger that 

threshold of at least as likely as not that 

whatever exposure occurred was a significant 

factor in causing, attributing or aggravating a 

disease, that's your challenge right there. 

MEMBER FRIEDMAN-JIMENEZ: This is 

George Friedman-Jimenez. A question for Mr. 

Vance, do you think it's realistic to think about 

rewriting the presumptions in a way that they're 

based only on objective or on well-defined 

categories that would appear in this chart and 

removing the term significant? 

So therefore, the presumption would be 

based on the intensity, the route of exposure, 

the frequency, duration, latency period and this 

is done for the World Trade Center covered 

conditions. It is problematic in that it can miss 

a lot of actual causation, but you can set it up 

so that it really doesn't over-diagnose 

causation, it just misses a lot. 

`So the question is then you have to 

have a backup stream, people that don't make the 
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presumptions then get evaluated according to a 

more labor intensive process using these defined 

metrics of exposure rather than just being made 

at the claims evaluator level based on whether 

they meet the presumptions or not. 

Do you think those presumptions could 

be rewritten without the use of the word 

significant, but using these metrics of exposure 

that can be plugged in and quickly determined by 

the Claims Examiners in many of the cases?

MR. VANCE: I'll answer that as 

politically carefully as I possibly can. The 

answer to that question is anything will be 

considered by the Department of Labor; however, I 

would not want to be part of the Board's Work 

Group reworking every single one of those 

presumptions to fit into the dynamic that you're 

talking about with the application of this form 

because the Department of Labor would need to 

have some sort of expertise to be able to do 

that. 

So I would just say it would certainly 
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be something that could be considered by the 

Department of Labor, but you're talking about a 

pretty intensive research project to look at how 

you would take those existing presumptions and 

all the medical health science that's behind that 

and trying to fit it into the application of what 

you're looking at in the form in front of you.

MEMBER FRIEDMAN-JIMENEZ: I believe 

this has been done for some of the presumptions, 

for example, the hearing loss and chemical 

exposure. I'm going to look at that right now in 

the Procedure Manual, but I don't think that this 

is entirely new, but yes, I understand. 

The question is, where are you going 

to put your resources in terms of expertise and 

time, evaluating individual cases or setting up 

presumption algorithms that can be applied at the 

Claims Examiner level for a reasonable minority 

or maybe even majority of cases? So that's the 

question that I'm raising.

MR. VANCE: The other question would be 

what kind of administrative efficacy would doing 
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this have? Because I think from where I sit, just 

my own personal viewpoint, the existing 

presumptive standards work fairly well. They 

integrate into our claim adjudication process 

fairly easily and if you would change that 

dynamic, to what benefit are you trying to 

accomplish as far as changing that or what would 

you hope to accomplish in that process by adding 

complexity or more exacting information to the 

case adjudication process? It's that question of 

time versus resources kind of thing.

MEMBER FRIEDMAN-JIMENEZ: Yes, I'm 

looking now at the hearing loss section and I 

don't see the word significant in here. They just 

say at least 10 consecutive years of verified 

employment exposed to carbon disulfide, 

ethylbenzene, et cetera, a list of chemicals. And 

the CE could assign this presumption based on 

what's in the exposure chart, the table that 

we're proposing. I think it has been done for 

hearing loss and the question is, if it's worth 

the time and effort to do it for others. 
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You know, your same experts that are 

trained in causation analysis can do this work 

either at an individual case level or at an 

algorithm presumption development level or both 

and I think that you can think about what is the 

best use of your resources. I know these are all 

very limited resources. What's the best use of 

your resources in terms of getting the work done 

and done as accurately as possible.

CHAIR MARKOWITZ: It's 11:01, Steve 

Markowitz. We're going to take a break for 15 

minutes. So, we'll be back at 11:15, thank you.

(Whereupon, the above-entitled matter 

went off the record at 11:01 a.m. and resumed at 

11:19 a.m.)

CHAIR MARKOWITZ: Okay, we're going to 

get started again. So one of the discussion 

points is, since the Board seems to have general 

agreement on this expanded Exposure Assessment 

Form as a way for the Industrial Hygienists to 

document in the report what they found, but, on 

the other hand, we don't really have agreement on 
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a recommendation regarding any change in how the 

program addresses the issue of significance by 

the Industrial Hygienist, that one way to move 

forward is to consider a recommendation that just 

looks at the Exposure Assessment Form, and to 

postpone further discussion regarding the 

Industrial Hygienist's use of that information to 

determine significance for either tomorrow or for 

another meeting, or perhaps send it back to the 

working group to look at the issue of the 

interaction with presumptions to make sure that 

we're not harming claimants in any way.

And so that seems -- that strikes me 

as a useful way to move forward over the next few 

minutes. Any comments on that? Yes, Dr. Bowman?

MEMBER BOWMAN: I'm just going to 

comment that I agree with your recommendation 

about that. We certainly -- the intent of the 

working group was about having better data to 

inform the medical, and not about trying to do 

anything about the presumption. So I agree with 

what you're saying.
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CHAIR MARKOWITZ: Okay. And this 

doesn't really concede that, you know, the 

current description of how significance is used 

is correct or optimal. It's just saying we'll 

take a further look at that and see whether 

actually we have any useful advice for the 

Department. 

So, I think we may have a draft 

recommendation. I think we may have one, Dr. 

Bowman.

MEMBER BOWMAN: Yes, we may. I believe 

I've sent it, and if it could be put up on the 

board.

CHAIR MARKOWITZ: Great. Thank you. 

For the Board members on Webex, can you see the 

screen here?

MEMBER BOWMAN: I would be happy to 

read this, if that would help.

CHAIR MARKOWITZ: Yeah, good idea. And 

remember there are public who may be in this 

meeting who maybe can't see the screen, so it's 

important that we read it.
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MEMBER BOWMAN: So, I'll do that now. 

So, the Board recommends that exposure 

assessments made by Industrial Hygienists be 

enhanced to specifically refer to the basic 

metrics of exposure science: 1) exposure 

intensity, 2) exposure route, 3) exposure 

frequency, and 4) exposure duration.

These elements can have distinct value 

in determining causation. The IH would select the 

relevant metrics for each case based on best 

available data. These metrics may further be 

divided by the facility and job under which they 

occurred for a claimant, as relevant. 

We recommend that DOL adopt an IH 

Exposure Assessment Form that puts the work of 

the IH in the context of these four basic metrics 

of exposure. Further details and rationale are 

contained in the May 2023 working group report to 

the full Board, along with an example form that 

was in the PowerPoint presentation given by Dr. 

Cloeren at the meeting on May 17th, 2023.

CHAIR MARKOWITZ: Steve Markowitz. Our 
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recommendations are always accompanied by 

rationales. I suggest we strike the last sentence 

and just put whatever we want in the rationale in 

reference to a form. Unless this is the only 

place where we refer to the form, then I agree 

with you that we should include that in the 

recommendation. But the details and rationale, 

working group report, all that goes in the 

rationale. Dr. Bowman?

MEMBER BOWMAN: Yeah, so, this is the 

only place in the recommendation where the form 

is referenced. So perhaps we would delete most of 

the sentence and start at the word "an example 

form" that was in the --

CHAIR MARKOWITZ: Yes. Well --

(Simultaneous speaking.)

CHAIR MARKOWITZ: We'd just say an 

example form is provided along with this 

recommendation.

MEMBER BOWMAN: Right.

CHAIR MARKOWITZ: Okay.

MEMBER BOWMAN: Okay, yeah, that's 
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fine.

CHAIR MARKOWITZ: Okay, so I have a 

question on line four, where it starts with --

well, the IH would select the relevant metrics 

for each case based on best available data, end 

of quote.

All right, is that saying that the IH 

selects from among the metrics on the form? Or 

do we believe the IH should, to the extent 

possible, complete -- provide all data for all of 

those metrics, to the extent possible?

We don't want them selecting from 

those metrics and deciding which ones they think 

should be addressed.

MEMBER BOWMAN: I would agree. I think 

the wording there should be altered.

CHAIR MARKOWITZ: Okay. Okay. Dr. Van 

Dyke?

MEMBER VAN DYKE: Mike Van Dyke. I 

think you could actually just delete that 

sentence.

MEMBER BOWMAN: I'm okay with that, as 
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well.

CHAIR MARKOWITZ: Okay. We're getting 

slimmer with every comment. Board members, Board 

members who are remote, if you have any comments 

or -- we're going to re-read this --

MEMBER FRIEDMAN-JIMENEZ: Yeah, George 

Friedman-Jimenez. I have a question that I'd like 

us to discuss. What do you do in the case that 

you have multiple medical conditions? For 

example, the case that I reviewed had prostate 

cancer, squamous cell carcinoma of the skin, and 

work-related asthma, question of work-related 

asthma?

So what exposures would be relevant? 

And how would the exposures be assessed? And 

should they be assessed all on one form, I guess 

with a limit of seven exposures for all three 

conditions? Or would it make more sense to have 

the exposure assessment specific to the medical 

condition? Because, you know, as we know, 

different medical conditions are caused by 

different chemicals, and different chemicals can 
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cause some conditions, but not others. So what's 

relevant for one medical condition is not 

relevant for another. 

So, that's the question I'm raising. 

How do we deal with multiple medical conditions 

that are all being proposed for compensation?

CHAIR MARKOWITZ: Kevin, could you 

bring up the form for a moment? I think the 

completion of this form is not -- doesn't depend 

or interact with what the claimed condition is. 

And so if a person has multiple conditions, this 

form isn't going to change. Correct me if I'm 

wrong. Because whether it's -- if you could just 

blow that up a little, yeah.

The frequency of their exposure to 

cement isn't going to change depending on whether 

we're looking at skin irritation or COPD. The 

frequency is the frequency of the work that the 

person did. This is true, I think, for all the 

other elements we're looking at. 

So I don't think the contents of this 

form changes depending on the condition. I think 
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the interpretation changes, for sure, and that's 

where they would get into the question of 

significance, whether it's the IH or the CMC. But 

the response isn't here. I don't see, George, how 

that changes or is dependent upon the condition.

MEMBER FRIEDMAN-JIMENEZ: Well, which 

exposure you assess does change. For example, 

what exposures are relevant to prostate cancer? 

Are they the same exposures that are relevant to 

skin cancer or to asthma? And I would say no. 

And so there -- different exposures would be 

relevant to different conditions. 

You know, for the most part, I think 

you're right that the intensity, frequency, route 

of exposure would be the same independent of the 

conditions, in most cases.

CHAIR MARKOWITZ: And I would agree 

with you that the toxins may differ depending on 

the condition. So the IH then has to determine 

whether there's one global assessment form for 

all the conditions or whether they have a 

specific form -- a form specific for a condition. 
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Dr. Cloeren?

MEMBER CLOEREN: I think the claimed 

condition up in the corner, if it happens that 

the exposures of interest are shared by a couple 

of medical conditions, you could put multiple 

medical conditions up there. And these are the 

same toxicants of interest. But a different form 

-- I agree with George, a different form would 

need to be completed if the toxicants are 

different.

CHAIR MARKOWITZ: Right. And so the 

question is: do we add that to the 

recommendation, to the text of the 

recommendation?

If you could give -- do you have a 

comment on the form or the recommendation? On 

the form? Good, go ahead.

MEMBER BOWMAN: Just a comment. I 

mean, I presume this is happening already under 

the context of the recommendation. And those 

might be the cases if there's so many conditions 

where that number might exceed seven.
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John Vance might be able to comment on 

that, but that would be -- if you get to seven, 

you haven't even touched the ones that would 

affect the other conditions being claimed. I 

would think that would be a case when more than 

seven would be given already.

MR. VANCE: Yes.

MEMBER BOWMAN: And so, not needed to 

change the recommendation.

MR. VANCE: Yeah, this is John Vance. 

Yes, that could, certainly, be a circumstance 

where you would be looking at more than seven. 

It's just going to depend on the dynamic of the 

case.

And then the information that would 

flow to the doctor would include all of the 

analysis that went into what toxic substances 

were being evaluated for what disease. Hopefully, 

that would be revealed in the Statement of 

Accepted Facts or the accompanying material that 

goes to the doctor for consideration.

Because the doctor is not just 
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receiving this assessment; they're also receiving 

all of the medical records that are relevant to 

the case. They are also getting information from 

the case file that's relevant to what they're 

being asked about on the opinion of causation.

CHAIR MARKOWITZ: Dr. Van Dyke?

MEMBER VAN DYKE: I think what we're 

talking about really is an upstream problem 

before we get to the form. And in terms of 

selecting the right exposures, we're not 

addressing that by the form, and we're not trying 

to address that by the form. 

I mean, I think it's, again, a 

discussion for another day. But I think focusing 

on really characterizing the exposures of the IH 

is given is where we're at.

CHAIR MARKOWITZ: But I think there's 

a simple solution here, which is to add to the 

recommendation that the toxins that are 

considered on this Exposure Assessment Form are 

those that are relevant to the medical condition 

being considered. And then the IH figures out 
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exactly how to do all that. But that would 

address that concern, I think, if we could go 

back to the recommendation.

Oh, okay. Oh, Mr. Catlin. There you 

are. Sorry.

MEMBER CATLIN: Yeah, Dr. Markowitz, I 

mean, I like that modification. My look at this 

is we're trying to be really clear and 

transparent about the exposure assessment and how 

that's being done, so that the claim examiner and 

the physician can be more clear on that. So, you 

know, whatever can be done to make these forms so 

they're more clear, rather than more -- than 

potentially confusing. So I like what you 

propose.

CHAIR MARKOWITZ: So if you could blow 

that up a little bit, because I just want to add 

a friendly amendment that -- if we could just 

write out the sentence first and then we'll see 

where it goes -- that the toxins that are 

considered on the Exposure Assessment Form are 

those that are relevant to this specific medical 
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condition for which the claimant is -- sorry.

MEMBER BOWMAN: I penned some, because 

it's easier to write it than to do it in my head.

CHAIR MARKOWITZ: Sure, go ahead.

MEMBER BOWMAN: I'll read it first, 

and then we can update it if there's agreement. 

The toxicants to be included on the 

form would be those determined relevant to the 

claimed medical conditions.

CHAIR MARKOWITZ: Sure, that's fine. 

Even better that it uses the word toxicants than 

toxins. So, you need to repeat that so Kevin can 

put it --

MEMBER BOWMAN: Yeah, so, the 

toxicants to be included on the form would be 

those determined relevant to the claimed medical 

conditions. And I would propose it become the 

second to last sentence.

CHAIR MARKOWITZ: Okay, so -- and, 

Kevin, if you could remove the three lines that 

are below. Yes. Okay, so I think we should reread this recommendation.
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Do we have another reader besides Dr. 

Bowman? I guess not, Dr. Bowman.

MEMBER BOWMAN: All right, I'm not 

shy. Was my reading not well? I could read 

slower or faster as --

CHAIR MARKOWITZ: It's good, it's 

good.

MEMBER BOWMAN: Okay. If you could 

blow it up a little bit. And, Steven, your head 

is slightly in the way. Sorry.

CHAIR MARKOWITZ: Sorry about that.

MEMBER BOWMAN: So, the current 

version, as just edited, reads: "the Board 

recommends that exposure assessments made by 

Industrial Hygienists be enhanced to specifically 

refer to the basic metrics of exposure science: 

1) exposure intensity, 2) exposure route, 3) 

exposure frequency, and 4) exposure duration.

"These elements can have distinct 

value in determining causation. These metrics may 

further be divided by the facility and job under 

which they occurred for a claimant, as relevant. 
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We recommend that DOL adopt an IH Exposure 

Assessment Form that puts the work of the IH in 

the context of these four basic metrics of 

exposure.

"The toxicants to be included on the 

form would be those determined relevant to the 

claimed medical conditions. An example form is 

provided with this recommendation."

CHAIR MARKOWITZ: Okay, is there a 

second to this recommendation?

MEMBER CLOEREN: Second.

CHAIR MARKOWITZ: Dr. Cloeren seconds 

it. Okay, it's open for discussion. Dr. 

Vlahovich, I think.

MEMBER VLAHOVICH: Kevin Vlahovich. My 

question is: who would determine which exposures 

are relevant to the medical condition?

CHAIR MARKOWITZ: Does anybody have a 

--

MEMBER FRIEDMAN-JIMENEZ: Yeah, this 

is George Friedman-Jimenez. Dr. Bowman and I were 

discussing this before the meeting. This is a 
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really key question. The decisions on which 

exposures to assess are really very important to 

the whole process. And, as the process is set up 

now, I'd say they seem to rely pretty heavily on 

the Site Exposure Matrix.

And I think, to a large degree, 

they're set up by the Claims Examiner. And we 

should discuss this. The completeness and the 

correctness of the Haz-Map database on which the 

Site Exposure Matrix is based is important. So we 

should discuss, I think, maybe this afternoon in 

the exposure matrix discussion, you know, how 

that's done and what is the information that we 

have on completeness and correctness of the HazMap database.

But I think that this is done, you 

know -- and Mr. Vance and I discussed it before -

- by a combination of processes, including the 

Site Exposure Matrix and the Claims Examiner, as 

well as the initial treating physician's proposed 

causal toxicant, and then the CMC and then the 

IH. 
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So, all of them have input into this, 

but it seems to me, from what Mr. Vance said this 

morning, that it's not very common that it gets 

reconsidered. In other words, if the IH thinks of 

an additional exposure that could cause the 

disease, they don't generally add that. 

Is that correct, Mr. Vance? That 

that's not commonly done?

MR. VANCE: Yeah, it's generally going 

to be -- the context of the referral is going to 

be what the Claims Examiner's asking the 

Industrial Hygienist to opine on. If the IH does 

see something that is noteworthy that they feel 

does need to be brought to the attention of the 

CE, that mechanism does exist.

CHAIR MARKOWITZ: Dr. Cloeren?

MEMBER FRIEDMAN-JIMENEZ: Yeah, 

typically, the CMC is the one that probably has 

the most broad overview on the causal literature, 

including the toxicology, the epidemiology, the 

medicine, as well as the exposure science. And 

the IH, to some degree, but maybe not as much as 
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the physician. So this is an important question, 

and I think we should discuss this.

CHAIR MARKOWITZ: Dr. Cloeren?

MEMBER CLOEREN: I think that there 

should be an easier mechanism for the Industrial 

Hygienist or the CMC to identify additional 

exposures. And that there should be kind of an 

explicit invitation to do that if there was 

something important missed.

CHAIR MARKOWITZ: Dr. Bowman?

MEMBER BOWMAN: I agree about the 

importance in the selection of the toxicants. 

They will -- they have a fundamental role in 

driving this, just like there's an importance in 

the further discussion about how significance is 

being assigned to the overall exposure.

But just in the context of our current 

discussion with this recommendation, I think 

those fall outside of the scope of this 

recommendation, and I would move that we maybe 

vote on this recommendation and open up the 

importance of discussing those items outside the 
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context of the recommendation.

CHAIR MARKOWITZ: Yeah. Steve 

Markowitz. I would agree with that. I agree about 

the importance of the question that the IH 

consider the proper set of exposures. But that's 

not what we're discussing here, and that is a 

longer discussion, a probably complicated 

discussion, which we should get to, but not at 

this moment. And if we were to pursue that now, 

it would railroad, actually, real consideration 

of this recommendation. 

So, is there further discussion about 

this particular recommendation?

Okay, is there any objection from 

people on -- from Board members on Webex to the 

separate consideration of this question that was 

just raised about the selection of toxicants? 

Can we set that aside for a separate discussion 

and recommendation?

MEMBER FRIEDMAN-JIMENEZ: Yes, I agree 

with Dr. Bowman on that. This is George.

CHAIR MARKOWITZ: If there's no 
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further discussion, then we will have a vote on 

this. Any Board members request a final reading 

of the recommendation or shall we go with what we 

have?

Then we turn it over to Ms. Rhoads for 

a vote.

MR. JANSEN: Actually, I'll record the 

vote. Dr. Bowman?

MEMBER BOWMAN: Yes.

MR. JANSEN: Mr. Catlin?

MEMBER CATLIN: Yes.

MR. JANSEN: Dr. Cloeren?

MEMBER CLOEREN: Yes.

MR. JANSEN: Dr. Friedman-Jimenez?

MEMBER FRIEDMAN-JIMENEZ: Yes.

MR. JANSEN: Dr. Markowitz?

CHAIR MARKOWITZ: Yes.

MR. JANSEN: Dr. Mikulski?

MEMBER MIKULKSI: Yes.

MR. JANSEN: Dr. Van Dyke?

MEMBER VAN DYKE: Yes.

MR. JANSEN: Dr. Vlahovich?
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MEMBER VLAHOVICH: Yes.

MR. JANSEN: Mr. Key?

MEMBER KEY: Yes.

MR. JANSEN: Ms. Splett?

MEMBER SPLETT: Yes.

MR. JANSEN: Ms. Whitten?

MEMBER WHITTEN: Yes.

MR. JANSEN: All yeses.

CHAIR MARKOWITZ: Okay, thank you. 

So these other -- these additional 

issues of selection of toxicants and the 

importance of significance we will postpone. If 

we have time this meeting to come back to this 

discussion, we will. Otherwise, I would suggest 

that we put that back into the working group for 

further work.

And now we're going to move on to the 

next topic, which is the Site Exposure Matrices. 

And just to review for a moment, the working 

group submitted a series of questions, requests 

for information. The Department provided in midFebruary a series of attachments from the 
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contractor regarding the operation of the Site 

Exposure Matrices. And then, over the last few 

days, provided additional information and 

responses to the questions that were asked. 

So we're not really going to review 

all that, but we're going to proceed further, and 

either address additional questions or areas that 

require clarification. 

So, Ms. Whitten?

MEMBER WHITTEN: Thank you. At our 

November Board meeting we were made aware that 

there was some information missing from the SEM.

So, since that time, we formed a 

subcommittee -- myself, Gail, and Lorna -- and we 

came up with some questions for Paragon. And we 

were hoping that they would be here at the 

meeting so that we could ask them, but instead 

they did send their responses to us. I think we 

got them last night. 

We do have some additional questions, 

though. And we were hoping we could get some 

answers today, maybe. I guess I'll start.
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The first one is, I was reviewing 

their standard operating procedure SEM03, Section 

3.5. And it mentions a closure spreadsheet. I 

don't know how they determine a site has met 

their closure data, and I don't know why it would 

be any different than their operational chemical 

listing, but we do have some examples. And I was 

hoping Kevin could pull one of them up for us on 

the SEM, kind of do a live showing of what we're 

dealing with.

So one of the issues that we were 

first noticed was 105-N Reactor building at 

Hanford, it was listed as a museum, and it only 

had a handful of chemicals on the SEM, whereas 

three, four, five years ago it had hundreds of 

chemicals. And, currently, it has, what, 12? 

Okay, go to Hanford. Okay, and then on 

the right, it will say "building information" 

about halfway down. All right, then arrow down to 

105-N. In 105 there's B, C, D, DR. That just 

means 105 means reactor building. So, if you 

scroll down a little bit, you'll see you there's 
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12 chemicals.

So, this was an operating nuclear 

reactor. It doesn't even list boron. It doesn't 

list graphite. And it used to list all of these 

chemicals, and I don't know where they went. I 

don't know who made the decision to delete them. 

And, also, if you go down a little bit 

farther, it will show the worksite process 

activities. So, my job -- I worked there for 12 

years. My job's not even listed on there. If you 

go back up to the top, there's many jobs not 

listed on there.

So you can go down to labor category 

and it will show you the only ones that are 

associated with that building. So, I mean, this 

kind of all goes back to the whole, how are the 

CEs going to get the toxic information to send to 

the IH if the list isn't even complete when they 

go and look up the building that somebody worked 

in for 25 years?

So, I don't know if Mr. Vance can 

answer what happened to all of that information. 
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And we can look at many, many other buildings. I 

have a whole stack of them here that are similar 

situation. Every single one of our reactor 

buildings has a different list of chemicals. And 

I don't know why that is because they were all 

pretty much cookie-cutter facilities.

But this is what Lorna and I came up 

with, and if she has something to add, go ahead.

MEMBER SPLETT: And this is Gail. I 

was interested in the Plutonium Finishing Plant 

because, obviously, anybody who's aware of 

Hanford knows that's a very, very significant 

facility and there was a major incident, what, in 

2018? It's not in the SEM. And it talks about 

the PFP being an active facility. It is now slab 

on grade. And it is not showing any of the D&D 

that's occurred in there, which, obviously, 

because of several things made national news. 

And I had talked to Mr. Lewis 

yesterday about whose responsibility is it to 

keep Paragon or DOL apprised of changes in the 

facility, as well as some of the information that 
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we have seen that has been deleted from the SEM 

at some point, as well as never been added.

One of the claims I reviewed, an 

individual worked in the building for 16 years 

and his job category was never listed, and 

accordingly did not get considered for those 

chemicals.

So it looks like it's a relatively 

generic, consistent problem. One of the things 

that the sub-team had talked about is having an 

assessment team go in and look, whether it's one 

facility or one site, and perhaps utilizing a 

subcontractor to do that. Or we turn to the 

Department of Energy and ask them to do that. 

I mean, it's clearly a large 

undertaking. There's no question about it. And 

we've also we talked about whether, Mr. Vance --

and I think it's the case, because I think I was 

the point of contact at Hanford. When they start 

out, they come out with a plan. Is there an 

overall plan for data capture for every facility?

MR. VANCE: Well, this is John Vance. 
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What I can say is that, you know, the Department 

of Labor and Paragon do do planning for data 

capture and collection of information.

Hanford is one of the sites that we 

have a huge amount of information on. I know it's 

one of the most -- the biggest site for which we 

have records. Like I would say in any other type 

of situation involving the Site Exposure 

Matrices, it's a data collection that is 

constantly being updated as we get new 

information.

As far as specific questions relating 

to why something is there or why it changed, that 

would be something that we would have to get that 

question and work with Paragon to try to 

understand what occurred. And we generally would 

be able to explain exactly the rationale for what 

changed in the Site Exposure Matrices. 

The other feature that I'll reiterate 

about the Site Exposure Matrices is that the 

information that populates the Site Exposure 

Matrices has to tie back to actual documentation 
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about the materials that were located at 

particular sites within Hanford or were involved 

with a work process that connects to employees 

that were at the site.

So, you know, we have a continually 

evolving process to collect information about all 

of these sites, and clearly it sounds like, you 

know, we need to continue to look at Hanford, 

which I know is an ongoing project for Paragon, 

not just for Hanford, but for a variety of 

different sites.

So I think we'll probably need to get 

that submitted as a specific question that we can 

then take to Paragon and ask them to give us a 

better understanding of what occurred.

CHAIR MARKOWITZ: Steve Markowitz. I 

have a question for Mr. Vance. So, if there's 

information that Ms. Whitten described that had 

been in the SEM removed from the SEM -- and 

probably very well documented by the Paragon 

because we read their procedures for documenting 

things, so we're sure it's documented. It no 
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longer exists in the SEM, wouldn't be accessible 

to the Claims Examiner if they're looking around 

looking in the SEM for it. 

So the question is, if that 

information has been superseded by more recent 

information -- not corrected, but simply 

superseded by a more recent characterization of 

what's true of that particular building or 

whatever -- but the old information exists, is 

that even available to the CE when they're 

looking for what important toxicants there are?

MR. VANCE: No, I would say probably 

not because the Site Exposure Matrices represents 

the best understanding of the toxins associated 

with whatever the relational parameter is. So if 

it's building, work process, labor category, or 

incident, you know, that information that's 

communicated in the Site Exposure Matrices at the 

time that the Claims Examiner is accessing it, is 

going to be the best information that Paragon can 

communicate based on the evaluation of the 

records that they have in their possession.
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You know, this would be a question we 

would have to look at and say, well, what was the 

rationale for changing or modifying the 

information on the Site Exposure Matrices? And, 

you know, each one of those questions requires 

Paragon to go back and look at their versioning 

to figure out what was the reason for why it may 

have moved from this relational parameter to 

something else.

Because, generally, it's not just 

being removed from SEM; it's because they're 

changing it. Like, it's not really supposed to be 

associated with this location; it needs to be 

associated with this.

So, there can be any number of reasons 

why things change and we have to look at the 

dynamics for each specific question.

MEMBER SPLETT: But, again, this is 

Gail. My concern is the N Reactor, for example, 

those toxins that Ms. Whitten had referred to, 

those are relevant for today. They aren't 

relevant for 1960. And some of our claims are 
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still from 1960. 

So if the Claims Examiners don't have 

access to them, they're not being referred to the 

CE, and they're certainly not going to a CMC.

And we're just looking at facilities 

that she and I and Ms. Zaback are intimately 

aware of. I don't have any way of knowing what --

if the same issues are happening at other sites 

and what that structured process is. 

So, Dianne, do you have any --

MEMBER WHITTEN: Well, this is going 

to be a big undertaking, because I did pull up 

some Savannah River buildings, too, and I believe 

they're having the same similar problem there. 

So, if it's happening here and there, it's got to 

be happening everywhere. And I don't know how we 

get Paragon to sit down with us and explain the 

rationale and how to put things back to where 

they were.

MEMBER SPLETT: Mr. Vance, how many 

people -- are your folks at Paragon assigned to 

specific facilities? I know we had one gentleman 
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in particular that came to Hanford on a regular 

basis. Do they sort of specialize by facility or 

location? And how large is the staff?

MR. VANCE: Yeah, I mean, I don't know 

the number of staff off the top of my head, but I 

think we did provide a lot of that information in 

the questionnaire that we provided.

I do know that Paragon will try to 

assign their researchers based on specific 

knowledge that someone may have about a 

particular site, or people that have that type of 

expertise, knowing what was going on at a 

facility. But their internal assignment of the 

researchers or the folks that are doing this work 

is really up to the Paragon management. 

So, again, for questions like that, 

we'd have to go back to Paragon and ask how to 

best answer any kind of questions about those 

kind of dynamics that exist.

MEMBER SPLETT: And, by the way, I do 

want to compliment you. Although I'm sitting here 

criticizing, we recognize this is a very hard 
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process. I remember having the discussions with 

your staff about we don't keep records by work 

processes. Show me your work process. We don't --

we have a million cubic feet of record storage 

and we don't keep them by work processes.

So it makes it a little -- clearly, it 

makes it difficult. But that doesn't mitigate our 

frustration with it when we're looking at some of 

the issues with trying to help some of these 

claimants.

MR. VANCE: Yeah, I mean, the 

Department of Labor's view is that, you know, 

this is an important, but evolving system. And, 

you know, the records that we obtain, it's 

continuous. You know, they just found a whole 

trove of records for South Albuquerque Works that 

we're looking at right now. So, I mean, it's 

amazing that these records keep popping up and 

that, you know, we need to go out and take a look 

at them.

And, you know, they've revisited these 

sites over and over again. And each time, they're 
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getting more information. So it's frustrating, 

and I can understand that, but it is a process by 

which we are trying to do our best to collect 

that information.

And the other big feature here is the 

Department of Labor really does need to have the 

SEM be as robust as possible, because it's 

singularly used to adjudicate these cases. And 

it's an important resource the Department of 

Labor sponsors to do that. Otherwise, claimants 

would be left doing this all on their own.

So I think that the Board has well 

within its discretionary authority to ask good 

questions, to make recommendations about 

improvements that could be accomplished within 

the Site Exposure Matrices.

And Paragon is very responsive to any 

questions that we put to them, and is always 

willing to look at issues relating to the 

communication of information in the Site Exposure 

Matrices. So, I'll leave that to the Board to 

ponder.
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CHAIR MARKOWITZ: Mr. Key?

MEMBER KEY: Yeah, Mr. Vance, again, 

as we brought up in November's meeting and Ms. 

Whitten has brought up today, how do you justify 

or explain the removal of a labor category out of 

this building? I don't know how you or Paragon, 

either one, could adequately justify the removal 

of a labor category of someone who has worked 20 

years in this building.

MR. VANCE: Yeah, my response to that 

is: it's generally going to be reliant on 

material that has been received and assessed by 

Paragon in clarifying that there needs to be a 

change in how the information is reported.

The Site Exposure Matrices is a broadbased exposure database. It's not -- it does not 

maintain good temporal data. It provides some 

information about the closure versus the 

production periods of time.

But any question regarding what 

specifically changed, if it can be identified 

that this was there and it was removed, we can go 
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back to the Paragon folks and ask them, you know, 

what was the basis for making those changes? And 

they're able to explain what occurred and what 

documentation changed. 

And, again, it's an evolving process 

to try to figure out what's the best, most 

accurate information to communicate in the Site 

Exposure Matrices. And so, you know, whatever 

information that could be provided when asking 

about why a particular change occurred in the 

Site Exposure Matrices, that's something that we 

can take back to Paragon and ask clarification. 

And that can certainly lead to additional 

consideration by the Board about that process.

CHAIR MARKOWITZ: Ms. Splett?

MEMBER SPLETT: Dr. Markowitz, is it 

in the Board's purview to ask for an independent 

assessment, separate from the Department of 

Labor, utilizing a subcontractor to do an 

assessment where they're picking one site, one 

facility, one area of a site to actually go in 

and, in-depth, do some analysis?
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Because we're just finding things just 

hit and miss in facilities that we happen to know 

about. I think it would be much more on a factual 

basis to do an in-depth assessment. And then, 

based on one, then I think there could be some 

much more detailed recommendations to the 

Department of Labor.

CHAIR MARKOWITZ: Providing advice to 

the Department on issues relating to the Site 

Exposure Matrices is within the realm of the 

Board's charter, sure. Dr. Bowman?

MEMBER BOWMAN: Just one, I was 

looking through the response to the information 

request. There's a lot of details, and, Dr. 

Markowitz, as you point out, there seems to be 

good documentation of any changes with removal.

But I'm trying to -- I was not able to 

pull out, from looking over the information 

provided -- there's a point in which there's a 

deletion that is approved. And I'm just wondering 

the underlying philosophy behind those approvals. 

If there is a documented case where a 
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chemical or a work status was present until a 

certain date and then was clearly not present 

after a date, would the decision be to keep or 

not keep in a case like that?

CHAIR MARKOWITZ: I don't think that's 

a question any Board member can answer. I don't 

know whether Mr. Vance wants to weigh in on that, 

or whether --

MR. VANCE: The best answer that I can 

provide to that would be, you know, what we don't 

want -- and I don't think Paragon operates like 

this -- is an arbitrary and capricious, kind of 

willy-nilly change. So there's going to be some 

sort of clearance process that exists within a 

review of the documentation to decide what needs 

to change and for what reason.

Now, the Department of Labor allows 

Paragon to manage this in a way that is going to 

be reporting accurate information. So, again, the 

question would be, what specific change is 

someone concerned about, and can they provide --

you know, or can Paragon explain what the 
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rationale for that was?

And it's one of these devil in the 

details. We wouldn't know what specifically 

someone's concerned about until we look at it and 

provide a response as to whether that change was 

justified or not in the view of the Board.

So it's just a matter of identifying 

what you want Paragon to report on and then 

taking a look at that rationale. And that will 

paint a picture of their process for reviewing 

these changes and updates. But, again, any change 

that they're going to make is going to be based 

on information and documentation in their 

possession.

MEMBER BOWMAN: Right, sorry. I think 

I understood that. My question was, in the case 

where, say, it's rather clear -- because the 

justification can go both ways. If something was 

there until 1980 and is clearly not there after 

1980, you could justify its removal because it's 

not currently there, therefore current employees 

would not be exposed to it. You could justify its 
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inclusion because former employees were exposed 

to it and were there. But it could either only be 

there or not be there, and both are true.

So I would think the Department of 

Labor might advise Paragon on what to do in such 

a very -- such a circumstance where it is clearly 

there and then clearly not there. Do we keep or 

don't keep?

MR. VANCE: Well, this is where it 

gets complicated, because once it's there and

once they've established that there was a toxic 

substance associated with, let's say, a labor 

category -- again, this is not reporting temporal 

data.

So it would be removed only in the 

sense that they have information that would 

suggest through the history of the site this 

labor category actually didn't use this material, 

or if there was some reason why it was reported 

in the past in error and it needed to be 

rectified or changed because of some new, 

accurate data about that particular toxic 
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substance.

That's why this is so difficult is 

because we just don't know until we ask what was 

going on here. And it could be a question of just 

accuracy and error based on some 

misinterpretation of prior documentation.

But if it is established clearly that 

this toxic substance was associated with the 

labor category or work process or what have you, 

then it will remain in the system and it will 

remain available.

The only way that it would be removed 

would be because there was a mistake in how that 

information was evaluated in the past. And, also, 

it could be removed because it was not taken 

totally out of the Site Exposure Matrices; a 

better understanding of that material was 

obtained and that exposure's associated with 

other relational parameters in the Site Exposure 

Matrices.

So it really is going to be dependent 

on looking at the specific question about what 
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change has occurred, or some deficit that the 

Board might see that they want clarified as to 

why this information doesn't exist or has been 

changed over whatever period of time.

MEMBER BOWMAN: Okay, thank you.

CHAIR MARKOWITZ: Ms. Whitten?

MEMBER WHITTEN: So, according to 

their standard operating procedure SEM-02, which 

is "Compiling and Entering Toxic Substances," it 

also applies to deletion of chemical profiles. 

Changes to the chemical profiles per the 

procedure can only be performed by the SEM 

Chemical Profile Manager. 

Could we request from the SEM Chemical 

Profile Manager all previous versions of the SEM 

for Hanford? According to N Reactor, it was 

updated September 27th of last year. Can we 

review the previous chemical listing to see if it 

was complete then, or maybe even the one previous 

to that and that?

According to their procedures, if the 

SEM gets too large, they have a process to 
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minimize it. Because these are all Excel 

spreadsheets that are probably humongous. And 

maybe something happened during that process, I 

don't know, but I would like to draft a letter or 

request to the Profile Manager to get some 

information from him, possibly.

CHAIR MARKOWITZ: Steve Markowitz. So, 

there's sizeable gap between the experience of 

some Board members with the SEM, and probably 

members of the public because we've heard this 

before, in terms of how information is dealt 

with. Or not just how information is dealt with, 

but the fact of changing the SEM in ways that 

don't make sense, given their own experience at 

Hanford, perhaps other facilities.

And so what we need is clarification. 

And we've gotten a certain amount in writing, 

which has been very useful. But we need further 

clarification because there's still pending 

questions.

So I would propose to the Board that 

we request that one or more personnel involved 
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with Paragon appear before the Board so that we 

can -- and we can submit the questions ahead of 

time so that it's clear what information we're 

after -- but that a person appear, or people 

appear, before the Board so that we can interact 

directly and get more detailed answers to 

questions and further clarification.

And that's my own opinion. I, 

obviously, would need the opinion of other 

members of the Board. I would remind the Board 

members that part of the Act says that the 

Department of Labor will make "make available" to 

the Board the Medical Director, the toxicologist, 

Industrial Hygienists, and support contractors 

for information provided to the Board. "Will make 

available to the Board." 

So I think a request for Paragon 

personnel to appear before the Board to engage in 

clarification and interaction would be useful. 

And I'd like the opinion of other Board members

about that. Dr. Bowman?

MEMBER BOWMAN: Thank you, Dr. 
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Markowitz. I agree with you. I think that would 

be very useful to have them here. I think it 

would be most useful if we, as a Board, submitted 

questions ahead of time so that they could be 

prepared to answer them. It will be less useful 

if they're not. 

I think including some very specific 

examples for which Board members have intimate 

knowledge, as was mentioned, and to get those 

details back would be helpful in that case. But 

then submit it ahead of time, because they're 

very detailed and I doubt any one person would 

know them off the top of their head.

CHAIR MARKOWITZ: Other Board members? 

Dr. Cloeren?

MEMBER CLOEREN: I agree with both of 

you.

CHAIR MARKOWITZ: Well said. Mr. Key?

MEMBER KEY: Totally agree.

CHAIR MARKOWITZ: Board members who 

are participating by Webex, do you have any 

comments or opinions? 
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So, I think, actually, we should take 

a vote on this. It's not a recommendation; it's 

not a specifically a Board request for 

information, which are our two mechanisms for 

making requests to the Department. But I propose 

that we actually vote on this request that one or 

more members of the Paragon staff appear before 

the Board to answer questions, many of which will 

be submitted ahead of time to the Department, for 

the purpose of helping us understand the SEM and 

clarifying aspects of the SEM. 

So, that's a proposal I think that 

needs a second.

MEMBER CLOEREN: Second.

MEMBER FRIEDMAN-JIMENEZ: This is 

George Friedman-Jimenez. I second.

CHAIR MARKOWITZ: Okay. In this case, 

three seconds. Is there any further discussion 

about this?

MEMBER FRIEDMAN-JIMENEZ: No.

CHAIR MARKOWITZ: Okay, so let's take 

a vote, if we could. And the minutes I think will 
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reflect what we're voting on, which I think is

pretty clear.

MR. JANSEN: This is Ryan Jansen. I'll 

record the vote. Dr. Bowman?

MEMBER BOWMAN: Yes.

MR. JANSEN: Mr. Catlin?

MEMBER CATLIN: Yes.

MR. JANSEN: Dr. Cloeren?

MEMBER CLOEREN: Yes.

MR. JANSEN: Dr. Friedman-Jimenez?

MEMBER FRIEDMAN-JIMENEZ: Yes.

MR. JANSEN: Dr. Markowitz?

CHAIR MARKOWITZ: Yes.

MR. JANSEN: Dr. Mikulski?

MEMBER MIKULSKI: Yes.

MR. JANSEN: Dr. Van Dyke?

MEMBER VAN DYKE: Yes.

MR. JANSEN: Dr. Vlahovich?

MEMBER VLAHOVICH: Yes.

MR. JANSEN: Mr. Key?

MEMBER KEY: Resounding yes.

MR. JANSEN: Ms. Splett?
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MEMBER SPLETT: Yes.

MR. JANSEN: Ms. Whitten?

MEMBER WHITTEN: Yes.

MR. JANSEN: All 11 Board members 

voted yes.

CHAIR MARKOWITZ: So is there further 

discussion from the SEM Working Group, additional 

items that were raised that might be subject to 

the questions that we would submit or otherwise?

I realize, you know, we've gotten 

recent responses regarding this that we need to 

comb through more thoroughly. Fair enough. But 

now is the time for further discussion.

MEMBER WHITTEN: I mean, I can show 

you more examples, if you wish, but for timewise, 

we can just work on --

CHAIR MARKOWITZ: Well, if you have 

another example, I would like to see it, 

actually. And while you're figuring that out, if 

anybody else has any comments.

MEMBER SPLETT: I did review all the 

standard operating procedures for the SEM, and 
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there was a lot, in very good detail, on the 

mechanics of how to get the data, where to put it 

in. But it really -- it missed that key issue for 

me, which is when -- what's the rationale for the 

deletion of the material. That was not in those 

procedures that I read, and I did read all of 

them. 

But I do think it will be really 

useful if we get some more detailed questions and 

some specific issues together and meet with 

Paragon at our next meeting.

CHAIR MARKOWITZ: But, you know, what 

puzzles me is that the SEM is not really about 

time. It's not time-dated. So it doesn't tell you 

any given exposure in relation to job titles, in 

relation to buildings, whether it was 1960 or 

1990.

It's not structured that way. They 

didn't intend to do it that way. So, as it 

evolves, I understand correcting mistakes in the 

SEM. You get rid of the mistakes and put in 

information that's correct, that you have 
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documentation that proves that it's correct.

And so what I don't understand though 

is -- the perception is that there's information 

that's removed that was not incorrect, but 

relevant to a certain time period, and still 

relevant to claims, and it's no longer there. 

That strikes me as a -- as just a puzzle that we 

need to figure out.

MEMBER WHITTEN: All right, well, if 

you want to see another example, Kevin, go to 

105-K. Stay on Hanford. And then go to the 

building site again on the -- halfway down the --

there you go.

105-K East. And it's similar to N 

Reactor. It was an operating reactor. And 

currently it has five chemicals listed. And, like 

I said, years ago it had a couple of hundred. It 

had a lot more labor categories, more work 

processes, and now they're gone. 

So, you know, if you were a new CE and 

you didn't know anything about Hanford, you 

didn't know about reactors, you would just have 
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to go with what you found on the SEM.

CHAIR MARKOWITZ: So I think it --

that example would be a useful one to cite.

MEMBER SPLETT: Don't we have to 

compare that to -- have them pull up 100-B. 

Kevin, the same thing, but 100-B. 105-B. 105 is 

all the reactor buildings, so then just the 

numbers after them.

So, 105-B currently is a museum, but 

it was the first reactor at Hanford and it has 

more chemicals listed than the other reactor 

buildings. It also has mice infestation, and I 

will tell you that the mice didn't stop at 100 --

at B Reactor. They also went to K and N and 

everywhere else. We tried to put up borders to 

keep the mice out, but it didn't work. 

Look at the labor categories there, 

Kevin, and see what's there. There's a few more 

there.

Do you guys want to see anymore else, 

any other examples?

MEMBER KEY: The labor categories 
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that's listed under the 105-B, would you say 

that, in your knowledge or experience at the 

site, that those are the exact labor categories, 

all-inclusive, that should be listed?

MS. WHITTEN: No, of course not.

MEMBER KEY: Okay.

MS. WHITTEN: We had maintenance 

people, fitters, we had --

MEMBER SPLETT: We had our admin 

staff, there were accountants, there were 

facilities folks, there were material handlers. 

There were any number of other folks in that 

facility.

MEMBER KEY: Thank you.

CHAIR MARKOWITZ: So, any further 

comments from the SEM Working Group? 

Okay. Well, if there are no other 

comments on the Board, we're going to break for 

lunch, I think a little early.

We'll break now at 12:15 p.m. and 

we'll resume at 1:15 p.m. So we're altering the 

agenda slightly. We'll be back at 1:15 p.m., not 
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at 1:30 p.m. Thank you.

(Whereupon, the above-entitled matter 

went off the record at 12:16 p.m. and resumed at 

1:24 p.m.)

CHAIR MARKOWITZ: Okay, so the Board 

members are all present here at the meeting in 

Idaho Falls and I'm wondering, I see Mr. Catlin. 

I'm hearing myself twice.

And I see Dr. Mikulski, Dr. Vlahovich 

and Mr. Vance. And I thought I saw Dr. FriedmanJimenez for a moment. Okay, well we have a quorum 

so we're going to get started.

So next on the agenda, we're going to 

review the Department's response to the 

recommendation that we made at the last Board 

meeting.

And also, their response to our 

information request so we had recommended -- let 

me read it. It's very brief. "The Board 

recommends that the Department of Labor provide 

instructions to Claims Examiners, Industrial 

Hygienists, Contract Medical Consultant 
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reviewers, that if there is evidence that a 

claimant's employment led to their routine duties 

being performed widely across a site, this be 

specifically noted in the claims file and that 

consideration be given in establishing toxic 

substances exposure and causation for exposures 

that are site-wide and not just limited to their 

work area of record."

And this was turned down by the 

Department and I guess the largest, part of the 

response, let me just read their response. 

"Regarding the current recommendation, Department 

continues to hold the position that broad-based 

generalizations are not appropriate in the 

absence of specific evidentiary support for 

particular labor categories.

However, we want to reiterate that the 

Claims Examiners are trained to consider the 

evidence on file specific to the individual 

claimant and use that data to link the particular 

employee to potential exposures.

The Procedure Manual also provides 
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clear guidance to Claims Examiners that 

examination of exposure is a holistic effort that 

considers information from many sources.

The information assembled by the 

Claims Examiner in the case file as described 

above can be considered if needed by subject 

matter experts like Industrial Hygienists and 

contract medical consultants.

In summary, the Department will 

consider any specific information provided by the 

claimant during the collection of evidence about 

their work, activities, locations and assigned 

exposure based on data that reasonably connects 

an employee to specific toxic substances through 

a labor category, work process, incident, or 

other factor."

So just by a little bit of history, 

this is actually the third time the Board has 

made some form of this recommendation that 

essentially a limited number of job titles like 

firefighter, security guard, health physics 

technician, and a few others whose jobs routinely 
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took them at their particular site many different 

locations, that their potential exposures be 

viewed very broadly rather than specific. And 

three times the Department has disagreed with 

this recommendation, not accepted it, and so I 

think we'll leave it at that.

You know, three tries was a good 

attempt and clearly we're operating from a little 

bit of a different paradigm from how the SEM is 

used. So anybody have any comments about that?

Okay, let's move on. We had submitted 

an information request to the Department and we 

got a response. I think this is mid-February. 

I'll just review it quickly.

One of the things we asked for were 

the number of times in claims that Industrial 

Hygienists were sent the file for review and 

actually we heard that this morning, the data 

from this year.

We heard something like 1,200 IH 

referrals and of roughly 1,800 relevant claims, 

mostly Part E claims, so a very high proportion 
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and the data we had requested on the same point 

from 2019 to 2022 showed the same results, 

basically.

That there were many referrals to the 

Industrial Hygienist, a very high proportion of 

claims were going to the Industrial Hygienist. So 

that was useful to know.

We had asked about malignant 

mesothelioma, which is a cancer fairly uniquely 

related to asbestos exposure. And the reason we 

had asked about that was because there had been 

back and forth between some recommendations we 

had made about presumptive criteria for people 

exposed to asbestos within the complex and partly 

in development of malignant mesothelioma.

So they did provide the data on that. 

And the reason why we were interested in part was 

could we use these data to better understand the

job titles who were at risk for asbestos exposure 

and consequent illness.

And actually, if you could just open 

up that Excel spreadsheet there, Kevin, that 
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would be great. So there were claims for 

mesothelioma under Part B that were denied, but 

mesothelioma is not a Part B claim. It's a Part E 

claim. And there were 40 during the relevant time 

period, I think it was 2018 to 2022, and 35 which 

were accepted and five denied.

So that's a very high proportion 

accepted, that's what we expected. That was good. 

Personally it would be of interest to know what 

the job backgrounds were of those 35 or 40 

people.

But I don't think it's actually going 

to answer the question we had, which was in 

addition to -- there are about 20 or 25 job 

titles within the Procedure Manual in which it is 

presumed they had significant exposure to 

asbestos.

And we were looking at whether there 

were a few other job titles that should be added. 

Specifically chemical engineer, mechanical 

engineer and I think industrial engineer. And we 

thought well, could we look at the backgrounds of 
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people with mesothelioma to bolster support for 

adding those job titles.

And I think it's extremely unlikely 

with these numbers of cases of mesothelioma that 

there's going to be enough data to support that, 

so personally although it would be interesting, I 

really don't see the point of requesting the job 

backgrounds of the people with mesothelioma.

Anybody have any comments on that? 

Okay. We can go back, Kevin, to the main 

document. We had requested the new quarterly 

medical examiner reports. So prior to 2020, the 

Medical Director of the program on a quarterly 

basis had reviewed 50 claims to look at the 

adequacy of the CMC report in those claims.

And we had periodically looked at the 

results of those analyses. And just to summarize, 

on the causation claims, finding a problem with 

the CMC report was rare.

In other words, when the Medical 

Director looked at the CMC report, something like 

20 per quarter for causation analysis, the 
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finding a problem with the CMC report error or 

whatever was very infrequent.

Whereas in the impairment reports that 

came from the CMC, actually errors were fairly 

common, to the tune of 15 to 20 percent. Many of 

those errors were minor, but it was a contrast 

with the causation analysis of the Medical 

Director.

So we noticed that there had stopped 

being reports and so we asked whether they could 

provide newer reports than 2019 and the answer 

was that they're working on a new system for 

this.

And so, just recently we received some 

documents, but they are still in draft form so 

we're not able to discuss them in public. But we 

will, you may recall those, those attachments we 

got recently and we will not discuss those just 

to be clear. 

And then, Item No. 4 had to do with 

the SEM and we had requested information about 

the SEM and how the contractor operated the SEM.
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And you can see we received eight 

attachments which helped to clarify that and some 

of which were discussed a little bit this 

morning.

And then finally, if you keep going, 

Kevin, this is where we pointed out, so this is 

to the point that Mr. Vance made this morning.

We pointed out that post-'92 tunneling 

work should be considered at risk for silica 

exposure and silicosis and it had been pointed 

out to us by a public commenter that the program 

had stopped accepting Part B silicosis claims for 

exposures that began after '92.

But Mr. Vance has explained to us this 

morning that that's been corrected. The Procedure 

Manual has changed with respect to that. Any 

comments or questions on this information we 

received? Okay. Yes?

MEMBER SPLETT: The first item where 

it showed the referral to the IH 92, 94 percent, 

is that what you would expect for Part E claims? 

It seems high, but again, not knowing whether 
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there was enough information for a Claims 

Examiner to make the determination without an IH 

or a review?

CHAIR MARKOWITZ: Well I was actually 

focusing more on the absolute number, you know, 

3,151 reviews were sent to the contract IH.

MEMBER SPLETT: But that's 95 or 94 

percent of the total claims. Does that seem to 

make sense? I mean, it's just a question. I 

don't have any knowledge one way or the other 

whether that's about what you would expect.

CHAIR MARKOWITZ: Yes, I think the 94 

percent actually is the percentage of -- the 

total there is 3,352. Those are the total number 

of IH reviews.

MEMBER SPLETT: Okay. 

CHAIR MARKOWITZ: And of those 94 

percent were sent to the contractor IH and the 

other six percent were done internally, my guess 

is by the national office. So --

MEMBER SPLETT: So that's what the 

number of claims, the percentage of claims going 
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to an IH, it's just the ones that are external to 

DOL?

CHAIR MARKOWITZ: Right.

MEMBER SPLETT: Okay, thank you.

CHAIR MARKOWITZ: Right. And that 

explains why we learned this morning probably 

roughly two thirds of claims in the first three 

months of this year have been sent to an IH for 

review, whereas in the data we were previously 

given it was consistently over 90 percent, so.

MEMBER SPLETT: Okay, thank you.

CHAIR MARKOWITZ: But we did get the 

answer to our question which was how many claims 

were sent to an IH. And it must have been the 

vast majority of claims were sent or many, many 

claims. 

So, on the schedule we have case 

review. But I would like actually to discuss 

something else which pertains to the topic we 

just discussed somewhat. And Kevin, if you could 

bring in the draft recommendation.

So let me read this recommendation and 
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it's really a starting point for discussion, so 

subject to change. But that the Board recommends 

that the EEOICP implement a mechanism to evaluate 

the validity and accuracy of the opinions and 

rationale that are expressed in the reports of 

the contract medical consultants, the CMCs, in 

the claims evaluation process with particular 

attention paid to the issue of causation of 

disease.

This mechanism should have sufficient 

independence of the current method of developing 

and obtaining CMC opinions in order to avoid 

actual or perception of conflict of interest.

So let me explain the background here 

a little bit. We know from the Medical Director's 

audits that I just mentioned prior to 2020 what 

kinds of aspects of the CMC reports were 

examined, what goes into the quality assessment 

of the CMC work.

And so these are the issues that are 

considered. One is, did they send the referral to 

an appropriate specialty? So if it's a question 
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of I guess general occupational disease, did they 

send it to an occupational medicine physician?

If it's an impairment claim, did they 

send it to someone who has expertise in doing 

impairments? If there's a question of cancer, 

oncology and diagnosis, did they send it to an 

oncologist who can weigh in expertly on whether 

that person actually had the cancer that was 

alleged?

And that's an important criterion, you 

want the CMC to be an expert in what they're 

being asked to review, so that was one aspect. 

Another aspect is the timeliness of the CMC 

report.

So that's good because you want to 

turn claims around in a timely fashion. Another 

aspect that was looked at was whether the report 

that the CMC gave was well rationalized, meaning 

did the CMC provide a logical and apparently 

complete analysis that supports the opinion, the 

conclusion that they reached?

And so one would look at the CMC 
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report for what their decision was and then the 

logic of how they arrived at their decision. 

What else was looked at? Timeliness, 

well I think the issue of references or 

citations, did they provide some citations or 

references that supported their opinion?

Another aspect was did the CMC 

actually address the questions that the Claims 

Examiner sent to the physician? So the Claims 

Examiner prepares the statement of accepted 

facts, they then assemble some questions and did 

the CMC actually use those facts and respond to 

the questions that were directed to that person

by the Claims Examiner?

There may be a couple of other 

aspects. So those are all elements of quality and 

they're important. But what is I think missing 

from that assessment of quality is whether the 

CMC was correct in what they said.

The opinion they expressed, does it 

really match what we know from the medical 

literature, from current medical facts and 
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thinking about the given occupational disease?

Now I appreciate that there's 

differences of opinions among physicians, that 

there are legitimate differences, that different 

physicians can look at the same set of facts and 

come up with different conclusions and emphasize 

different aspects of that.

And that that is acceptable, that in 

some instances that it's not exactly black and 

white what a person has or whether it's caused by 

occupational exposures. And so you need, in a 

quality assessment, to accommodate that kind of 

variation and opinion. 

But from reviewing cases which we're 

going to get to and which the Board has done 

previously, it's also clear that there is a 

subset of the opinions, the reports produced by 

CMCs in which frankly, the opinions expressed 

were just plain wrong. And they just got it 

wrong.

They didn't understand the disease and 

they didn't understand causation with respect to 
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that given case and they got it wrong.

And my impression is it's by no means 

the majority, it's a minority. It's I would think 

probably not a large minority, I think it's 

probably less than 20 percent, but I don't think 

it's 1 or 2 percent. I don't think it's a rare 

phenomenon. And let me explain sort of the 

background and I'd actually like other people to 

weigh in on this who are experienced with 

occupational medicine.

So our field covers a very broad set 

of activities and areas. And we routinely occupy 

very different niches of this spectrum. So my 

background is in internal medicine, occupational 

medicine, epidemiology.

I know a lot about causation, I know 

about research and I know virtually nothing about 

impairment. I know nothing about drug testing. If 

I had to work for a company within their 

environment, I would be lost, most of the tasks 

that would be assigned to me. And that's not a 

problem because it's not what I chose to do. 
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Likewise, I'm in charge of the residency advisory 

committee at Mount Sinai so I see the new 

residents come through all the time.

And they pick a niche to go into and 

sometimes we cross niches over time, but often 

not. Someone who's going to be heading into 

consulting or corporate occupational medicine has 

a whole different set of areas that they're 

interested in.

Some of them learn about how to do 

proper physical examinations for truck drivers 

and the like, drug testing, which I mentioned 

before, et cetera.

And they're very good at that. And 

that's acceptable. I mean, that's just the nature 

of what we do. And so it means that you can send 

a case to an occupational medicine physician who 

occupies one niche and ask them about the other 

niches and although from the outside they look 

like they ought to have the expertise, they're 

occupational medicine docs, they don't.

And I think we run across that some in 
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this program. I don't really necessarily need to 

go into the details, but I think particularly 

those of us who have been on the Board for a 

while or have reviewed these cases have seen 

this.

And I think the challenge is how to 

sort through this and how to identify instances 

in which the CMC opinion is not well-founded and 

is incorrect.

And there will be the opportunity for 

a more correct, accurate opinion, whatever that 

decision is, a more correct, accurate opinion to 

be expressed.

And so, what this recommendation is 

about is for the program to develop a way in 

which those errors can be detected and corrected. 

And I think they have that in the industrial 

hygiene sector.

I think there is that kind of quality 

review either within the contractor or by the 

national office which looks at all the IH reports 

that come back.
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I don't think they have it in medicine 

and it would need to be developed. So let me stop 

there for a moment and just open it up to 

discussion, comments.

Now, you give the impression that I've 

covered it all. That's not possible. Okay, Dr. 

Vlahovich?

MEMBER VLAHOVICH: Yes, I agree with 

you that it's difficult to figure out who to send 

a case to. And as you said, you could send one to 

an occupational medicine physician, but they 

would certainly not all know every different 

specialty within that.

I've done case reports myself and, you 

know, usually the Claims Examiners are very good 

at sending me things that I'm familiar with.

But if they send me say a cardiology 

case, really that would be up to me to refuse 

that because that's not within my scope of 

practice. And I would hope that other Claims 

Examiners do the same if they get something 

they're not familiar with, that they would refuse 
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to do that one or pass it on.

But I don't know how to monitor that. 

When we were reviewing cases, I saw in the files 

that were sent to us the specialty was 

occupational medicine, but I don't know what 

niche within that that particular physician was 

familiar with.

So, yes, I agree with what you were 

speaking of before.

CHAIR MARKOWITZ: Yes, Dr. Bowman?

MEMBER BOWMAN: In the context of this 

recommendation we don't specify a mechanism, only 

that the mechanism should not have or appear to 

have a conflict of interest.

Are there mechanisms to evaluate 

medical decisions like this that are approved in 

the literature in the field? You had given some 

examples of clear-cut cases where there can be 

accepted differences of opinion.

And then there's potentially clear cut 

cases where there's just a mistake, but I guess 

there is going to be a lot of at the grade, you 
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don't even know which of those two it is and is 

there in the field an accepted practice to 

determine that?

CHAIR MARKOWITZ: You know, a protocol 

or some sort of algorithm? I can't think of any. 

Dr. Bowman, can you?

DR. BOWMAN: No.

CHAIR MARKOWITZ: Dr. Mikulski, 

Friedman-Jimenez, Vlahovich, can you think of any 

exercise that we could point to that would help 

the Department? Dr. Cloeren, while they're 

thinking.

MEMBER CLOEREN: Well I wonder if the 

idea of the referee opinion might be leveraged 

for this purpose. So the referee technically is 

to resolve the conflicting opinions between 

usually the treating or more the Former Worker 

Program and the CMC.

But that's kind of an independent 

doctor that's used to reviewing these cases so I 

wonder if that role could be leveraged somehow.

CHAIR MARKOWITZ: Mr. Vance, the 
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referee, I know it doesn't occur often, but the 

referee physician reports, is that done by the 

same contractor as the CMC reports?

MR. VANCE: Yes.

CHAIR MARKOWITZ: Okay, yes, okay. 

Yes, Ms. Splett?

MEMBER SPLETT: Is the intent to just 

do an audit or is this a continual process 

checking every opinion that comes in?

CHAIR MARKOWITZ: Yes, I think that's 

up for discussion. In some respects, an audit 

would probably suffice, but then if you find a 

fair percentage, then you might have to consider 

a broader audit.

This recommendation uses the word 

validity and accuracy. Are those the right terms? 

Is there enough specificity in this 

recommendation that gets across what the 

intention is? Dr. Cloeren?

MEMBER CLOEREN: I don't know if 

you're ever going to be able to say this opinion 

is valid and this one's not, but maybe I think 
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what we're talking about maybe is an interrater 

reliability almost. In which case, you might need 

two people looking.

CHAIR MARKOWITZ: Yes.

MEMBER FRIEDMAN-JIMENEZ: This is 

George Friedman-Jimenez. Yes, you raise some 

important questions. In New York State the 

workers' compensation board has an impartial 

specialist unit.

And I served on that for a number of 

years and basically they send you cases where the 

treating physician's opinion differs from the 

IME, the so-called independent medical 

evaluator's opinion.

And they're unable to resolve it and 

the judge asks for an impartial specialist to 

essentially make the call. And so you have to 

evaluate all of the provided information, 

sometimes even see the patient and then come to a 

decision that then supersedes both decisions of 

the treating physician and the IME.

Now this is different because it's not 
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an evaluation of the opinions of the treating 

physician or the IME, but it is an independent 

impartial re-evaluation.

The problem here with the words 

validity and accuracy are they sort of presume a 

gold standard as Marianne was alluding to. 

There's no absolute clear correct answer, you 

know, and it's a matter of evaluating evidence 

often that is incomplete, maybe inaccurate, 

sometimes not available.

And then coming to a conclusion, a 

forced decision under a lot of uncertainty and so 

different evaluators are going to come to 

different conclusions quite frequently.

So I agree that we're really in the 

space of some sort of interrater or inter-judge 

reliability or repeatability or agreement rather 

than accuracy or validity which presume that 

there is a known correct answer.

So yes, this is not easy. I mean, this 

is a whole field in itself, the causation 

analysis, and I think it's something that we 
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should discuss and try and improve on.

I think that there are probably some 

improvements that we can make in the process, but 

it's not an easy thing and we're not going to 

come to a completely clear and completely 

accurate methodology.

CHAIR MARKOWITZ: Yes, my problem with 

interrater reliability and exercises like that is 

they apply to populations and they apply to 

research and perhaps a clinical activity that's 

structured as such.

And this is about finding CMC reports 

that are just plain off. You know, so I 

understand the underlying issues, challenge of a 

gold standard, but I will discuss one of the 

cases today in which they're just wrong. Sorry.

And so, I think if you assembled a 

number of experts in the area that we would all 

agree on that. So I agree that, you know, the 

absolute might be hard to achieve, but we can 

certainly do better than nothing at present. Dr. 

Cloeren?
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MEMBER CLOEREN: I had a thought about 

like, sampling. Maybe looking at cases where the 

Claims Examiner reversed the original decision 

where the original decision was based on a CMC 

opinion and then additional information came in 

and the Claims Examiner decided to accept it.

That might give DOL a pool of cases to 

review where it could have been that the CMC 

report was faulty. I mean it could have been 

additional information or it could have just been 

another opinion explaining things a different 

way, if that makes sense.

CHAIR MARKOWITZ: So you're saying 

cases in which the Claims Examiner received the 

CMC report and then based on subsequently 

received information decided differently from 

what the CMC concluded?

MEMBER CLOEREN: Where there was a 

denial with the CMC report and it was appealed 

and then accepted.

CHAIR MARKOWITZ: Based on new 

information?
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MEMBER CLOEREN: Based on another 

opinion or whatever.

CHAIR MARKOWITZ: Yes. You know, 

that's probably a relatively small number of 

cases and wouldn't really give us the look at the 

much broader number of TMC reports that are 

issued so there would probably be some real 

selection problems there I would think.

MEMBER FRIEDMAN-JIMENEZ: This is 

George Friedman-Jimenez again. Another model that 

we can think about which is used all the time in 

clinical medicine in a somewhat different sense 

is the quality assurance model where charts are 

reviewed or cases are evaluated looking for very 

specific sampling, essentially inclusion or lack 

of inclusion of certain things like is there a 

smoking history in the note, you know, did they 

perform the number of physical examination items 

that they reported they had performed, et cetera.

Similarly, we could do something like 

that and see whether specific items in the 

statement of accepted fact are clearly 
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documented, accurately documented, whether 

certain exposures were considered, you know.

So it doesn't actually measure the 

accuracy or the validity of the conclusion, but 

it does evaluate whether the process was 

performed in a way that is likely to support an 

accurate evaluation. And it's more doable. I 

mean, it's more feasible.

CHAIR MARKOWITZ: Dr. Bowman?

MEMBER BOWMAN: With the stated goal 

being to identify cases in which there was just a 

clear error in judgment by the CMC, I was 

thinking in the context of this recommendation 

and then whatever mechanism is used or method is 

used to assess this we probably need to advise 

on, basically in essence, a statistical power 

analysis.

To what degree is this? I mean, are 

we trying to find a one in 10,000 cases that has 

this? There must be some level that we want to 

ensure that there's, it's not more than I'll say, 

not more than 1 percent or maybe not more than .1 
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percent that have this error.

And so there is, you know, statistical 

approaches we can do to assign how many cases 

need to be randomly selected to ensure that such 

errors don't occur at more than 1 percent.

And perhaps we should provide guidance 

in the recommendation as to what degree of 

confidence we're looking for that these things 

aren't happening.

If it is one case every ten years that 

we're looking for -- I don't think it is, that's 

an exaggeration -- that would be near impossible.

We should think about what is doable 

in the context of this request because clearly 

we're not to rule out that it's happening every 

other time. We would know that by now, right?

I think we're trying to establish a 

confidence that it's not happening at a level 

that we currently don't know. And so in that 

sense, maybe we should provide guidance as to, 

you know, we want this to be looked at so we can 

have confidence that this isn't happening at less 
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than this percentage of cases.

CHAIR MARKOWITZ: Well, yes, Dr. Van 

Dyke?

MEMBER VAN DYKE: So I mean the way 

it's written, this is a huge task. And really, 

thinking about this, I mean do you want to kind 

of pare it down a bit and think about cases that 

were denied?

Because I think you might be able to, 

you know, get the denial letters and see the 

reasons that they were denied and base your 

sampling on that.

Because I think really what we're 

after is, you know, the most important thing is 

we want to avoid inappropriate denials. So 

thinking about the positive makes it a bigger 

task than thinking about the negative.

CHAIR MARKOWITZ: Steve Markowitz, 

then you're saying that we could simply add we 

would recommend that you apply this exercise only 

to denied cases?

MEMBER MIKULSKI: Another idea, and 
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this is Marek, might be to begin with the 

decisions that have been marked as not well 

rationalized. In other words, the CE assessing 

the CMC's opinion as not well rounded.

We know of several metrics that have 

been used in that process and maybe those could 

be used in an assessment of the accuracy of those 

opinions.

CHAIR MARKOWITZ: So, Mr. Vance, 

question of fact here. When a CMC opinion is 

identified as not well rationalized, what happens 

next?

MR. VANCE: Well, the role of the 

Claims Examiner is to make sure that whatever 

medical opinion is presented is well 

rationalized.

The question would be how well do all 

of our staff comply with that. But if it is 

determined that the CMC has not provided a wellrationalized opinion, either they're reporting 

inaccurate information, they're not using the

data that's been provided to them and 
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characterizing it differently than let's say what 

the Industrial Hygienist is saying or some other 

defect, and I've seen this in some CMC opinions 

where I don't understand how it works.

Then that opinion can't be accepted 

and we've got to go back to the contractor and 

rectify whatever the deficit is in asking for 

clarification from that doctor.

If we feel that the doctor is unable 

to provide information that overcomes whatever 

that defect is, we're going to find another 

physician to render a separate opinion and that 

can certainly happen.

So that's the process by which we 

would look at it. It's really a discretionary 

evaluation of the opinion of the doctor to make 

sure that it conforms with what our expectations 

are for a well-rationalized opinion.

CHAIR MARKOWITZ: So, Dr. Mikulski, so 

those cases are already flagged, they're already 

identified as being erroneous. And it's the other 

CMC reports, the ones that don't appear erroneous 
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because they appear to be well rationalized that 

are clearly the vast majority and I think are the 

challenge.

Getting back to your point, Dr. Van 

Dyke, if we added a sentence that said that we 

recommend that this process be applied only to 

denied claims, does that satisfy your question?

MEMBER VAN DYKE: Well, I mean I'd 

love to see it for both denied claims and claims 

that are approved. But I just think the task is 

too big when we start thinking about it that way.

So trying to help DOL I think denied 

claims would be the first target.

CHAIR MARKOWITZ: Yes, Steve 

Markowitz, I agree. And it's in line with I think 

the thrust of the philosophy of the program that 

they don't want to inappropriately deny claims.

So can we add then on the fourth line 

just before it says this mechanism? And this 

process should be applied only to denied claims. 

Dr. Cloeren?

MEMBER CLOEREN: So what if this is 
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done and it's done well and it shows there's no 

big problem? Like at what level or benchmark 

would we say that's okay?

So it wouldn't necessarily need to go 

on, like this could start as a spot check rather 

than an ongoing process if it turns out that it's 

a very low percentage, right? 

CHAIR MARKOWITZ: The program has 

ongoing quality assessment in multiple aspects. 

It's not a one off or if I understand it 

correctly, a temporary kind of check.

It's we want a good program and that 

remains good and so that quality assessment is 

not time limited. Isn't that right, Mr. Vance?

MR. VANCE: Yes, that is correct. I 

mean, as far as quality assurance is concerned, 

we do have multiple tiers of review, we do have 

instances where we worked with CMCs in the past 

to promote improvements in the written quality of 

the reports and highlighting issues that we've 

seen with regard to either the application of 

causation analysis or impairment ratings.
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So we have those mechanisms in place 

to work with our contractor and, you know, the 

oversight of that contract falls within the 

policy branch so I'm well aware of what we've 

been communicating to our contractor with regard 

to certain aspects of the work that they do.

So that would be what you're talking 

about is that the Board would be looking at the 

same kind of thing that the Department is looking 

at but maybe with a focus on a different aspect 

necessarily than what we do because we're not 

looking at correct or incorrect.

We're looking at how well rationalized 

and supporting of the contract expectations, you 

know, how well is the CMC conforming to contract 

expectations?

We would be looking at that wellrationalized component, but we're not going to 

specifically look at do we think the doctor was 

right or not?

Does the doctor's opinion seem well 

rationalized in the sense that they explain it 
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well enough that it offers a compelling 

justification for an approval or denial?

And you've discussed how big of a 

challenge that would be and I agree that that 

would be a challenge to look at a doctor and say, 

oh, he's wrong or she's wrong and this is why.

Because the doctor is providing an 

opinion of an interpretation, so just something 

for the Board to consider.

CHAIR MARKOWITZ: This is Steve 

Markowitz. I want to return to a point that Dr. 

Bowman raised about whether we should advise on 

how to do this or for instance, how many cases 

they should look at in a given period.

And I think at this point I don't 

think it would be helpful to do that. I think if 

they accepted this recommendation in some version 

and wanted assistance in the design of that, I 

think, you know, we could do that.

Part of the reason I say that is we'd 

have to agree on what an acceptable error rate 

is. And that would take us a long time to agree 
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on that. And I'm not sure we would come to 

agreement on that.

What do we accept, a 1 percent, a 3 

percent? Because that's going to determine what 

the sample size is, how many claims you have to 

look at, so that's part of the reason why I don't 

think we should go into that detail. If they 

accept this and they ask us, then we can have 

that discussion if that makes sense.

MEMBER BOWMAN: It does. I was 

thinking more of like, there could be difference 

of opinions on how low would be acceptable. But 

there would probably be consensus that it 

shouldn't be any higher than this.

You know, some are going to say a .1 

percent, .5 percent, 1 percent, at some point 

there will be a number where we're all lower than 

that.

So for example, in the case of the 25 

cases we're reviewing, if there was one in which 

there was an egregious error, that's 4 percent.

And we're having this conversation 
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because we found potentially one out of 25 so 

clearly 4 percent error is not acceptable to the 

entire Board.

And so I was thinking of some minimal 

-- you're right, some of us might say 1 percent 

is enough, but if they do the analysis and they 

say we know for sure it's not 10 percent or 

higher, that would not be satisfactory I think.

CHAIR MARKOWITZ: Right. One thought I 

had about this is, and this goes to the issue of 

conflict of interest, is whether this function 

should be integrated in -- and again this 

actually is the kind of question that the 

Department would address and it's their business 

to address, but would you integrate this set 

quality assessment into the current contractor 

who hires the CMCs? Or would it or should it be 

done by a separate party?

Again, this gets into how the 

government operates and so I sort of hesitate to 

even explore this, but the reason I raise it is 

because of conflict of interest.
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And the question is, I'm a little 

uncomfortable with the idea that this might be 

taken on by the same contractor who produces the 

CMC reports because I don't know how you avoid 

the perception at least of conflict of interest.

And I'd feel more comfortable if the 

Department hired a couple of consultant 

physicians who were experts in causation or 

impairment, whatever the issue is, and 

independent of the contractor, and had them 

review those and make these determinations so 

that the expertise was brought in house, in a 

sense, similar to the national office has 

industrial hygiene expertise.

To me that distance from the people, 

the entity that produces the CMC reports, it 

would be more comfortable in terms of conflict of 

interest or perception.

I'm wondering how other people view 

that. Dr. Bowman?

MEMBER BOWMAN: I would agree with 

that assessment in terms of as well as building 
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public confidence in that assessment as well.

CHAIR MARKOWITZ: Yes.

MEMBER BOWMAN: I think it contributes 

to both of those.

CHAIR MARKOWITZ: Board members who 

are on Webex, any comments here?

MEMBER FRIEDMAN-JIMENEZ: Yes, this is 

George Friedman-Jimenez. I have two comments. I 

think that self-evaluation is something that we 

do all the time in quality assurance.

And, you know, if there's a welldefined methodology, the optics can be okay about 

it, but I agree with you that there is some 

discomfort about the perception of conflict of 

interest.

Similarly, I'm a little concerned 

about applying this only to denied claims. And I 

would form this as a question to the Department 

of Labor leadership. What do you think?

You think that there is going to be 

any pushback or any perception that we're onesided here? That we're ignoring any errors that 
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would tend to overcompensate and only looking for 

errors that would tend to undercompensate?

I know there's the mandate to be 

claimant-friendly, but it would seem to me that 

we could do, you know, a different percentage of 

cases of denied and accepted claims, and then 

produce some information that would probably 

confirm that most of the accepted claims are on 

pretty solid reasoning and that the problem is 

more toward the denied claims.

But that remains to be seen and what 

do you think? Is there any problem with 

perception here if we only limit this to denied 

claims?

MR. VANCE: This is John. Yes, let me 

just give you a word of advice from many years of 

working in the United States government. And this 

is just for consideration here.

The thing that I would say, this is 

just my own personal view and it's something to 

promote discussion. You have to be very careful 

with what you wish for.
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If you ask the question, you may not 

get an answer you're going to like. So in other 

words, if you do have individuals that are 

looking at this process, be aware that they could 

come back with recommendations or viewpoints that 

may not align with what you wanted or expected.

So in other words, let's say you have 

physicians that are being tasked to look at this 

either denied or accepted cases that are very 

conservative in their viewpoint about how this 

process would work, and maybe are saying that 

this program's way too flexible in how they are 

processing these cases. 

So you just have to be very careful 

with these kinds of notions of having external 

auditors or what have you because they may bring 

in their own perspectives that may not 

particularly mesh with what you are hoping to 

achieve.

So, just something to be thinking 

about. I would say, Dr. Friedman-Jimenez, 

whatever the Board would recommend would be taken 
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very seriously by the Department of Labor and we 

would put some real deliberation into what would 

be recommended as far as what the population to 

look at here.

Are we talking about denied cases or 

accepted cases or a combination of both? I think 

that would just play out in the dialogue that the 

Department of Labor would have with the Board.

So I would certainly encourage more 

dialogue among the Board members about this, but 

I think that this is something that we would just 

whatever the Board would recommend, we would 

deliberate on it and provide some feedback to 

that recommendation if this would be something 

the Board would proceed with.

CHAIR MARKOWITZ: Thank you. Steve 

Markowitz. One problem with doing accepted claims 

is they're accepted. The Claimant has been told 

that their claim is accepted and then a month or 

two or six months later they learn, no, actually 

we made a mistake.

Your claim is not accepted. That 
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strikes me as being very awkward and probably not 

going to be tolerated to the reversal of an 

accepted claim so the error of over-accepting is 

a different kind of error than denying 

inappropriately .

MEMBER FRIEDMAN-JIMENEZ: We could do 

this without identifying the individual case. You 

know, this is essentially a quality assurance 

exercise.

So I don't think that we would be 

obligated to reverse the decision in an 

individual case. But we could at least say, you 

know, out of a hundred claims that were accepted 

we found problems with three of them.

Whereas out of 300 cases that were 

denied, we found problems with 40 of them. So, 

you know, we could get a sense of where the 

errors are and that might be perceived by 

Congress or by other outside observers as being 

more balanced.

I don't know if this is a problem that 

we need to address or if this is not likely to be 
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a problem. That's what I was asking.

CHAIR MARKOWITZ: Steve Markowitz, one 

last comment and then the others who want to 

speak here. If you had the resources to do 

additional claims, wouldn't you want to do 

additional denied claims rather than do accepted 

claims so that you get that much better a handle 

on the problems of wrongly decided, you know, CMC 

reports?

Dr. Van Dyke, I think your card was up 

next.

MEMBER VAN DYKE: So I think that, you 

know, the issue of doing denied claims, you know, 

to do those anonymously and we identify claims 

that should have been awarded and they weren't, 

that can't be anonymous.

There has to be some action that comes 

from that identification, because if there isn't, 

it's just not a good exercise to go through.

CHAIR MARKOWITZ: I'm sorry, Steve 

Markowitz, are you saying is or could there be a 

mechanism in place to use the revised CMC opinion 
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or the new CMC opinion to change the decision in 

the claim?

MEMBER VAN DYKE: If we find a claim 

that is denied in error --

CHAIR MARKOWITZ: Right. What happens?

MEMBER VAN DYKE: Yes, what happens?

CHAIR MARKOWITZ: Mr. Vance --

MEMBER VAN DYKE: Something needs to.

CHAIR MARKOWITZ: Mr. Vance, what

would happen?

MR. VANCE: It would be re-opened. If 

we had reason to believe that there an erroneous 

denial, the Director would, under her authority, 

vacate that denial and we would likely send that 

case back for further development.

CHAIR MARKOWITZ: Thank you.

MR. VANCE: As we have done in the 

past from instances where the Board has 

identified issues with cases where we needed to 

go back and revisit the case, we've taken action 

to go back and re-evaluate cases based on input 

from the Board.
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CHAIR MARKOWITZ: Okay, additional 

comments? Dr. Bowman?

MEMBER BOWMAN: Yes, two. One is, is 

there any chance that this process could occur 

rapidly such that it could be done before a 

decision is made that avoids this whole are we 

looking at accepted or denied?

CHAIR MARKOWITZ: Well, Steve 

Markowitz. Now you're talking, you know, 

timeliness. That's extremely important to the 

program. Mr. Vance, is there an answer to that 

question or, besides timeliness is important?

MR. VANCE: So it would be 

exceptionally difficult because you would be 

inserting yourself into the temporal development 

of individual cases. You're not going to have all 

of these available at the same time.

So you're talking about a moving 

target as cases are going through adjudication 

steps, you know, and that dynamic changes over 

time. Am I going to say it's impossible, no. Am I 

going to say it's possible, yes.
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I think it just would be very 

difficult with the time allocation available to 

the Board, but again, I always defer to you can 

always ask and you will get an answer. So that 

would be the answer to that question.

CHAIR MARKOWITZ: Dr. Bowman?

MEMBER BOWMAN: And this, sorry, and 

the second point given the discussion we had 

about the perception of fairness maybe is the 

right word in terms of if we're stating to only 

do denied claims.

My understanding is the recommendation 

to add this for denied claims was a matter of 

feasibility to put the attention to something 

that was feasible.

So we currently have the statement on 

the recommendation that this should be applied 

only to denied claims, but if it's for the 

purpose only of feasibility and it's not an 

unacceptable thing that if some accepted ones 

were analyzed, perhaps this should just say this 

process may be applied only to nine cases, 
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basically to give the Department the opportunity 

to restrict it if they wanted to, but if they 

needed to expand it, they could.

CHAIR MARKOWITZ: How about this? 

This process may be most usefully applied.

MEMBER BOWMAN: I like it.

CHAIR MARKOWITZ: That's why I'm up 

here.

MEMBER BOWMAN: Yes.

CHAIR MARKOWITZ: I'm sorry, Dr. 

Vlahovich, before you go, Kevin, could you just, 

the third line from the bottom where it says 

process. Then write may most usefully be applied.

And then you can take out the should 

be applied. Okay. Thanks. Dr. Vlahovich?

MEMBER VLAHOVICH: Sure. Kevin 

Vlahovich. Just considering what do we want the 

goal of this to be? Do we want to identify 

individual claims to re-evaluate or are we trying 

to take a broad view and just identify a 

potential problem that would then need further 

evaluation to determine what it is?
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Or to find particular CMCs who are not 

doing a good job and need remediation? I mean, 

what is the overall goal of having this review?

CHAIR MARKOWITZ: I can take a stab at 

answering that question unless somebody else 

wants to. So I think it's literally to identify 

incorrect CMC reports, and also secondarily to 

understand the magnitude of the problem. 

Because if it's, if you know, in a 

given quarter you do 10 percent of all reports, 

and then you find that 20 percent of them were 

problematic, I think it's unlikely, but then 

you'd say well we've got a systematic problem 

here we have to address.

So I think it's both to identify 

problematic reports, but also to understand the 

magnitude. And then, you know, I think there 

would be some ramifications that flow from that 

in terms of identifying certain CMCs who may not 

be optimal for the program.

But that's, you know, sort of beyond 

certainly our recommendation at the moment. Does 
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that answer the question?

MEMBER VLAHOVICH: Yes. Thank you.

CHAIR MARKOWITZ: Anybody else? 

MEMBER FRIEDMAN-JIMENEZ: Yes, this is 

George Friedman-Jimenez.

CHAIR MARKOWITZ: Yes, go ahead, 

George.

MEMBER FRIEDMAN-JIMENEZ: I see the 

awkwardness of a disagreement between the 

evaluation that we would do and the evaluation 

that the CMC did.

And I also see that, I believe it's 

probably more common that claims are denied 

erroneously than that are accepted. One way to 

get around that would be to do this 

prospectively.

In other words, to do the evaluation 

of the evaluation before or at the same time that 

the CMC is doing it and compare them before the 

final decision is made.

And if they agree, obviously we would 

go with the agreed decision. If they disagreed, 
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then it could be, you know, sorted out before the 

decision is made formally and avoid the awkward 

situation.

And it would still give us the 

information that we're looking for of whether 

there is a problem in the process of the causal 

analysis. So that's another option that we could 

do is to do it simultaneously or prospectively.

Obviously it would have to be done 

timely because these are people that are waiting 

for their compensation decision.

CHAIR MARKOWITZ: Steve Markowitz. 

Yes, I think that addresses the design of this 

kind of evaluation if it's undertaken. And it 

certainly would be an option you know, with 

logistic tradeoffs for the program which I'm sure 

the program would have, you know, feelings about.

So I don't think we should get to that 

level of detail in this recommendation, but 

should it be accepted and our advice asked about 

the design then we could certainly, you know, 

float that as an option.
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I would like to get back to the issue 

of accepted claims and so we have two choices 

here. One is we can leave out the accepted claim 

as a friendly amendment to this recommendation.

Or we can try to incorporate it in a 

way that the majority of the Board members would 

vote for. And so, for instance, one could say 

this process may most usefully be applied to 

denied claims so the Department may wish to apply 

it to a limited number of accepted claims, which 

at least puts the issue on the table.

Or, some variation of that or we could 

just leave out the accepted claims. So I don't 

really get a sense of how the Board members come 

down on this, which option would be approved. So 

think about it for a moment.

We could put in some language around 

accepted claim. Just vote on that as a yes/no, as 

a friendly amendment to this recommendation we're 

looking at and if it's voted up then we include 

it. If it's voted down then we exclude it. And 

then we'll revote on the core recommendation with 
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or without the accepted phrase. Does that make 

sense? Okay, we're hitting that post-lunch 

period.

MEMBER FRIEDMAN-JIMENEZ: Question --

CHAIR MARKOWITZ: Dr. Cloeren?

MEMBER CLOEREN: I think --

MEMBER FRIEDMAN-JIMENEZ: Do we have 

any evidence from the past case evaluations that 

we've done, the case reviews of accepted claims 

being erroneous?

I don't remember any. Do you remember 

any that were accepted, but that we thought 

shouldn't have been accepted?

CHAIR MARKOWITZ: Yes.

MEMBER FRIEDMAN-JIMENEZ: I don't 

remember any cases like that.

CHAIR MARKOWITZ: Steve Markowitz. I 

don't. My reaction would have been like wow, 

that's generous. I don't remember having that 

reaction to any claim, any CMC report.

MEMBER FRIEDMAN-JIMENEZ: So we do 

have some evidence that supports this applying it 
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only to denied claims. I mean, it's not 

systematic, it's not officially tabulated.

But unless anyone can remember even 

one case where we thought that it should not have 

been accepted and it was, then we have some 

evidence there because we probably reviewed what, 

about a hundred cases so far?

CHAIR MARKOWITZ: A sizeable number I 

would think since 2017.

MEMBER FRIEDMAN-JIMENEZ: And it's 

informal, but it is evidence.

CHAIR MARKOWITZ: Yes. Dr. Cloeren?

MEMBER CLOEREN: I think a potential 

solution could be, and I guess it's maybe getting 

into the design again, but for accepted cases, if 

it makes sense to sample some of them, to do 

those in a de-identified way so that there's not 

an opportunity really and certainly not an 

obligation to reverse an accepted decision. It 

would be handling it differently than the denied 

claims, but I think that the onus on, you know, 

what to do about an erroneously denied claim is 
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different.

CHAIR MARKOWITZ: Well, Steve 

Markowitz. I mean, to me that gets into how the 

program actually operates which is probably more 

detail than we need to address or maybe should 

address at this point.

Because the Program's going to make 

their own decision about that, you know. Other 

comments?

MEMBER FRIEDMAN-JIMENEZ: Just one 

quick one. My feeling is that we have identified 

several workable mechanisms. We believe that this 

is feasible and can be done and I agree with you 

that we don't have to specify which of those 

mechanisms the Department should choose.

I think there are multiple mechanisms 

that this could be done and I feel satisfied that 

it's a feasible recommendation.

CHAIR MARKOWITZ: So let me ask you, 

Dr. Friedman-Jimenez, because you're the original 

proponent of considering accepted claims, do you 

still support including accepted claims in the 
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evaluation?

MEMBER FRIEDMAN-JIMENEZ: I actually 

would prefer to do it prospectively to avoid the 

really, I agree, awkward situation where someone 

has already been compensated and then you decide 

that it's not correct.

So we could do a small percent 

prospectively and the rest retrospectively, the 

retrospective only being denied claims. That 

sidesteps the whole issue of the awkward 

reversal.

And if they want to re-open a denied 

claim, I think that's fine. But you definitely 

don't want to re-open an accepted claim.

CHAIR MARKOWITZ: So let me propose, 

then, that we add some language here that 

addresses the accepted claim issue. And so in the 

sentence that we just added or revised, this 

process may most usefully be applied, I would 

take out the word "only" to denied claims, but 

may also be applied to accepted claims, if the 

Department desires. Okay, capital D. 
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Dr. Bowman?

MEMBER BOWMAN: Just to go with what 

Dr. Friedman-Jimenez was saying, might it instead 

it be: but may also be applied prospectively in 

the small number of cases? Just to avoid this 

issue of re-opening accepted claims.

CHAIR MARKOWITZ: So I --

MEMBER FRIEDMAN-JIMENEZ: I think 

that's --

CHAIR MARKOWITZ: What's that, Dr. 

Friedman-Jimenez?

MEMBER FRIEDMAN-JIMENEZ: Yes, I 

agree. I think that would be a better way to 

phrase it. It doesn't even open the issue of 

evaluating accepted claims.

CHAIR MARKOWITZ: Okay. So you're 

saying that after --

MEMBER FRIEDMAN-JIMENEZ: May also be 

applied prospectively.

MEMBER BOWMAN: To a fraction of --

how to say it correctly? We can just say it may 

also be applied prospectively.
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CHAIR MARKOWITZ: To a certain number 

of claims.

MEMBER BOWMAN: Yes, right.

CHAIR MARKOWITZ: Okay. Yeah, to a 

certain number of claims. 

MEMBER BOWMAN: Not that the entire 

analysis would be done prospectively, but a 

fraction.

CHAIR MARKOWITZ: And then you can 

take out the "accepted claims, if the Department 

desires."

MEMBER FRIEDMAN-JIMENEZ: Claims under 

current evaluation, maybe.

MEMBER BOWMAN: I guess the word 

"prospectively" would mean that. Right?

MEMBER FRIEDMAN-JIMENEZ: Yeah.

CHAIR MARKOWITZ: There is -- you 

know, we are going to have a rationale that goes 

along with this, so we'll have an opportunity to 

explain what we mean. So you can take out "if the 

Department desires." 

Okay, any other friendly or unfriendly 
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amendments to this language?

MEMBER FRIEDMAN-JIMENEZ: A certain 

number of claims -- it's asking for some more 

words here. Currently --

CHAIR MARKOWITZ: It's asking whom?

MEMBER FRIEDMAN-JIMENEZ: It feels 

incomplete. A certain number of -- because that 

could be accepted claims, that could be denied 

claims, it could be unevaluated claims. 

Prospectively should be claims that are being 

evaluated or currently being evaluated.

CHAIR MARKOWITZ: I see, right. Under 

evaluation.

MEMBER FRIEDMAN-JIMENEZ: Under 

evaluation, yeah.

CHAIR MARKOWITZ: Yeah, okay.

MEMBER BOWMAN: Instead of a certain 

number, should we just say some? That's a 

question not a --

CHAIR MARKOWITZ: How about a number?

MEMBER FRIEDMAN-JIMENEZ: A small 

sample.
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CHAIR MARKOWITZ: What's that? Some?

MEMBER CLOEREN: Why say it in one 

word when you can say it in four?

(Laughter.)

CHAIR MARKOWITZ: Exactly. How about 

just "to a number of claims" in there?

MEMBER BOWMAN: Sure.

CHAIR MARKOWITZ: Yeah, to a number of 

claims. Leave it open-ended. 

Okay. This is the recommendation. Is 

there a second? We're going to have -- there's 

more of a chance for discussion. Don't worry. Mr. 

Key, I know you're dying to weigh in here. 

Is there a second?

MEMBER BOWMAN: Second.

CHAIR MARKOWITZ: Okay. Any final 

discussion? 

Okay, I'm going to read the 

recommendation. The Advisory Board on Toxic 

Substances and Worker Health recommends that 

EEOICP implement a mechanism to evaluate the 

validity and accuracy of the opinions and 
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rationales -- rationales; it should be plural --

that are expressed in the reports of the Contract 

Medical Consultants in the claims evaluation 

process, with particular attention paid to the 

issue of causation of disease. This process may 

most usefully be applied to denied claims, but 

may also be applied prospectively to a number of 

claims under evaluation. This mechanism should 

have sufficient independence of the current 

method of developing and obtaining CMC opinions 

in order to avoid actual or perception of 

conflict of interest. 

So it's time for a vote.

MR. JANSEN: All right, I'll record 

the vote. Dr. Bowman?

MEMBER BOWMAN: Yes.

MR. JANSEN: Mr. Catlin?

MEMBER CATLIN: Yes.

MR. JANSEN: Dr. Cloeren?

MEMBER CLOEREN: Yes.

MR. JANSEN: Dr. Friedman-Jimenez?

MEMBER FRIEDMAN-JIMENEZ: Yes.
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MR. JANSEN: Dr. Markowitz?

CHAIR MARKOWITZ: Yes.

MR. JANSEN: Dr. Mikulski?

MEMBER MIKULSKI: Yes.

MR. JANSEN: Dr. Van Dyke?

MEMBER VAN DYKE: Yes.

MR. JANSEN: Dr. Vlahovich?

MEMBER VLAHOVICH: Yes.

MR. JANSEN: Mr. Key?

MEMBER KEY: Yes.

MR. JANSEN: Ms. Splett?

MEMBER SPLETT: Yes.

MR. JANSEN: Ms. Whitten?

MEMBER WHITTEN: Yes.

MR. JANSEN: All 11 Board members 

voted yes.

CHAIR MARKOWITZ: Okay. Yes?

MEMBER KEY: Dr. Markowitz, could we 

have a printout before the end of the meeting of 

the recommendation?

CHAIR MARKOWITZ: Yes. Okay, we have 

20-odd minutes before break, and so we're going 
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to start on our case review. So, two members of 

the Board have been asked, on each of the cases 

that we've looked at, to review the case and 

discuss the case. It's all with personally 

identified information obscured so no details 

will be provided whereby any claimant could be 

identified.

These cases were given to us, by way 

of background, in 2022, we asked for only certain 

types of cases. I think mostly denied cases, 

denied claims. But there were some cancer cases, 

some beryllium, some chronic lung disease, some 

Parkinson's disease cases. And then at that time 

we were also interested in impairment, and we 

asked for some of those cases. We're not going to 

discuss impairment cases today. We're going to 

discuss the other cases. 

And any other background that people 

need to know that I haven't mentioned? 

Okay. So, why don't we start with a 

beryllium case that Dr. Van Dyke and Dr. Cloeren 

were assigned, last four digits 2157?
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MEMBER CLOEREN: So, my challenge is I 

did them a week ago and I submitted the form and 

didn't keep copies.

CHAIR MARKOWITZ: Okay.

MEMBER VAN DYKE: I did not. I have my 

notes from the --

MEMBER CLOEREN: Okay.

CHAIR MARKOWITZ: Okay, so --

MEMBER CLOEREN: You take the lead and 

I'll chime in if --

MEMBER VAN DYKE: How about that? All 

right, so as Dr. Markowitz said, this is a 

beryllium case. This is a case that had a final 

decision in 2019. And, you know, just for 

reference, the claim was filed six months 

earlier. So about a six-month time from initial 

claim to final decision. 

This was an individual who indicated 

they worked at a beryllium vendor, more than 30 

years at that beryllium vendor. They filed the 

claim in 2018 after receiving two abnormal 

Beryllium Lymphocyte Proliferation Tests. They 
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also had letters to support their diagnosis from 

the beryllium -- I'm trying to make sure I don't 

say names here -- the beryllium vendor medical 

director. 

And then, you know, I think the most 

interesting thing about this case is this person 

had a BeLPT that was positive in 2018; however, 

in the early 1990s, this person had been sent to 

a physician and had been evaluated for beryllium 

disease. At that time, he was evaluated, CT scan 

as well as biopsy, both consistent with beryllium 

disease, but he had a negative Beryllium 

Lymphocyte Proliferation Test, which really meant 

that, you know, they called the diagnosis 

sarcoidosis rather than beryllium disease.

So this person, truthfully, met the 

pre-1993 criteria a long time ago in terms of 

having three of those potential issues related to 

beryllium, but it was not officially compensated 

until 2019 after the positive Beryllium 

Lymphocyte Proliferation Test. 

So, I mean, I think that's the 
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interesting piece about this. You know, in terms 

of kind of how it was handled and how it went 

through the process, really a straightforward 

case, in that you worked at a beryllium vendor 

and, you know, beryllium exposure was pretty 

well-established by a letter from the vendor. 

There was no IH report. The Statement 

of Accepted Facts was correct, and it provided 

correct information to the CMC. And, you know, 

the CMC drew the correct conclusions, including a 

diagnosis date so they backdated the date of 

onset of CBD to 1990, rather than calling it in 

2018.

Do you want to add to that? Is that 

enough detail?

MEMBER CLOEREN: That was great. I 

agreed. I thought it was well-handled, and 

actually kind of appreciated the vendor medical 

director kind of advocating also for the right 

decision.

CHAIR MARKOWITZ: 1990 medical record, 

but because they had a negative beryllium blood 
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test -- because the claim was after 1992, when 

you needed a positive blood test, didn't have 

that positive blood test back then, it could only 

be accepted more recently when they developed the 

positive blood test.

MEMBER VAN DYKE: You know, I think 

you would have met criteria in 1990 because he 

would have been diagnosed under the pre-1993 

criteria. But he didn't file until 2018.

CHAIR MARKOWITZ: Right, yeah.

MEMBER VAN DYKE: When he was leaving 

employment at his current place.

CHAIR MARKOWITZ: Interesting. Okay, 

thank you. 

There's a chronic lung disease case 

that Mr. Key and Dr. Friedman-Jimenez signed up 

for, 2282.

MEMBER FRIEDMAN-JIMENEZ: I have not 

reviewed that case yet. Can we do it tomorrow or 

later?

CHAIR MARKOWITZ: Yeah, we'll have 

time tomorrow, I'm pretty sure.
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MEMBER FRIEDMAN-JIMENEZ: Okay, yeah, 

I've only gotten to one out of the three.

CHAIR MARKOWITZ: That's fine. I mean, 

if we run -- I mean, I reviewed the case so if we 

run short, I can fill in. But let's postpone it 

and do a different case.

How about a chronic lung disease by 

Ms. Splett and Dr. Vlahovich, 2347?

MEMBER SPLETT: Kevin, do you want to 

start?

MEMBER VLAHOVICH: Sure. I can go 

ahead and start. So this was a gentleman who 

worked as a Navy, at Naval Reactors Facility from 

1985 to 2002, and then at INL from 2003 to 2019. 

He had submitted a claim for COPD, or chronic 

lung disease/COPD. The claim was eventually 

denied for emphysema, as well. So it was --

sorry, I'm reading off my notes.

I believe it was denied for emphysema, 

even though that was one of the -- or the 

diagnoses that he had submitted a claim for 

because there was documentation lacking from the 
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medical record of that specific diagnosis. 

Do you want to add anything?

MEMBER SPLETT: Yeah, I was a little -

- this is one of the claims I was concerned about 

in that he was an RPT and they went to the SEM.

CHAIR MARKOWITZ: RPT, what's that?

MEMBER SPLETT: Radiation Protection 

Monitor. They went to the INEL SEM and took those 

eight toxins, but he worked at a specific 

building for which there is a SEM, but his job 

category was not listed. But his almost 16 years 

was in that facility, and that facility had like 

a 128 toxins and those were not considered for 

his claim.

And, I don't know, I guess for Mr. 

Vance, I don't know if we can ask you those 

questions, whether is that normal if you get 

someone, an HPT or an RPT, that we know is at a 

facility that would have that function, but it's 

not in the SEM, would it be more appropriate for 

him to be considered under that portion of the 

SEM versus INL overall, which only has eight 
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toxins?

MR. VANCE: Yeah, it's really 

difficult for me to be able to comment 

specifically to the case. I mean, they're 

generally going to apply their analysis to the 

employment, the labor, or the location to the 

employee worked, or a combination of those, in 

trying to profile out and prioritize which toxins 

had the greatest eventual effect in the case.

Really hard for me to know without 

looking at the specifics, but that's how they 

would approach it. They would look at what 

information do they have that ties this employee 

to a job or a location or a combination of those, 

and then try to filter through which toxins are 

the ones that are most likely to be tied to 

whatever disease was being claimed. It sounds 

like it's a respiratory disorder.

So they're trying to make these 

filtered connections to what they need the 

physician to look at after it goes through that 

IH assessment.
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So, I don't know whether I'm answering 

your question, but that's how they would approach 

it.

MEMBER SPLETT: But, again, INL 

overall had eight toxins. They sent seven. He 

indicated a number of other toxins and the 

building he specifically worked at had 128 

toxins, but it did not have him as a job 

category. They only had two categories in that 

building and, logically, you know, there were 

more. 

So that was my problem, and other than 

that, Kevin was absolutely right. Emphysema was 

mentioned multiple times, but there was no 

documentation in the medical record anywhere, 

other than, you know, sort of casually, yeah, I 

think he has emphysema, too. But no further 

testing. But his lung disease was also denied.

CHAIR MARKOWITZ: Is this case an 

instance of someone who had one of these sitewide job titles, health physicist tech, in which 

--
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MEMBER SPLETT: Yes.

CHAIR MARKOWITZ: -- it's uncertain, 

actually, both what they might have been exposure 

to and the extent of exposure?

MEMBER SPLETT: He was in that one 

facility for 15.9 years, doing that job in that 

facility.

CHAIR MARKOWITZ: Right.

MEMBER SPLETT: And that's all 

documented. But the SEM does not have that job 

category, so they considered him under the INL 

RPT that just had eight toxins.

So, other than that, it was welldeveloped and what not, but I just felt that was 

probably a miss.

CHAIR MARKOWITZ: Steve Markowitz. You 

know, this is a case, like other of the site-wide 

job titles, that in my view might benefit from an 

interview by the Industrial Hygienist of the 

claimant to really get a better sense of what 

they were exposed to and the extent -- really, 

the extent of their exposure, because it's 
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unclear from the job title.

I mean, even given what you're saying 

about being in one building, it's still unclear, 

and there's only so much detail you get from the 

Occupational Health Questionnaire or from the EE3. But an interview, a direct interview, with the 

claimant would provide that detail. It doesn't 

dictate how the case is going to go, how the 

claim is going to go, but at least you're 

confident that you've got the detail about 

exposure in order to make a decision. 

Anything else on this case? Okay. 

I know, Mr. Key, you and I had a case 

of cancer, 0014. And while you're welcome to go 

first, I'm betting you may defer to me. But it's 

up to you.

MEMBER KEY: Yes, I'll defer for you 

to start and I'll --

CHAIR MARKOWITZ: Okay. This is a 60-

plus-year-old person. Thyroid cancer and lung 

cancer, Paducah, and the person was an 

administrative assistant, an executive 
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administrative assistant, for five years at 

Paducah. And said that she toured the plant, she 

used to give tours of the plant to visitors, and 

she also handled contaminated records. That was, 

I think, from her Occupational Health 

Questionnaire.

It's a denied case. The industrial 

hygiene report concluded that she had the 

potential for exposure to asbestos, but no 

evidence that exceeded regulatory standards, that 

language from a couple of years ago. So it was 

denied because, basically, there was no evidence 

that she had exposure to -- significant exposure 

to any agents that produced thyroid cancer or a 

lung cancer.

I agree with that decision. I think 

it's unlikely that she would have had enough 

exposure to cause a lung cancer or a thyroid 

cancer. I would have felt somewhat more 

comfortable if someone had probed a little bit, 

somewhere in the process, probed a little bit 

about her perceptions about her exposure giving 
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tours of the plant. Personally, I'd like to know 

how often they occurred. When you say 

contaminated records, what's that mean? Again, 

how often it occurred. 

So I'd like more information about the 

exposure, but, ultimately, I doubt that the 

decision would have been different, even with 

that information. As a matter of process, though, 

I would have felt more comfortable with more 

detail. 

Mr. Key?

MEMBER KEY: Yeah, what was surprising 

to me in the review of this case was the fact 

that the Contracted Medical Consultant in his 

review of the case used the infamous wording that 

it is as likely as not that her exposure did 

cause her lung cancer. And I'm surmising that the 

CE disregarded the Contract Medical Consultant's 

opinion and denied the case, which I do not agree 

with. 

As far as the exposure that she may or 

may not have contracted as her responsibilities 
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of reviewing contaminated records stored in a 

CONEX storage container, clearly evidence 

historically has pointed to the fact that 

personnel monitoring of individuals in areas of 

toxic substances did not occur on a regular 

basis, and do not occur still today.

CHAIR MARKOWITZ: So, you and I have 

different memories about what the CMC said, so 

tonight I'm going to check to see. Because you 

remember the CMC accepting the case; I remember 

them not accepting the case. So that factual 

point we'll clarify.

Personally, I would like to see the 

Industrial Hygienist list what they reviewed on 

the exposure side. I want to see them write that 

they affirmatively reviewed the EE-3 document, 

the OHQ, which I think they do, but to, me it, 

should be in the reference list.

They have a stereotypic reference 

list. It's usually the same six references we see 

every time. I'm not sure what the value of some 

of those references really is, but, regardless, 
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at least we should have the comfort that we know 

they said they reviewed pertinent exposure 

documents and included that in their evaluation. 

Okay, anything else? No? We're good.

MEMBER KEY: No, sir.

CHAIR MARKOWITZ: Okay. There's a case 

by Mr. Catlin and Dr. Mikulski, a cancer case, 

7539.

MEMBER MIKULSKI: Yes, and Mark, are 

you okay if I start and then you'll eventually 

pitch in?

MEMBER CATLIN: Oh, sure. It's an 

interesting, complex case.

MEMBER MIKULSKI: So this is a twopart claim for a 70-year-old Savannah River Site 

employee who claimed breast cancer and salivary 

gland cancer. That employee worked at the 

Savannah River Site for a total of almost 13 

years in jobs in the custodial department, as 

well a painter and photographer.

The initial breast cancer claim was 

filed in 2020 under both Parts B and E. The claim 
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was denied based on probability of causation 

lower than 50 percent which sparked the denial of 

a Part E claim, as well.

This claim has been re-opened since 

then based on the new designation, Special 

Exposure Cohort designation, for construction 

trade employees from Savannah River Site, but 

there is no updates on the status of this claim 

in the file. 

The claimant filed a second claim 

under both Parts B and E for salivary gland 

cancer, which was eventually denied. But it seems 

that the Claim Examiner did all the steps in 

order to make sure to assure that this is not a 

separate cancer claim. They consulted an expert 

in oncology, who noted that the pathology of the 

initial breast cancer claim is overlapping with a 

common salivary gland cancer. And without any 

further evidence of this being a separate tumor, 

this may have led to a confusion in filing this 

claim. 

An interesting issue was identified in 
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the NIOSH referral for the initial breast cancer 

claim. The NRSD that was submitted by the Claim 

Examiner only included a single job title. It did 

not cover different job titles. They only 

included the claimant's work as a painter. 

However, the referral was made properly for the 

entire period of that claimant's employment, so I 

don't know to what extent this may have affected 

the probability of causation calculations.

But, in any case, this case, looks 

like, has been re-opened under the new 

designation of Special Exposure Cohort. So my 

guess, assumption, would be that this was 

eventually accepted.

MEMBER CATLIN: Thank you, Dr. 

Mikulski. So, there was no IH report, and you 

mentioned that. The part that stood out to me is 

the Claims Examiner used the SEM at the site 

looking for chemicals causing breast cancer. And 

the SEM came up with nothing related to breast 

cancer, so that didn't -- that evaluation didn't 

go any further. Which is a little puzzling, given 
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it seems that there's, in the medical literature 

and the exposure literature, a growing number of 

studies showing that women exposed to solvents 

have an increased risk of breast cancer.

So that was what stood out mostly for 

me. And I remember, in 1989, IARC came out and 

said painting is carcinogenic trade for lung 

cancer and other cancers, and there's been 

growing evidence there.

So that would be the biggest part of 

this case that I would think someone could look 

into more. Hopefully, her claim on both the 

radiation side and on the chemical exposure side 

is given another review. And I hope Dr. Mikulski 

is right that the claim will be accepted.

CHAIR MARKOWITZ: Anything else? 

Okay. Thank you. It's 3 o'clock. We're 

going to take a break until 3:15 p.m.

(Whereupon, the above-entitled matter 

went off the record at 3:00 p.m. and resumed at 

3:21 p.m.)

CHAIR MARKOWITZ: Okay, let's resume. 
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We have a chronic lung disease case. 

Dr. Cloeren, do you have any of your 

notes or no? You have them? Okay. With Ms. 

Splett, 7716.

So, let me remind you, obviously we 

don't share personally identifiable information, 

but if the combination of gender, age, and site 

are unusual, and therefore is a potential for 

identification, if you could just omit the site, 

or omit the gender or the age. That way there's 

no suggestion that anybody could identify anybody 

from these cases we're reviewing. 

MEMBER CLOEREN: Okay, hello. So, this 

was an interesting case. I'm just going to skip 

the site; it's not relevant, I don't think. This 

was a -- let me see, what was the job? Class A 

maintenance worker, maintenance mechanic, and 

also welder, who filed a claim for a new 

pneumoconiosis, which wasn't really clear what 

was meant by that. And squamous cell cancer of 

the lip. And, really, the development focused on 

the squamous cell cancer of the lip.
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This was a little bit unusual in that 

the -- well, the exposures of concern included --

and these are identified by the Claims Examiner 

using the Site Exposure Matrix, the Occupational 

Health Questionnaire -- uranium, isocyanates, 

asbestos, silica, blah, blah, whole bunch of 

things. But the Claims Examiner also identified 

arsenic as a potential exposure of concern, and 

that was not one that had been identified by the 

claimant or the doctor. So I thought that was an 

interesting aspect of this case. 

It was referred to an Industrial 

Hygienist, whose report was okay. The Industrial 

Hygienist report was then sent to the treating 

doctor. And based on the treating doctor's 

reaction, I guess, and reflection to the IH 

report, the causation was attributed to the 

arsenic, you know, for the lip cancer and the 

claim was accepted.

So I thought this was interesting in 

that it did not go to a CMC. The Claims Examiner 

identified the exposure of concern, the most 
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important exposure of concern, and obtained, you 

know, corroboration, really, by the Industrial 

Hygienist and then worked with the treating 

doctor for a determination.

I don't know, Gail, did you have any 

other things, too?

MEMBER SPLETT: You got all of it.

MEMBER CLOEREN: Okay.

CHAIR MARKOWITZ: There's a case on 

beryllium, 7755. Dr. Vlahovich and Dr. Bowman, 

7755. And then, after that, we're going to do 

case -- while you're looking for it -- we're 

going to do 7016, that's Dr. Van Dyke and myself. 

Anyway, 7755.

MEMBER VLAHOVICH: Dr. Bowman, do you 

want me to start or do you want to go?

MEMBER BOWMAN: It would be great if 

you could.

MEMBER VLAHOVICH: Okay, great. So, 

this was a case for beryllium sensitivity that 

was denied. It was an individual at Los Alamos 

National Lab who worked there from I believe it 
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was 1999 to 2020. And they were an R&D engineer 

at the explosive firing grounds. They had been 

exposed to beryllium, as well as depleted uranium 

high-explosives, radiation lasers, and other 

chemicals.

The diagnoses that they'd submitted a 

claim for were beryllium sensitivity and lung 

weakness. Lung weakness, I believe, was denied 

because there was not enough specific information 

as to exactly what that meant.

They had a normal chest X-ray, normal 

spirometry, and, from my review, they had a total 

of four BeLPT tests. One was normal, one was 

uninterpretable, and two were borderline.

And the claim was ultimately denied 

due to no positive BeLPT. It was reviewed and 

approved for occupational asthma, however. 

Dr. Bowman, did you have anything to 

add? Or did I get anything wrong?

MEMBER BOWMAN: No, you covered what 

my notes had. I had the -- yeah, you covered what 

my notes have.
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MEMBER VLAHOVICH: Okay. So, yeah, I 

guess my question was if, with all those tests, 

because I know a year/a year and a half ago there 

was a recommendation to approve multiple 

borderline tests for positive, if this individual 

might have qualified had this been reviewed if 

those recommendations were used in reviewing this

case.

CHAIR MARKOWITZ: This is Steve 

Markowitz. I don't think the policy or the Act 

has been amended and would address the finding of 

borderlines.

MEMBER VLAHOVICH: Yes.

CHAIR MARKOWITZ: The borderline BeLPT 

as equivalent to a positive BeLPT.

MEMBER VLAHOVICH: Okay.

CHAIR MARKOWITZ: Mr. Vance, anything 

to add to that?

MR. VANCE: That is correct. The Board 

did make recommendations about treating multiple 

borderline BeLPTs as a positive, but that would 

require the Department to change the statute. 
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We've had that conversation. As far as the status 

now, that has not changed. So the position of the 

Department remains that statutory requirement 

necessitates the presentation of an abnormal 

BeLPT.

MEMBER VLAHOVICH: Yeah, and that was 

not present in this case.

CHAIR MARKOWITZ: Dr. Cloeren?

MEMBER CLOEREN: Just by way of 

information, there is a bill, I think it's still 

in Congress, sponsored by Patty Murray that would 

change that. So, we can look forward to that 

decision.

MEMBER BOWMAN: From my notes on this 

one, there was one borderline and then two 

normals. Right? Does that match what you saw?

MEMBER VLAHOVICH: I believe I saw two 

borderline, but I would have to go back and 

review it. There was a normal, an 

uninterpretable, and I put in my notes two 

borderline, but I may be incorrect on that.

CHAIR MARKOWITZ: Okay. Anything else 
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on that case? 

Okay. We're going to do 7016, which is 

a chronic lung disease case, Dr. Van Dyke and 

myself. I don't know whether you want to -- do 

you want to start?

MEMBER VAN DYKE: I can start. So, 

this is a chronic lung disease case that was 

denied. This is an individual that was diagnosed 

with idiopathic pulmonary fibrosis in 2020. This 

person had a 35-year work history as a lab tech 

at one of the smaller sites. 

In his self-reported exposure -- I 

don't know if it's a he or she, actually -- this 

person reported a number of different exposures 

to things like plastics, metals, adhesives, 

resins, a number of different solvents, as well 

as exposure to powdered metals and possibly 

exposure to asbestos and fiberglass. So, a huge 

number of self-reported exposures. 

Kind of the way it appears that this 

case went is that the Claims Examiner went to the 

SEM and looked up those particular substances 
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that were both present at this site and linked to 

pulmonary -- or, I'm sorry, and linked to 

pneumoconiosis-other and also matched with what 

this person said.

So we ended up with these exposures of 

concern that included aluminum, graphite, silica 

gel, crystalline silica, titanium dioxide, and

kaolin.

This was sent to an IH to do an 

exposure assessment and it was identified that he 

had significant asbestos exposure until 1986, 

frequent, very low to low. Post-1986, his 

asbestos exposure was more occasional, very low 

to low. And then he also had exposure to 

graphite, kaolin, silica gel, and silica, 

occasional very low to low exposure. 

Do you want to do the CMC or do you 

want me to?

CHAIR MARKOWITZ: No, you can go 

ahead. I'll just wait.

MEMBER VAN DYKE: Okay. All of this 

information was sent to the CMC and the 
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conclusion was that his employment and exposure 

was not a significant factor in IPF.

There was a lot of justification put 

forward, things like the CT abnormality were not 

consistent with asbestos, aluminum, or silica; 

titanium dioxide -- or titanium is associated 

with hard metal disease, and this really didn't 

look like hard metal disease.

Graphite, in order to cause pulmonary 

fibrosis, requires a high exposure, so it 

couldn't be related there. And then as far as 

kaolin goes, they really justified that, you 

know, kaolin is aluminum and silica, so they 

discussed it above.

From my perspective, I mean, I think 

the interesting thing about this is that, you 

know, this individual listed a ton of different 

exposures, and some of those exposures could be 

related to something that could look a lot like 

pulmonary fibrosis, and those weren't kind of 

carried through the process. 

So, you know, whether that's a factor 
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of, you know, we have a bad diagnosis, a bad 

description of diagnosis, a bad linkage between 

the different exposures in the diagnoses, or some 

combination of all of those, I think that's an 

issue.

And then, you know, what I did like is 

that the Industrial Hygienist did consider the 

information from both the exposure questionnaire 

as well as what was sent down.

As far as the CMC, you know, this is 

like that -- you'd think another occ med person 

is not qualified to evaluate this. I want to hear 

what Dr. Markowitz thinks about that.

CHAIR MARKOWITZ: So this is a 35-year 

lab tech and, you know, lab techs are tricky. 

Right? Because they work -- can work with a lot 

of different products that do different things 

that if you go back, this person worked in the 

'60s.

We don't know the exposure conditions 

and so it makes me a little nervous to actually 

go off a standard list of agents of the toxins 
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that you listed.

Clearly, it went into the SEM through 

the other pneumoconiosis route because the person 

had pulmonary fibrosis and that's within the SEM 

synonymous with other pneumoconiosis and that's 

how they came up with kaolin and all those other 

things. Most of which, this person wasn't exposed 

to because they were a lab tech, they weren't --

But the person did send in a letter 

with their exposures including isocyanate. 

Actually and I looked up isocyanate, it can 

occasionally cause pulmonary fibrosis.

So I worry about lab techs about the 

extent and what they were exposed to over a 35-

year career. My problem with this case is that 

the occ med doc said at the CT scans said this is 

what's called usual interstitial pneumonia, which 

is a medical term, a vague term, for essentially 

almost idiopathic, unknown pulmonary fibrosis. 

And he said this is incompatible with asbestos 

exposure which is false actually.

His reasoning was this, the findings 
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on the CT and this usual interstitial pneumonia 

don't coincide with the findings in an asbestosis 

case. Actually they do.

I mean, that's just a factual error. 

But it got worse. They said it was, I don't see 

any scarring in the pleura outside the lung. We 

usually see that with asbestos so no pleural 

fibrosis, therefore, this can't be asbestosis of 

the lung tissue itself.

That's a mistake because not everybody 

who has asbestosis lung tissue has the, also has 

the scaring of the pleura. So it's a, when you 

see somebody with you're not sure what the 

pulmonary fibrosis is and you look for pleura 

fibrosis and you see it, yes, okay, asbestos.

But if it's not there, you can't say 

it's not asbestos because some people get one 

without the other. And I think that this is one 

of those instances in which they didn't have any 

experience with asbestosis.

Actually they quoted Medscape and 

something else and they just got it wrong, so 
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this was one of those instances in which it 

wasn't just a like, this is what I think, this is 

what you think maybe we're both right, but 

factually it was incorrect. But anyway, Dr. 

Cloeren?

MEMBER CLOEREN: I reviewed a case 

with the exact same argument so it may be more of 

a trend than a one-off, but anyway.

CHAIR MARKOWITZ: Yes.

MEMBER CLOEREN: So.

CHAIR MARKOWITZ: Yes, I mean, look, 

if you did occupational medicine in Chicago, you 

probably learned about silicosis. If you did 

occupational medicine in New York, you probably 

never saw a case of silicosis.

And so that's that variation that I 

was referring to before and if you trained at, 

you know, in New York, the idea that you needed 

pleural scarring in addition to lung fibrosis is 

just, you know, ridiculous.

But in addition, I think that the fact 

that someone didn't pick up that maybe one of 
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these other agents they work with, isocyanates or 

other could relate to this and there really 

wasn't looked into. I think that's a misfortune 

so, otherwise I agree with what you had to say.

MEMBER VAN DYKE: Can I just add one 

more thing?

CHAIR MARKOWITZ: Sure.

MEMBER VAN DYKE: If you trained at 

National Jewish everything looks like 

hypersensitivity pneumonitis.

CHAIR MARKOWITZ: Yes.

MEMBER VAN DYKE: Which, I mean, 

chronic hypersensitivity pneumonitis can look 

like fibrosis too, if I'm --

CHAIR MARKOWITZ: That's right.

MEMBER VAN DYKE: -- correct.

CHAIR MARKOWITZ: And a number of 

these agents have been associated with 

hypersensitivity pneumonitis, as well. So that's 

the first thing that popped out to me. I, you 

know --

CHAIR MARKOWITZ: Yes.
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MEMBER VAN DYKE: -- asbestos isn't my 

thing.

CHAIR MARKOWITZ: Right, right.

MEMBER VAN DYKE: So.

CHAIR MARKOWITZ: Right and it 

occurred to me this could be hypersensitivity 

pneumonitis and I think that that's what 

isocyanate might do actually.

How much he handled, we don't really 

know so we just don't know.

MEMBER VAN DYKE: I was thinking more 

the epoxies, as well.

CHAIR MARKOWITZ: Why not? Okay. 

There's a case of cancer, Dr. Friedman-Jimenez 

and Ms. Whitten, 7855. I feel like we're ignoring 

Dr. Mikulski so next we'll do 8387, the 

Parkinson's disease case, but right now we're 

going to do 7855.

MEMBER WHITTEN: George, you want me 

to go first or --

CHAIR MARKOWITZ: Oh, George, did you 

get a chance to look at this? Because if you 
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haven't gotten a chance to look at this, then --

Maybe he's looking for it now.

Why don't we go to 8387? Dr. Mikulski 

and Ms. Whitten on Parkinson's disease.

MEMBER MIKULSKI: Sure. Diane, do you 

want me to start?

MEMBER WHITTEN: Yes, please. You're 

the Parkinson's expert.

MEMBER MIKULSKI: So this is a denied 

claim for Parkinson's disease in an individual 

who worked for almost 10 years on the assembly 

lines, one of the final assembly plants in the 

DOE complex.

They were diagnosed with Parkinson's 

in the early 2020s and the claim was denied 

almost a year later. It looks that the main issue 

with this claim and the Claim Examiner identified 

all the recently updated exposures in the 

Procedure Manual or rather in the SEM.

But the main issue with this claim was 

the CMC's review who claimed that this is, the 

Parkinson's disease is a disease of aging and did 
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not take into account any occupational history 

that this worker had.

The CMC supported themselves with 

fairly outdated references. They did not take 

into the account any new research or the evidence 

that we have presented when making the 

recommendation about the Parkinson disease.

And the claim was ultimately denied. 

So anything else? Anything else to add?

MEMBER WHITTEN: Yes, going over his 

information, it appeared he worked, he worked 

under a top security clearance. They never took 

that into consideration. They didn't call a 

clearance specialist to review his work history 

or anything. 

And it appeared to me that the IH 

actually agreed in their report that his 

exposures could have more likely than not 

contributed to his Parkinson's disease. But then 

the CE decided to send it to the CMC and that's 

where the CMC referenced one document that was 

put out in 2003, denied the claim.
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CHAIR MARKOWITZ: So, Dr. Mikulski, I 

didn't quite catch everything you said about the 

CMC report. Was that, the opinion expressed 

within sort of a reasonable degree of variation 

that we can accept or was it, you know, way off 

base?

MEMBER MIKULSKI: I believe so. 

Another issue was this is that the CMC was an 

expert in occupational medicine rather than 

urology. And in all fairness, the CE tried to 

reach out actually to the treating physician, but 

had not received any response from them on this 

case.

And hence the choice of the CMC who 

was not an expert in urology to make those kinds 

of statements.

CHAIR MARKOWITZ: Okay. Next case, 

Parkinson's disease, it's 9787, Dr. Van Dyke and 

Dr. Cloeren, 9787.

MEMBER CLOEREN: I can get started. 

This was somebody who -- it doesn't matter where 

they worked I don't think, but the work years 
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were 1974 to 2008 for 33 years.

The job was a photographic lab 

technician and graphics leader at like many 

different jobs sort of increasing responsibility 

over the years.

And I didn't read every one of the 400 

or so pages, but it appeared that there was some 

sort of back-and-forth about the exposures and 

that claimant identified a specific exposure of 

concern that was not found in the Site Exposure 

Matrix which was potassium permanganate which is 

a manganese-containing chemical.

And manganese can cause something very 

similar to manganese exposure toxicity from it 

cause something that looks very much like 

Parkinson's. So in any event, it went to the CE.

I mean it went to the IH and the IH 

appropriately I think determine that there would 

have been very frequent exposure to the 

identified hazardous chemical in the claimant's 

job even though it wasn't in the SEM.

And then it went to the -- so the 
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treating doctor thought that there was a causal 

relationship. The CMC wrote a really short 

report.

Like the medical information in the 

CMC report was limited to six lines or six lines 

that sort of covered the whole medical case. And 

the exposure discussion was just nine lines and 

the CMC basically said that the parkinsonian 

syndrome caused by manganese would not be 

responsive to levodopa which is a commonly used 

drug to treat parkinsonism and the medical 

documentation in this person's case showed that 

they did respond to levodopa.

So therefore, the CMC's opinion was it 

was not manganism but rather regular old 

parkinsonism not caused by the manganese. And 

anyone add to that or correct, Mike, before I 

give my opinion?

MEMBER VAN DYKE: No, I think that's 

all correct. I mean, the thing I'd add is I think 

the good thing here is that there was that back 

and forth with the claimant --
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MEMBER CLOEREN: Yes.

MEMBER VAN DYKE: -- to try and 

identify appropriate exposures.

MEMBER CLOEREN: Yes.

MEMBER VAN DYKE: I mean, it feels 

like, you know, they've built a list of causative 

agents or agents linked with Parkinson's in the 

SEM and they said were you exposed to any of 

these?

It didn't really say that, but that's 

kind of what it felt like. And they were able to 

appropriately identify one of those agents that 

they were exposed to.

So I thought that part was, it showed 

a good back and forth and a good, you know, 

claimant-friendly environment.

MEMBER CLOEREN: And I thought that 

the IH exposure in determination, you know, was 

also appropriate which was great. I thought that 

-- I did a little review and, you know, and I 

think that the bulk of medical evidence does 

agree with the CMC's opinion that manganism 
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reacts differently to levodopa than parkinsonism.

So as far as that went, I think that 

is fine, but I felt like this person was exposed 

to tons of things. And parkinsonism, you know, 

has been associated with others and it doesn't 

seem like there was any consideration given to 

other potential exposures that may be related to 

the disease.

But I know that the answer to the 

Claims Examiner's questions.

CHAIR MARKOWITZ: Steve Markowitz, was 

the potassium permanganate identified through the 

SEM or through the claimant?

MEMBER CLOEREN: The claimant.

MEMBER VAN DYKE: There was nothing in 

the SEM for that job --

MEMBER CLOEREN: Yes.

MEMBER VAN DYKE: -- category.

CHAIR MARKOWITZ: But if you looked at 

the, well maybe you didn't do it, but if you 

looked at the SEM for Parkinson's disease, they 

identified permanganate?
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MEMBER VAN DYKE: Yes.

MEMBER CLOEREN: Yes. But not his, not 

his job working with it. And it was denied.

CHAIR MARKOWITZ: Dr. Bowman?

MEMBER BOWMAN: I'm just going to 

comment on the manganese-related parkinsonism and 

the non-levodopa responsiveness. This is, you 

know, usually the case in the context of 

manganism where there's a very high manganese 

load and you get a parkinsonian like feature that 

is in fact mostly, but not always unresponsive to 

levodopa.

In this case, of course, there's a 

much longer latency and I thought and from your 

discussion, and I had looked over this one 

briefly as well, the consideration of the 

evidence by the CMC was focused solely on these 

sort of acute dosing with manganese and 

associated with Parkinson's disease.

And the lack of the levodopa 

responsiveness ignoring recent work such as from 

the work of Brad Racette with welders and their 
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exposure to manganese that shows a lower level 

exposure to manganese.

Chronic can increase risk for actual 

classic Parkinson's disease which would be 

levodopa responsive. And so the -- it seems to me 

the opinion here is rests solely on one potential 

weighting could cause the parkinsonian features 

and not all potential ways manganese could cause 

parkinsonian features.

CHAIR MARKOWITZ: Interesting. I think 

we're going to move on to the next topic. I know 

we still have a few cases, but I'm not sure how 

long this next topic is going to take.

I want to leave a little time for it. 

It has to do with hearing loss and dementia. And 

Mr. Key raised this issue so I'm going to let him 

or if he wants to start off the discussion.

MR. KEY: Yes, I had reviewed a 

medical report that linked causation. 

And so I wonder within the Department, 

do we have individuals who routinely review 

outside medical reports on diseases, illnesses, 
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et cetera?

MR. VANCE: This is --

CHAIR MARKOWITZ: I think this is a 

question, yes, Mr. --

MR. VANCE: -- yes, this John.

CHAIR MARKOWITZ: Go ahead.

MR. VANCE: Yes, we do have, we do 

have a federal toxicologist that is looking at 

health effect information. She also does research 

into causative standards and health effects so 

she's researching information on petitioners that 

are being put forth to establish new health 

effects in cases.

So she would be the one that would be 

looking at any kind of referral that looks at, 

you know, is there some new data in medical 

health science community that's suggesting that 

there is an established humanistic health effect 

between an exposure to a particular toxin and a 

disease.

CHAIR MARKOWITZ: So Mr. Key raised 

this issue with hearing loss and dementia and, in 
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general, cognitive impairment in relation to 

hearing loss, and had sent me some information 

about that. I can't remember the source exactly. 

But I started to look into it a little bit. It's 

a very interesting issue.

I'm skeptical because I approach all 

new disease-exposure links with skepticism with 

like, you know, you've got to prove that there's 

a link here.

And this is not a question of a toxin 

causing a disease. Because we're talking about 

hearing loss and we're talking about cognitive 

impairment or dementia.

This falls into more like the, what 

the program would consider consequential 

condition. Hearing loss might be, might be caused 

by DOE exposures.

And a person has hearing loss they may 

eventually develop the question is, you know, may 

they develop cognitive impairment or dementia as 

a consequence of having had hearing loss.

And there's a class of compensated 
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conditions that correspond to this consequential 

condition. So the question whether hearing loss, 

how could hearing loss cause dementia or 

cognitive impairment? Next slide.

I only have a couple of slides because 

I really didn't have a chance to look into it. 

But here's a more recent study and it's just one 

study. There are multiple studies in populations, 

but let me explain what this study did.

On the left side, at time zero if you 

look at the bottom, the horizontal numbering, 

years of follow up. The zero corresponds to when 

the study began. And then the vertical axis is 

proportion free of dementia.

And so I can't remember the sample 

size. It was significant. For that matter, I'm 

not, I think it was a U.S. study, but I'm not 

sure where it occurred. 

And so they looked at time. They 

followed this group over 18 years. And they saw 

that the group who had hearing loss -- that's the 

lower brown line -- over time, a certain 
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proportion of them developed dementia.

So the vertical axis is proportion who 

are free of dementia so what that means is by 

year 18 in the brown line, the ones who developed 

hearing loss or who had hearing loss, excuse me, 

during that 18-year period, at the end of the 18-

year period, 50 percent had dementia and 50 

percent did not have dementia.

So for the group that had hearing 

loss, there was a 50 percent dementia rate at the 

end of the 18-year period. And you can see how it 

goes down gradually over time. Right?

In ten years it was closer to a 25 

percent who had dementia. The upper line, the 

black line is the ones -- that's the group that 

didn't have hearing loss. And of course, people 

without hearing loss also developed dementia. And 

you can see that at the end of the 18-year 

period, about 25, 27 percent of them or so had 

dementia. So for the group that didn't have 

hearing loss, a quarter of them developed 

dementia; the group with hearing loss about half 
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of them had developed dementia. That's a huge, a 

huge difference over time. 

So this is just one study. I didn't 

really get a chance to summarize other studies. 

And you know, this doesn't necessarily mean 

causality. It means a number of different 

studies, done different ways, et cetera. You've 

got to look at other factors besides hearing loss 

and dementia.

But if you go to the next slide, I was 

interested in well how could it be that hearing 

loss produced cognitive impairment and forgive 

the typo here.

But one idea is that the brain has so 

much capability of cognition and if a certain 

amount is absorbed in overcoming the mental work 

of hearing loss that it decreases the mental --

the reserve for other mental functions including 

memory and related cognitive functions that would 

lead to either the cognitive impairment or to 

dementia.

I'm not sure I really understand that 
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mechanism why there would be -- exactly there 

would be a tradeoff between the cognitive work of 

hearing loss and the work of memory, but it's not 

my area of expertise anyway.

The second made a little bit more 

sense to me which is that hearing loss tends to 

isolate people because they have less social 

interaction and that can be related to cognitive 

decline because people use their brains 

differently.

A decrease -- in general, social 

isolation would contribute to cognitive 

impairment. One thinking is that maybe to have a 

common underlying pathophysiology or the things 

going on biologically which is that people have 

cognitive impairment have problems with small 

blood vessels.

And that same kind of problem can 

involve hearing loss so maybe they simply have 

like a problem with the microcirculation that is 

showing up as hearing loss and showing up as 

cognitive impairment.
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And then there's some evidence through 

ways of imaging the brain that some of the areas 

the brain that are affected by hearing loss are 

also -- would affect cognitive decline.

So there's some sense here, there's 

some plausibility to this connection. It doesn't 

mean that there is a connection, it just means 

that it's not outlandish to think that there 

might be a connection.

And to me it boils down more to well, 

you know, you study significant groups of people 

in different ways, can you -- what does it show? 

Does it show the people who have hearing loss 

has impact on cognitive function or not?

So it's the kind of disease-exposure -

- and it's not really exposure, excuse me, 

disease-disease link, consequential link that the 

question is, is this something that ought to be 

looked at by the program because there are a lot 

of people with hearing loss.

And maybe not that many compensated by 

the program because of the requirements for 
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exposure to a select group of toxic solvents and 

a select group of occupations during a ten-year 

consecutive exposure prior to 1990.

But there's still sizeable numbers of 

people with hearing loss and obviously cognitive 

decline and dementia is common. So -- and 

expensive.

So it's not a small issue if the 

program were to take it up or not. The question 

is, should the program actually look more in 

depth -- is there enough here to suggest the 

program should look more in depth?

And I haven't -- I don't think I've 

really done a fair job at presenting the data 

there or over the last ten years or so a 

considerable number of studies done of sizeable 

numbers of people, different populations, 

different countries that show that there may well 

be something here.

So personally I'm willing to work with 

the other Board members if we want to just look 

at this a little bit more and see what we find. 
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Really, as an example of whether our collective 

scientific expertise can contribute to an issue 

that may be of importance to the program. I'm 

willing --

MR. VANCE: Dr. Markowitz, can I add 

some clarification to this, to this topic?

CHAIR MARKOWITZ: Sure.

MR. VANCE: So just to sort of 

everybody's education, you know, the standard for 

consequential illness is not the same for 

causation under Part E as at least as likely as 

not and all of that.

It really is a question of medical 

rationale provided by a physician who is 

considering all the different factors that are 

involved in an individual that has work-related 

hearing loss.

It could very well be that a physician 

using this medical health science and other kinds 

of information could make a salient argument that 

an individual that had work-related hearing loss 

and dementia, that the dementia could have been 
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significantly accelerated because of the workrelated hearing loss.

That would be the basis upon which the 

Department of Labor would be able to accept that 

case. We would be looking for how well does a 

physician support an argument suggesting that the 

dementia is in some interpretation of the 

evidence in their view consequential to that 

accepted illness of hearing loss.

So there's not a particular 

presumption that needs to be made here. What just 

needs to be illustrated to the scientific 

community or anyone that's looking at one of 

these cases involving hearing loss is that it 

could very well be that if that individual does 

have hearing loss and there is a dementia 

diagnosis involved, their physician could 

certainly fashion an argument along the lines of 

what you're discussing here, as far as what is 

convincing that physician that the hearing loss 

is contributing to or aggravating or accelerating 

dementia because that would then satisfy the --
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if the doctor provides a well-rationalized 

position about it, that would be sufficient for 

the Department of Labor to accept that claim for 

the dementia as a consequential illness.

So I don't know whether this is 

something that we need to look at from a 

programmatic standpoint, but I just wanted to 

clarify that mechanism exists for physicians to 

make these arguments and to support these kinds 

of claims for a consequential relationship 

without having to have absolute epidemiological 

proof that dementia and hearing loss are 

connected.

So long as the doctor has some sort of 

salient basis and reason and rationale that they 

want to utilize including this graph that I think 

is a very pertinent illustration of the 

situation, would be something that a physician 

could argue and a CE would have to weigh it to 

determine whether or not that's sufficient and 

compelling to allow for an acceptance of a 

consequential illness.
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CHAIR MARKOWITZ: Yes, Steve 

Markowitz. So that's very interesting actually. 

But wouldn't the program want to know as a 

general matter -- let's say you got that letter 

from that personal physician making that 

argument, well-rationalized argument whatever 

that consists of.

And you got that and you were looking 

at that. You said, well is this a consequential 

condition or not? You know? Is there a 

relationship here?

Wouldn't the program want to know as a 

general matter whether hearing loss and dementia 

are connected before deciding whether a 

convincing letter on an individual person from a 

personal physician can win the day?

MR. VANCE: This is what the 

Department of Labor does already with regard to 

all of the opinions that we're getting from 

claimant physicians that are disconnected from 

any kind of health effect data that's maintained 

in the Site Exposure Matrices.
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Very similar kind of situation where a 

physician is looking at and then forming an 

opinion of in this particular situation causal 

relationship to a consequential illness.

It is going to always be the 

discretion of the CE looking at the information 

that's provided by the physician to determine 

whether or not the medical health science the 

doctor seems to be relying upon is sufficiently 

supporting the position being taken.

So in other words, if a doctor would 

utilize the example that you've used in 

fashioning an explanation as to why he or she 

thinks that the individual with work-related 

hearing loss that has dementia, that the dementia 

has been affected by hearing loss.

We see this in all kinds of claims 

nowadays where a claimant's physician is arguing 

some individualistic characteristics of an 

employee's exposure to a particular toxic 

substance contributed to a disease.

Not cause and effect, but contributed 
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to. The example I can go back to is that 

degenerative disk disease that a physician was 

making an argument about with regard to lead 

exposure and the position of the physician in 

showing that there was medical health science in 

his view that supported that position.

And so, you know, the Claims Examiner 

has to look at and evaluate that and say, does 

this medical health science identify the 

condition? Does it, does it proffer an argument 

that is supporting or does that medical health 

science support in a reasonable way what the 

doctor is arguing?

So that would be something the Board 

could certainly look at. Is that mechanism of 

what the CE has to go through to weight this type 

of medical health science that a lot of 

physicians are relying on and promoting as far as 

this is what I'm using to support a position of a 

contribution relationship between either an 

exposure to a particular toxic substance or a 

consequential relationship between one disease 
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and something else that's been accepted by the 

program as work-related.

CHAIR MARKOWITZ: That's an odd, that 

strikes me as a very liberal standard actually. I 

take it that the consequential, the whole issue 

of consequential condition is not in the SEM.

It's not a matter for the SEM because 

the SEM's about toxins and exposures and 

diseases. It's outside that. And within the 

Procedure Manual, I know during the COVID-19, 

that as a consequential condition, that the 

program decided to cover it for certain 

underlying conditions that people had.

Does the Procedure Manual otherwise 

describe certain consequential conditions?

MR. VANCE: Yes, there's entire 

section of the Procedure Manual that's dedicated 

to talking about the steps that are taken to 

evaluate claims for consequential illness and the 

thrust of the guidance to our staff is how well 

does the physician formulate an argument 

supporting a relationship between a work-related 
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illness that we've already accepted and either 

the development or the aggravation or 

contribution or acceleration of some other 

problem, and so there is content in our Procedure 

Manual that speaks to that.

Our Procedure Manual also discusses 

this process by which we evaluate claimant 

submitted medical opinions from their own 

physician that is attesting to some sort of 

individualized response that an employee is 

having to a particular exposure so it's something 

that we have in our procedure that discusses this 

process for both causal relationship in that 

disease, then exposure component and also in the 

consequential illness component.

CHAIR MARKOWITZ: Okay, so I gather 

then that there would be no need for the Board to 

take this on, look at this issue because it 

wouldn't assist the program.

They don't need any sort of thorough 

analysis that demonstrates the link to support 

their decision making which is just fine. 
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Dr. Cloeren?

MEMBER CLOEREN: If there were to be 

data among -- well, if there -- would there be a 

consideration of making dementia a presumptive 

acceptance for the small group of people that 

have hearing loss that's accepted and also have 

dementia?

You'd need to have an argument for 

that I know and so that might be a reason to 

think about it.

MR. VANCE: Yes, I mean, the Board 

could certainly consider that. It would be very 

similar to what occurred with the COVID-19, that 

if certain conditions are satisfied, then the 

program would be in a position to just accept it 

outright. That we wouldn't really need to have 

any kind of a specific medical opinion about it 

because if certain conditions were satisfied, you 

know, we would be in a position to accept it 

automatically.

And I mean, you would look to that 

COVID-19 standard that the Board recommended and 
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doing something along those lines and you could 

do that for a variety of medical conditions. In 

fact, you wouldn't have to limit that to just 

hearing loss.

CHAIR MARKOWITZ: We should take a 

look at that. Okay, we have just a few minutes 

before the public comment period. We're just 

going to break for five minutes, stretch our 

legs.

I'm going to get the names of the 

public commenters.

(Whereupon, the above-entitled matter 

went off the Record at 4:07 p.m. and resumed at 

4:15 p.m.)

CHAIR MARKOWITZ: It's 4:15 p.m. We're

going to open the public comment period. I have a 

list of public commenters who've signed up to 

speak. 

There are five people so far. We never 

know when additional ones might be added. I would 

ask that the public comments to try to limit 

themselves to about seven minutes. That means 
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that I may, unfortunately, have to interrupt you 

a bit, but so be it.

The first one if they're available is 

Stephen Towler. 

(Off mic comments)

CHAIR MARKOWITZ: Yes. No, no, we're 

giving the last word to somebody else. You want 

to have a -- if you could speak into the mic so 

we can record it that would be great.

MR. TOWLER: Is it on? I don't have 

to say testing or anything? No, I kind of deal 

with both sides of the WHPP Program. I 

participate in that, but I also have a mother 

that worked out at the site for 33 years and I 

deal with her under the EEIOCP and I've managed 

her health care for about ten years.

But I'm kind of curious and it's, you 

know, they're both good programs. I don't have 

any problem with them, but I had more of a 

question really than a comment, I think.

And I was curious if, as the disease 

progresses and other symptoms or what's the right 
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word, other impairments become apparent in the 

process, do you re-evaluate or are you allowed to 

go back and say hey, we need to re-look at this 

now and say there's more going on here now than 

there was before?

CHAIR MARKOWITZ: I'm sorry, Steve 

Markowitz. All right so this is for a condition, 

a health problem for which the claim has been 

submitted and accepted by the program?

MR. TOWLER: Correct.

CHAIR MARKOWITZ: Okay. And then 

either the condition gets worse or there are 

other conditions that develop afterwards that 

flow from that original condition?

MR. TOWLER: Correct.

CHAIR MARKOWITZ: Okay. So I'm going 

to -- that's a question for Mr. Vance. If you 

want, that's a specific, targeted, and answerable 

question so if I could turn that over to Mr. 

Vance.

MR. TOWLER: Thank you.

MR. VANCE: Not a problem. Yes, I 
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think the question is touching again on that 

question of consequential illness --

MR. TOWLER: Yes.

MR. VANCE: -- so the program does 

have guidance that states that in an instance 

where you have a condition that is worsening or 

has caused a separate diagnosed problem, that's 

called a consequential relationship.

And we have a process by which you can 

file a new EE-1 for an employee seeking coverage 

for that consequential illness. And basically 

what you would need to do is present the medical 

documentation that establishes that the condition 

has been diagnosed.

It does not have to necessarily have 

been diagnosed after our accepted condition. It 

just needs to be shown that the condition exists 

and that a physician using good interpretive 

analysis, the use of appropriate medical health 

science supports a position suggesting that new 

illness is in some way either having caused or 

aggravated or contributed to that consequential 
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disease.

And Dr. Markowitz, I have sent Carrie 

some information about that that I'm going to 

have her look at and refer to you. I'm just 

talking about that process, but there is guidance 

in our Staff Procedure Manual that's available 

online in Chapter 23.

This is something that you can go to 

our website, look for our regulations and 

procedures, look for our Procedure Manual for 

administering the program, Chapter 23 has all the 

information that is needed to know how to file 

those claims and what the process is by which the 

program would evaluate that for adjudication.

MR. TOWLER: Okay, thank you.

CHAIR MARKOWITZ: So yes, this 

happened, this happens all the time and we just 

said that the Worker Health Protection Program, 

the medical screening program for Idaho workers 

also provides some assistance around these issues 

so you should feel free to --

MR. TOWLER: I am.
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CHAIR MARKOWITZ: -- contact the 

person who's sitting behind or David Frye, Gaylon 

Hanson or David Frye.

MR. TOWLER: Well, it's on my mother. 

It's not for me for the WHPP, because I 

participate in that. I don't think I have any 

problems yet.

CHAIR MARKOWITZ: Okay. Good, well, we 

hope we won't find any. Thank you very much.

MR. TOWLER: You know, it was 

surprisingly refreshing to find an answer when 

she developed breast cancer because I'd seen the 

advertisements on TV for the program and I 

thought, hey, maybe these people can help me get 

her back and forth from treatments and what not. 

I wasn't looking for anything else.

CHAIR MARKOWITZ: Right.

MR. TOWLER: And the people, were did 

she work at the site? Yes. Okay, what did she 

do, blah, blah, blah and on, on and on. And they 

said, oh, well you qualify for this.

And I says, okay, then we'll afford 
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the rides that way. So, thank you.

CHAIR MARKOWITZ: Yes.

MR. TOWLER: It was a nice, a bonus --

CHAIR MARKOWITZ: Okay.

MR. TOWLER: -- for working out there.

CHAIR MARKOWITZ: Okay, thank you.

MR. TOWLER: Bye.

CHAIR MARKOWITZ: All right, next is 

speaker, commenter is Robert Marcinko.

MR. MARCKINKO: Hey.

CHAIR MARKOWITZ: Welcome.

MR. MARCINKO: Again, my name is Bob 

Marcinko. I want to thank you for inviting me to 

this as well as being able to comment. I think 

what you're doing is wonderful and the program is 

exceptional.

And being able to attend your meeting 

gave me a better understanding of some of the 

challenges you are dealing with which is 

extremely interesting.

I want to hit you with a little 

historical information. You may have heard or 
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seen some of this yourselves in the past. But I 

started at the INL for Exxon Nuclear in 1981 and 

worked until 2012 where I ended up being the S&H 

Manager at the ATR Complex.

So I worked in a lot of different 

management positions and dealt with a lot of good 

challenges here. But my biggest challenge was 

surviving my first week on the job here at the 

INL.

Prior to being hired, I worked for 

Wyoming OSHA for four and a half years and then I 

went on to the University of Utah and got my 

Master's degree in industrial hygiene.

So when I walked in the door, I knew 

what I was doing. The first day on the job I was 

pretty much told by my boss, walk around get 

acquainted with the operation.

And the Idaho Chemical Processing 

Plant at that time was a huge operation. Most all 

of it's been demolished at this time, but there 

were over 1,200 employees there at that time.

As I proceeded with my first walk 
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down, I came upon a pipefitter raking insulation 

off of a streamline with a hammer. I talked to 

him about it and asked him to stop and told him I 

was going to go talk with the supervisor.

In regard to looking for a supervisor, 

I was told he was in another building, walked 

into that building. It was a large fuel handling 

and storage facility.

Several hundred feet long, hundred 

feet wide, 50 foot ceilings, you couldn't see 

from one end to the other. They were doing 

sandblasting of a fuel storage cast at the far 

end. I went and stopped that job.

And again, my OSHA background. In 

proceeding to find the supervisors, I had no 

luck. Went back to my office and heard the 

operations manager and the maintenance manager 

screaming at my boss wondering who the hell I 

was.

I ended up in that meeting and we 

talked briefly. I was advised at that time in my 

walk-arounds, not to talk to any employees. And 
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at that point a meeting was held with the 

president and our lawyer for the company.

And at that time it was presented that 

OSHA was required to be part of the contract that 

Exxon had to follow. So the lawyer saved my job 

at that time otherwise I was due to be fired.

Anyway it was a challenge from then on 

and obviously I survived and did 31 years. But 

those early days were amazing. It was a free for 

all. There were no controls on any of the 

chemical hazard activities.

I came across an instrument lab that 

had beads of mercury everywhere. They were using 

the wrong cartridges on respirators for certain 

chemicals. It was a challenge.

I had no budget to work with. I had no 

monitoring equipment. And I had support from 

management. Anyway, couple of years later, 

Westinghouse had taken over the contract.

I was put on some assessment teams. I 

ended up at Savannah River, Hanford, and West 

Valley. And what I found at some of those 
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facilities particularly West Valley is they were 

in no better condition than the Idaho Chemical 

Processing Plant was three years prior.

It was a mess and it was also a 

surprise to their management that they had no 

industrial hygiene program and they had little to 

no controls over simple things in my mind as 

asbestos knowing that it's hazardous.

It was, in my mind, a surprise in that 

it was a fellow DOE operation and DOE was well 

aware what I did when I first showed up in 1981.

And that information wasn't 

communicated on to any of the other facilities. 

So in my mind, you know, DOE, you know, is 

embracing this program.

They imparted that it was morally and 

ethically something that they needed to do, but 

back in those early days, they were negligent. 

They had contractual obligations to impose on 

their contractors and they didn't do it.

I have acquaintances that I know that 

have passed away from some occupational illnesses 
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from the INL. So this is, excuse me, this is 

somewhat of a personal thing for me.

So I really do appreciate what you 

guys are doing. It's valuable, there's a lot of 

employees out there that were exposed unknowingly 

and routinely. It was a free-for-all for handling 

a lot of chemicals so.

CHAIR MARKOWITZ: Thank you very much.

You know, this period you're 

discussing, the early '80s, the people who would 

have started either the chemical processing 

facility, or some of the other sites, would have 

been you know, 20 years older.

So meaning that now, they'd be in 

their 60s, you know, still reasonably young.

MR. MARCINKO: Exactly.

CHAIR MARKOWITZ: With an expected 20 

year life expectancy if, if they lead normal 

lives.

So, that means there must be a lot of 

people out there who work in those conditions, 

and would still be at risk.
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So, thank you very much.

MR. MARCINKO: Oh, without a doubt, so 

thank you again.

CHAIR MARKOWITZ: Next is Robert 

Stanton. Sorry, Ralph Stanton. Ralph Stanton. 

Sorry about that.

MR. RALPH STANTON: That's all right, 

I've been called worse.

CHAIR MARKOWITZ: I won't ask.

MR. RALPH STANTON: This is my wife 

Jodi here. She is also an INL employee.

Jodi and I are both exposed workers at 

the INL. I'm a card carrier. Yes, I was exposed 

in November 8 of 2011 at the Zero Power Physics 

Reactor facility.

It was uncontrolled airborne release 

of plutonium-239, americium-241 in which I 

received, I was a ARS survivor.

I spent eight months down in the 

basement and of course, I was told that I was 

clean when I was sent back, and I wasn't. I 

wasn't even close.
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Because I filed a whistleblower 

complaint, another gentleman and myself that is 

now deceased, Brian Simmons.

And we both, we both had you know, the 

blood markers, the clinical symptoms, the dose 

dependent clinical symptoms of ARS in the hours 

and days following expose.

We were told that we had influenza, 

which we later found out we were at later able to 

get our blood CBC counts, and see that our white 

blood cells were down next to nothing after five 

hours, which would indicate triple digit dose.

When I was given my dose assignment, I 

didn't know a thing about radiation dose, but I 

instantly knew that my dose was falsified.

Because I started off with a dose of 

256 millirem for the year, and after spending 

eight months down in the basement, because my 

urine and fecal were too hot to work in a 

radioactive area, I was told that I had, I ended 

up the year with 200 millirem.

So I think, I don't know, I just 
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looked at them and they told me that with a 

straight face.

And I just said, hey, is it magic 

plutonium that you got here, is that, is that 

what we're exposed to, to actually takes away 

dose?

But anyway, so I became compelled to 

learn the art and science of internal dosimetry. 

And on November 19, 2014, they brought out dose 

experts, NIOSH did, and I was able to prove that 

my dose was falsified.

And the guy that was with me, Brian 

Simmons, he is also an ARS survivor, or he was. 

He died last, August 29. And anyway, he was also 

part of figuring out that our dose was falsified.

But I went in there and they stopped 

me about 60 percent of the way through, and they 

said hey, it's pretty obvious that there are 

serious issues with your dose calculation, and 

that's when I knew about 30 percent about what I 

know now.

I can now add medical fraud, and 
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illegal destruction of exposure evidence to those 

accolades, not to mention with the, the lung 

count manipulation.

And you know, I got a lot of people 

that were a lot smarter than me that helped me 

out with this.

And you know, these kinds of themes, 

they affect epidemiology studies, health studies. 

They affect decisions on, you know, eligibility 

for medical help.

And something's got to be done about 

that. This, you know, you can't, you can't allow 

the same contractor -- and it was also determined 

that it was willful negligence, so this was a 

rare case where in Idaho, there's a law where we 

can go directly after the company, which we did 

when we filed whistleblower lawsuits.

But you can't, it's such a conflict of 

interest to allow the contractor, who is 

financially motivated by DOE, to show low dose 

assignments, to destroy exposure evidence.

Now this is not, these are not just 
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accusations I'm making. These are things that I 

can show you with paper, with evidence. I can 

show it in a court, which is why they decided not 

to go to court with me.

But what I've done is I'm here to 

basically you know, offer my services to, to 

teach a Board how to spot this stuff.

Because I've been doing it for the 

last 10 years. And unless you know what to look 

for, you're not going to see it.

But it's a problem. If you look at the 

EEOICPA regulations, you know, it says in there 

that 98 percent of all DOE radiologically induced 

cancers within the DOE complex were deemed to be 

caused at safe levels.

Now, that tells me that there's a lot 

of dose falsification going on. And the INL is 

not the only place that it's going on.

But I would be more than happy to come 

in and talk to, or teach, or show you what to 

look for, in any capacity.

You know, also I was kind of a lucky 
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guy because I had, I had a blood ferritin level, 

and I'm not sure if there's any physicians here 

or anything like that, or if they understand what 

a blood ferritin level is, but it's a correlation 

with how much heavy metal is in your body. Heavy 

metal in my body was americium and plutonium.

And I did biopsies of my bone marrow 

and my liver, because my liver and my kidneys 

were going south.

And they found heavy stores of 

plutonium. And, which I was told I lost those. I 

was 20, 20 percent lower in my final dose than 

what I started with. They don't pay attention to 

things.

So, anyway, you know, this kind of 

stuff can't go on if you're going to, if you're 

going to keep accurate, if you're going to keep 

accurate records.

If you're going to truly be able to 

say nuclear workers are safe, you know, you've 

got to be able to, to rely. You've got to be able 

to rely on that doctor, you know, doing his 
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fiduciary commitment to his patient, which he 

didn't.

And you know, I've got a dead friend 

because of it. The guy was standing right next to 

me, 38 years old.

And when he, he was actually killed. 

But when he was killed, he had, he had been 

vomiting blood for three years.

He had nose bleeds. He had paranoia 

schizophrenia, which a lot of the Chernobyl ARS 

survivors developed.

Like is said, I was lucky. I went 2017 

when I had all those issues. They told me they 

were going to keep me as healthy as they could, 

for as long as they could.

And she found a scientist who 

developed a detiered deplete (phonetic) of water 

that actually was able to chelate the 

radionuclides out of my body, which had never 

been medically done before.

Because if you, if all the medical 

science that I've read, is once that the isotope 
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reaches the organ of choice, it's there until it 

you know, just finally kicks off.

Not true with this water. After three 

months, my kidneys and my liver came back on 

line, perfectly functioning. But my lymphocytes 

were still low.

Which still is in line with the 

Chernobyl ARS survivors. Some of their, some of 

them their lymphocytes came back after five 

years; some of them they never did.

Mine were still low after 10 years, 

but I met a medical scientist who watched one of 

my podcasts, and gave me free treatments.

And was able to bring my lymphocytes 

back up, which I think has never been done as far 

as I understand.

I've done a lot of research on it. I 

mean, I don't have the perfect, you know, I don't 

have the perfect, I haven't seen everything in 

the world.

But from everything that I've ever 

read, you know, these are things that I would be 
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glad to share.

And you know, they could have Homeland 

Security implications because what we were 

involved with, was the same thing as a dirty 

bomb.

And this water chelated everything out 

of the body. And so that would eliminate a lot of 

the, you know, risk to people who are in 

something like that.

Just, just an idea.

CHAIR MARKOWITZ: Thank you. Thank you 

for discussing this, thank you.

MR. RALPH STANTON: Yes, but I've left 

my information up there so --

(Simultaneous speaking.)

CHAIR MARKOWITZ: Okay.

MR. RALPH STANTON: -- if it, that's 

something you'd like to do, just give me a call.

CHAIR MARKOWITZ: Okay, thank you.

MR. RALPH STANTON: Yes.

CHAIR MARKOWITZ: Next, I think we're 

going to hear from someone on the phone, Sandra 
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Thornton?

(No audible response.)

MS. VLIEGAR: This is not Sandra 

Thornton, this is Faye Vliegar.

CHAIR MARKOWITZ: Okay, so we'll go 

with Faye Vliegar? Okay, sure, okay, Faye 

Vliegar.

(No audible response.)

CHAIR MARKOWITZ: Okay, so what are we 

doing? You think she is on the line? Okay.

MS. THORNTON: I'm on the line.

CHAIR MARKOWITZ: Okay, and is this 

Faye Vliegar?

MS. THORNTON: Hey, Dr. Markowitz, this 

is Sandra Thornton, I've been here.

CHAIR MARKOWITZ: Oh, great. Okay, 

okay, go ahead, Ms. Thornton, welcome.

MS. THORNTON: Thanks.

Yes, I talked a couple of times on 

this Board, and I really appreciate you leading 

the Board, and I appreciate the Advisory Board.

These are issues I've staffed over and 
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over for three years personally, and I don't want 

to tie it to time anymore.

I sent you an email for Carrie to post 

for public comment and you know, I'm talking 

about Case 50024054.

I just decided that as good as you 

try, that the system probably isn't going to fix 

the rest of this case.

So, I just wanted to hop on to say 

you've got my message to post in the minutes, but 

thank you for an opportunity to do that.

I'm just going to go to Washington and 

hit up the committees I need to, to speak to the 

people to get some things to change, because 

they're not.

And they affect everybody, and I just 

happen to be a big mouth that points it out.

But anyway, so I won't bother tying up 

your time with this case. I know I've sent a lot 

of information to try to give constructive 

feedback to identify the issues.

And again, this Board is, tries really 
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hard, and works really hard, but there's only so 

much you can do. And after that, you know, it's 

just out of your realm.

So, thanks again, Dr. Markowitz. I 

always, always appreciate you and the rest of the 

specialists on this team, to try to help these 

nuclear workers who really paid the price, and 

are struggling.

So again, thank you. I appreciate it 

and I won't bother you. Take care.

CHAIR MARKOWITZ: Okay, thank you, Ms. 

Thornton.

Next, we have Mr. Calin Tebay. 

Welcome, welcome back. You aren't ready?

MR. TEBAY: Hi, my name's Calin Tebay. 

Thank you for letting me speak today.

As a former board member, I appreciate 

everybody's participation and effort, and 

continued effort.

In my role, my primary role, I work at 

the Hanford Workforce Engagement Center, which is 

not primarily Hanford anymore.
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We, there's three of us at that 

office. We educate current and former workers and 

their families, on potential programs that apply 

to them.

EEOICPA, L&I, short-term, long-term, 

paid family medical leave. We get into some VA 

benefits.

We help people once they decide a 

path, how to, how to navigate those paths. The 

conflicts in those systems. It's evolved and it 

continues to evolve.

As of this last week, I think we've 

had 15,500 I should say communications, meaning 

people that walk through the door, appointments, 

some people communicate via phone, email, all 

different ways, right?

So, we deal with people that want to 

file new claims; people that have filed and been 

denied. Just you think of it, we've dealt with 

it.

To this day, and I, and you're not 

going to hear anything from me that you haven't 
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heard before, and you haven't been working on for 

years.

But to this day, our single largest 

problem is still work history. We are relying on 

resource centers, which now is not just resource 

centers because we can, anybody can now get on 

and electronically file a claim from your own 

home.

And if the work history is not 

captured correctly, the information we all know 

from there, is tainted. And it's interpreted a 

few times from there.

Now whether we're dealing with the EE3 or the OHQ, that information is filled out.

If you're not asking these people the 

correct questions, they're not giving you their 

full work history. Some people are just not good 

at communicating that part of their work history.

We have learned over five years how 

to, actually for me, it's my fifteenth year. But 

over the last five years, even more, more.

So, we've learned how to communicate 
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with people to get aliases out of them. Processes 

out of them. Where they worked. Get this stuff 

documented correctly from the beginning.

But once that gets to, and they start 

communicating that to people that help them file 

their claims, authorized representatives, 

resource centers, we see a lot that it's not 

correct.

The resource center folks, and I'm 

happy for all their help, and our authorized 

representatives, but if you don't know the site 

that they're claiming for, or the processes that 

they've worked in, or the trades, or whatever it 

is, for that role, odds are you're not going to 

get that work history correct.

So, that information going in right 

off the bat is tainted. Then it's interpreted, 

and we can't expect the Claims Examiners to get 

this right every time if the information going in 

isn't correct.

We can't expect the IHs to get it 

right, or the CMCs to get it right, if it's not 
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correct.

I really like the chart. I think we're 

headed in the right direction. But I don't see a 

way that we are going to, ever going to get it 

truly correct until we have some kind of an 

interview process that happens at the IH, or the 

CMC level.

I mean, really unless it's an SEC 

claim, there's got to be somebody that's 

knowledgeable verifying that information at that 

IH or CMC level is correct with the worker.

I know we've talked about this. I know 

we continue to work at it. I appreciate that. But 

I think that that may be the bridge that, in the 

immediate, can solve that problem.

Currently, we're working a claim right 

now for somebody that we went in and with all the 

aliases, right, the names, or the alias, or the 

job roles have changed so many times, that if 

you're a Claims Examiner and you did not work at 

those facilities, and you don't know how to 

interpret those aliases, and you start trying to 
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verify the information, we have found that a 

power operator, for example, had several aliases, 

worked in several of the same facilities. But 

under different aliases, have different 

exposures.

Well, if we're trying to take that 

information, and that Claims Examiner does not 

have that information correct from the beginning, 

and they don't know how, or are not familiar --

for instance, we also have where we were pretty 

comfortable with the Seattle office in that 

Hanford area. But now their claims are being 

spread out through Cleveland, Florida, places 

like that.

Our Claims Examiners, we're struggling 

to set up some kind of a communication, or a 

history and some knowledge where they understand 

that site.

So, all in all, you put that all 

together and in the end when the recommended 

decision comes back for denial, and the, as Diane 

and I talked earlier, the claimant is basically, 
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the burden's on you to come up with an answer,

right.

How do I object, how do I rebut this 

information? What information, what doctor do I 

see? Who can I count on to help me verify my 

existence, my exposures.

The burden is nearly impossible for 

that worker to overcome.

If your primary care understands the 

minute you say EEOICPA, or Labor & Industries, 

for example, and I'm sure everybody here is aware 

of this, you're done.

In fact, normally in our area, if they 

find out you're coming in for any EEOICPA claim, 

or an L&I claim, they won't allow you to set up 

an appointment.

Or they'll tell you they're done 

supporting that appointment, or not having that 

discussion about that occupational condition.

So, now you've got a worker that 

doesn't have any resources to find that extra 

additional information that DOL's looking for.
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We have one individual that we know 

that works in that, in that world, but he 

services four or five states and the odds of 

getting in -- and some people just are not in a 

position to pay for that out of their pocket, 

right? And get that information they need, and 

the support.

So, I am super happy that the Board 

continues to have these conversations, and work 

this issue.

I think today we've identified some 

really great avenues to start closing those gaps. 

But unfortunately, it always sounds like we're 

picking holes in the DOL.

But the more we dig in, the more we 

find holes. And we haven't started filling those 

holes in that part yet, that, that's -- we have, 

but we haven't, and the claimant, and the 

claimants are still struggling.

I can tell you that's our major issue. 

And I think, I would hope that DOL would, would 

really get after this and partner with the Board, 
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and try to find some ways to plug some of these 

major holes.

So, I appreciate your time. The HWEC 

is an office, we named it the HWEC because at 

Hanford, we like to you know, shorten everything 

up with some kind of a weird acronym, right?

But anyway, it's open five days a 

week, 10 hours a day. You can come in, you can 

call. We service other sites.

We're pretty good you know, most of

the time the exposure, you're just plugging in 

different exposures to the programs.

We're pretty knowledgeable on the 

Procedure Manual so if anybody needs help, please 

give us a call.

CHAIR MARKOWITZ: Thank you.

Just a point of information, you know, 

there is a mechanism whereby an interview can be 

conducted.

There actually was a recommendation 

made by the Board years ago, accepted by the 

Department, whereby a claimant can request an 
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interview around, to give additional detail on 

exposure.

MR. TEBAY: Yes, but we --

(Simultaneous speaking.)

CHAIR MARKOWITZ: So it's not used 

much, I understand.

MR. TEBAY: We haven't seen one to this 

day in our office, of all those that have ever 

been utilized.

CHAIR MARKOWITZ: But you can spread 

the word that it is a mechanism people can use, 

and they can reach out to DOL and request it.

MR. TEBAY: I do fear that if we do 

have an IH interview, that does not have a Claims 

Examiner or somebody from the DOL involved, we're 

not going to capture all of that information, 

right?

Because then the IM, the CIH is going 

to have potentially different information than 

the statement of the fact.

So, I think it takes more than just 

the CIH, but we do have to plug that hole.
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CHAIR MARKOWITZ: But as I understand 

it, that interview would be with the Claims 

Examiner.

MR. TEBAY: Okay.

CHAIR MARKOWITZ: That they would be, 

definitely be part of the process.

MR. TEBAY: Well, like I said, to this 

--

(Simultaneous speaking.)

CHAIR MARKOWITZ: This --

MR. TEBAY: -- to this day, that 

burden is put back on the claimant themselves, 

and that interview process is not being utilized.

CHAIR MARKOWITZ: Okay, thank you.

MR. TEBAY: Thank you.

CHAIR MARKOWITZ: Yes, take care.

Is that it? Okay, anybody else who 

want, we have a few minutes. Anybody else who 

wants to speak, you're welcome to come.

MS. STANTON: I would like to.

CHAIR MARKOWITZ: Sure.

MS. STANTON: If that's okay.
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CHAIR MARKOWITZ: Come on, come on up.

MS. STANTON: I'm a people person. I 

watched the reaction my husband got, and I want 

you to know the things that go on out there, that 

are not right, that are corrupt, that are wrong.

I've begged families not just as --

and our children, but they affect our parents, 

our siblings, something needs to be done to 

change the practice that goes on out there.

There cannot be another blind eye 

turned to what is going on. People's lives are 

changed and damaged, for the rest of their lives.

I have got my own health problems I'm 

trying to deal with, and every day I wake up with 

a husband who is breathing is a blessing to me. 

But that accident should have never happened. The 

Simmons family should never have lost their son 

the way they did.

I thank God every morning I get, I can 

spend one more day with my husband because it is 

a miracle that he is here today.

And no family should have to walk the 
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shoes I'm walking in right now. I want you to 

hear this, and I want to see some changes.

And not just for me and for him, and 

our family, but for all of the other workers out 

there who are exposed and don't even know it.

Thank you for letting me speak.

CHAIR MARKOWITZ: Thank you.

Anyone else? Yes, come on up. Just 

give us your name.

MR. JACK STANTON: My name is Jack 

Stanton, and I'm Ralph Stanton's brother.

I'm a freelance writer. I knew nothing 

about what went on out there, or what goes on out 

at site on a daily basis.

And then he was in an accident. An 

accident where they falsified doses. They just 

happened to mishandle the urine for two days 

straight, both the A and B samples of the most 

affected.

You have 16 people coming in. There's 

evidence of them kicking the head of the lab out 

because she was complaining about it at a bus 
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stop, every time their urine came in.

They flew somebody in to look at the 

blood counts from Oak Ridge, and he's like, oh my 

God. It's like historic, the exposure.

They stopped doing blood. Supposed to 

do it for two weeks. Why would you do that? Fecal 

matter. They gave him a clean bill of health. He 

was passing uranium. Legally, you're not allowed 

to do that.

At what point? Price Anderson gives 

contractors indemnity. They don't have any 

responsibility.

Several months before this accident, 

there was almost a Chernobyl. Contractors were 

allowed to write it off as something else.

Dennis Patterson's book, 

Whistleblower, describes what happened. These are 

criminal acts.

When you are hiding or destroying 

evidence, I hear this gentleman over here talking 

about aliases, and how they don't, you know, 

people have several aliases.
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You got one ID. Do you have several 

IDs, do you have several Q clearance, Sigma 

clearance? No, you have one.

And the simple fact is under the Price 

Anderson Act, government doesn't want to pay out 

of it, so they deny claims. They keep people 

ignorant.

This gentleman was talking about oh, 

there should be a change. Well, when somebody's 

in an accident, there should be a pamphlet that 

they're told their rights. That doesn't happen.

You have contractors who are trying to 

claim that medical done on workers, is work 

product. And that the workers aren't allowed to 

have their own medical. Now think about that.

And then they start sending them to 

psychologists. This is something, I talked to a 

New York Times reporter about this.

It's been going on since the '70s or 

'80s. You have a problem employee, send them to a 

psychologist who's on the take.

So you have a psychologist who sits 
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there and does whatever the contractor says, so 

the person will lose their clearance.

Then they lose their clearance, they 

lose their medical, they're blackballed from the 

industry because they got in an accident or they 

were exposed. What did they do?

My brother, Brian Simmons, the other 

14 people. Actually, there are more than 14 who 

were exposed, but 16 is the official number.

But there were actually more based on 

video tape and everything else, that they had to 

FOIA to get a hold of.

Those guys showed up to work to do 

their job that day. They were good employees. You 

had people that had Sigma clearances. You don't 

hear about Sigma clearances because it's top 

secret.

They nuked a lot of them. Wasn't your 

typical Q clearance. These were the best people. 

People who had done stuff.

And then you have the head of DOE 

Idaho going to meetings like this. And sitting 
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there, allowing BEA and the other contractors, to 

sit there and lie.

They're able to sit there and keep 

your information from you, the FOIA guys laughing 

that you're never going to get certain 

information that you're entitled to.

And these people, all they did was 

show up to work. That's what they did.

Now, Department of Labor, I assume, 

has the ability to oversee when people are 

committing fraud, committing crimes. Because when 

you're falsifying information, isn't that a 

crime?

I have a time line of all the 

management that worked out there. It goes into 

their histories, their work histories, their 

education, their families, where they've been, 

what they've done.

These people who went about falsifying 

all this information got promotions. In the case 

of a former DOE head, he opened up a contractor 

business. He's the president, he's getting, what, 
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million dollar contracts for looking the other 

way.

That's pretty great, pretty great. I 

didn't know anything about that. Now I have 

100,000 pages of documents that it was a surprise 

to me.

I had workers coming up bringing me 

stuff that has nothing to do with that, that they 

kept after they left the site and retired.

I have maps where there are illegal 

dumpings that have happened. They're still 

contaminated, going down to Twin Falls through 

the aquifer.

It has nothing to do with what I'm 

doing, but you know, it's funny since 1957 and

the Price Anderson Act that brought contractors 

in, I think there was one guy, one person who's 

actually gone to jail.

I mean, at what point do you not 

promote these people? At what point does the 

government get serious about worker safety, and 

prosecute people who are putting other people's 
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lives in danger?

Hanford, Los Alamos, here, Oak Ridge. 

Why is it that they have higher incidents of 

cancer? Why is it that workers have higher 

incidences of cancer? It's because of that.

You got medical people. When they were 

in this accident, they were exposed to 5.5 

million d per m of contamination. At 20, you 

should be in a suit. So, 5.5 is just a little bit 

more.

The DAC reading just going up, and up, 

and up as they're in the control room. And the 

contamination level is just exploding.

They were in literally one of the 

worst nuclear accidents since Three Mile Island, 

and yet the whole point of everything was to just 

hide the damage.

See, the thing is, if you aren't part 

of an accident, you're not entitled to have 

medical. And, that's the whole thing.

They're not going to sit there and let 

you go take medical tests, or pay people to see 
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how badly contaminated you are. Because it will 

prove how bad the accident was.

At the time, BEA was coming up on 

their 2013 multi-billion dollar contract. And 

they had issues before that.

They were allowed to just like, here's 

the thing. People out at the site are 

professionals. So what are the odds that the lung 

count would be done wrong?

The urine would be botched? Fecal 

samples would be botched? And that the blood work 

would be stopped? What are the odds of that 

happening at that professional facility?

Now, either all these people that the 

site has hired are just horrible at their job and 

should be fired, or they're not horrible. They 

were told to do something else.

Now how is it that four tests, four 

tests, like seriously, would you keep people on 

staff who were that incompetent?

Or would you keep them on and give 

them promotions, because they did exactly what 
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you wanted?

That's the whole thing, is math is 

math. How is it that all four things were allowed 

to happen, and get manipulated?

You've got people working out there 

who were exposed, who were having issues. They go 

to work every day because if they don't, they're 

not -- they're in their 40s, they're in their 

50s.

If they go away, they leave that, 

they're not going to be able to pay the future 

medical. They're going to lose their homes, their 

houses, everything.

Because the site and the contractors, 

are allowed to do things that are basically 

illegal.

You're the Department of Labor. I used 

to drive. I have better protections than the 

nuclear workers. That blows my mind.

And also when it's proven. My brother 

proved in front of NIOSH, that his doses were 

falsified.
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At that point, there should have been 

an investigation into the people responsible. 

Because if they're doing it to him and the other 

15 people, who else are they doing it to?

You read Dennis Patterson's 

Whistleblower book, you'll see the same names, 

the same people, doing the same stuff. Which is 

beautiful about having that book.

Because what happened to Dennis, and 

what happened to my brother, are two different 

things, but managers ultimately protected.

And by the way, this isn't about 

national security. Which a lot of times they say 

they can't do things because of national 

security.

It's because they don't want to admit 

how bad they are. They work on milestone bonuses 

out there.

If they don't get the work done on 

time, they don't get the bonuses. That's how 

managers make their money.

My brother filed a lawsuit along with 
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Brian Simmons, because they started to get PRAF 

(phonetic).

They had a manager approach them a few 

weeks before this incident, and they wanted them 

to falsify 21 type-one work procedures. These are 

felonies, by the way.

Brian and Ralph said they're not going 

to go to jail for this guy, so they reported him. 

That manager wanted them, asked them if they 

could do it.

So, they reported it to the main guy 

who was just new on the job, and who also oversaw 

everything that happened later with the cover 

ups.

And then they sent him down to New 

Mexico for the accident down there. Some 

interesting reporting on that. It kind of follows 

a pattern we see.

So anyway, they want them to falsify, 

commit felonies. And you know what happened to 

those 25 type-one work procedures? I know the 

people they forced them to sign at the threat of 
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their jobs.

Why would they do that? The work 

wasn't done. There's so many issues with this. So 

many issues.

When you sit there and you give 

contractors no responsibility, if they blew up 

the site, it's the government that's paying for 

it because of the Price Anderson fund.

They're going to do whatever they can 

to make money, but you know, for the ZPPR 

incident, they have a log book. Log book was 

present when the accident happened.

Now we would agree that that's one of 

the most secure sites in the world. Security does 

a fantastic job not letting anybody in. Or 

letting anything out.

Somehow, those log books just 

disappeared with all the information. And during 

that accident, they said oh, we've got them in 

our head.

That kind of medial information? 

People who aren't trained medical? But also the 
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doctor out there, these guys were in a nuclear 

accident with horrendous readings.

In the DOE report, they put it down as 

all 16 people just happened to get a case of 

influenza.

The flu? Seriously? You're part of a 

nuclear accident and you just got the flu, and 

that's why everybody's throwing up. Not the 

radiation that they were exposed to, of course.

The CAM went off for the first time in 

five years. The outside CAM to the outside world. 

This is in the DOE report.

And I don't know about you, but what 

are the coincidences that the constant air 

monitor that leads to the outside world, went off 

for the first time in five years?

Since right after a nuclear accident, 

right after, somehow BEA decided it was a radon 

leak.

Never went off before with a radon 

leak. It did that day, right after a nuclear 

accident.
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Everyone caught the flu, right after a 

nuclear accident. That day. Nobody else did. No, 

the doctor didn't test for the flu, by the way, 

but that was his conclusion. It's in the DOE 

report.

Why would somebody at the DOE okay 

that kind of report? That's what happening just, 

I could sit there and, hate to say it, I can go 

on for hours because when you study something, 

and you research, and you have 100,000 pages of 

documents, you can go on forever, and you 

shouldn't have to.

They didn't have showers available at 

the facility.

I tracked down the guy who probably 

put the plate in that caused the exposure 30 

years before. I tracked him down. He's the only 

one who's still alive from the people who worked 

at ZPPR.

Do you know one thing? They worked 

with contamination suits, they had showers at the 

facility.
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I tracked down people who said there 

are showers out at the site that the cisterns 

below, which are treated as waste, are full at 

the end of the fiscal year.

And they're not cleaned out because 

they all know contractors want to pocket the 

money, and then ask the DOE for more money.

Why the hell wouldn't you have 

operational showers? That's like, that's like 

nuclear accident 101.

They were swabbing my brother down 

with handi-wipes, the types that you get at 

Kentucky Fried Chicken, which closes the pores 

and locks the contamination in. It doesn't clean 

it off.

He took contamination home because he 

didn't have a shower. Their vehicles were 

contaminated. Their homes were contaminated.

The nuclear signature coincides with 

the nuclear signature of the accident. Meanwhile, 

you have BEA, you have all these managers talking 

about oh, it can't be from the nuclear accident 
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even though it had the signature.

Brian Simmons and Ralph had to spend 

tens of thousands of dollars to get independent 

labs because you know what? The government 

threatens to withhold funding to most labs who 

work with them, if they don't follow and play 

with the play book.

So, anyway, there's so many issues and 

you've got to do something. I'll tell you one 

thing. Make people criminally responsible when 

they do things like this, because they are 

killing people.

We put people in jail for killing 

people. You deny them health care. You make it a 

slow death. You literally make it a slow death. 

That's just B.S., you know? Seriously.

Then you take away their careers. Take 

away, my brother's driving a truck. He's one of 

the smartest people I know.

It's because he's not in the nuclear 

field anymore. You had Brian Simmons who, when he 

was having issues, they were associated with the 
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exposure.

They weren't going to give him any 

help, because to help him would be to admit it. 

To admit it would be to somehow lose financially.

BEA got a clean bill of health. They 

got their safety bonus. I think 100 percent for 

2011 despite having one of the biggest nuclear 

accidents since Three Mile Island, in this 

country.

What was safe about that? So anyway, I 

appreciate your time.

CHAIR MARKOWITZ: Thank you, thank you.

MR. JACK STANTON: Have a good day.

CHAIR MARKOWITZ: Yes.

MR. SIMMONS: My name's Hal Simmons, 

Brian was my son. And if I could teach any of you 

about this, it is that when you go home tonight, 

are you an honest person?

Because evidently the people out there 

that were in management and in the medical 

profession, are not honest people.

Now, you depend on a doctor to give 
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you a prescription, right? My son didn't get a 

prescription. He got, well, you got influenza.

For nine months him and Ralph drove 

back and forth together, and sat in the basement 

to do nothing because they were so contaminated, 

they couldn't be around the other people. But 

nobody wanted to admit that.

I'm telling you, my son was told at 27 

or so thereabouts, that he couldn't have any 

kids. They knew that.

I don't know what I can do here today 

to get you to make people responsible that should 

be responsible for their working people.

I have a business. I'm responsible. If 

somebody gets hurt, I help them take care of it. 

I make sure they get the --

My son was an honest person, and he 

was pretty damn good at what he did because he, 

they had him help build the Mars Rover battery, 

which is up there evidently now, doing its job.

He was also told that when they needed 

to train new people, they brought them to Brian 
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to teach them.

When they needed a critical thing 

done, they brought them to Brian to do it.

But they also had managers that got 

right in his face and screamed at him, and tried 

to tell him that he had done something that he 

hadn't done.

And I don't know the story, but 

somebody brought a teddy bear out there with 

something on it, and they accused Brian of doing 

it.

And Brian says, I didn't do it. I can 

tell you today, my son's an honest person. He 

called me the day of the accident and he says, 

dad, it's pretty bad.

He says, I've been in an accident and 

I don't know what's going to happen. The next day 

he says, I'll call you back.

The next day he calls me back. 

Meanwhile, I'm freaking out, you know, what's 

happening to my son?

He says, well dad, they brought a 
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accident report and they want me to sign it. And 

I says, he says, it's not right, but he says, 

it's close.

I said to him, okay, Brian, my history 

is you either sign it and give it back to them 

and go along with their, whatever they're doing, 

or you mark out what you don't believe in, and 

write it back.

So I took it that he marked out what 

he didn't know was right and sent it back, 

because him and Ralph went to court on it.

You know, we talk about the, what's 

the air force base that they're having the 

contaminated water?

And they have billions of dollars set 

by. You know, this is basically no different than 

our military people coming back and not being 

able to get the support they need to help them, 

because they sacrificed.

I am saying that what would really be 

great and make me happy, is that if you could go 

after these contractors that were falsifying this 
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shit, and that's what I'm going to call it, shit, 

and contaminating these people.

I also know some of the other people 

that were there at the facility. Ralph and Brian 

were told that they couldn't talk to them.

Well, what the heck's with that? They 

were all there. They all know what happened. I 

mean, you guys, the more you dig into this, the 

deeper the pile of you know what gets.

And I don't know about you guys, but 

my son at about 27 years old told he can't have 

kids, and yet he's stuck in a basement for nine 

months because he's got influenza.

Come on, where's the doctors? These 

guys are getting paid. We, the people, are paying 

their wages. What the crap are we paying for 

here?

All's I'm trying to tell you is, is 

yes, if I could grab them by the throat, I'd do 

it. And I don't care if that goes out to 

everybody on record.

Because they're liars, they're 
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cheaters, and they're just -- if that's the way 

business is done, we ought to shut the whole damn 

thing down.

Thank you.

CHAIR MARKOWITZ: Thank you.

So, I think that's the end of our 

public comment session.

Thank you to all the people who 

provided comments. They're very meaningful to us.

And I think I turn it over to Mr. 

Jansen, adjourn for the day?

Oh, we have one more? Oh, okay, come 

on up.

Will you just give us your name?

MS. THATCHER: Yes. I'm Tami Thatcher, 

I'm a former safety analyst at the Idaho National 

Laboratory.

I remember when the accident happened. 

I wasn't working there, but I was very interested 

to follow what the doses for the workers were, 

and so forth.

And waited for the reports to come 
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out, and started studying. And it's been a long 

time of studying.

And I became acquainted with Ralph, 

and his family. And I continued to study. And 

there were such strange things.

Because there were lung counts taken, 

and because INL did not have a procedure for 

translating the lung counts into a dose, the lung 

count reports results were then given to Oak 

Ridge, because they had a procedure for 

translating the lung counts into a dose.

Which they did. And yet that report, 

which the workers were never supposed to see, but 

did get emailed to them kind of by accident.

His first day's lung count wasn't in 

that report. That first day's lung count would 

have shown a six rem whole body dose, over the 

annual limit.

So, it simply was excluded from what 

was sent to Oak Ridge. That was interesting.

Ralph's lung count, his first day lung 

count was the highest of the group. Brian's was 
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the second. Ralph was the closest to the 

material.

Each lung count I now would give, the 

dose would get lower. Well, the you know, intake 

would get lower, and lower. Each lung count that 

they gave.

As I studied those lung counts, there 

were actually error messages in the reports, peak 

surge errors. And other error messages.

And BEA would claim this was no 

contamination. There was no intake, there was no 

contamination.

And you had these error messages. And 

you have, if you start looking at them, all kinds 

of irregularities in the lung counts.

And the reason for it was they were so 

contaminated, that their normal way of 

manipulating the lung counts didn't get rid of 

the doses.

The fact is, the software for the lung 

counts allow the operator to input gain factors, 

peak delete functions, that are not documented in 
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the lung counts.

And the irregularities in the lung 

counts, and the tweaking that went on, are 

criminal. And basically, NIOSH should never 

accept results from any site as being honest for 

the lung counts.

That six rem was an under estimate 

based on his actual nasal swabs, which were over 

4,000 dpm in a single nostril for just plutonium239, not the americium.

The fact is, they expected their lung 

counts would cheat successfully. And it wasn't 

happening smoothly, because they were so 

contaminated.

And the lung count process used by the 

Department of Energy, allows the operator to 

tweak it, manipulate it, and lower the doses.

That's why Ralph's whole body dose is 

far greater than six rem. It's far higher than 

the lung count showed.

And, BEA's final dose for Ralph was 

102 millirem from that accident. That's 100 times 
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too low.

So, you just ought to be aware of, you 

know, more of the dose fraud. It's real.

Thank you.

CHAIR MARKOWITZ: Thank you.

I think that concludes our public 

comment session.

Thank you very much for all the public 

commenters, and we will adjourn for today and 

resume tomorrow at 8:30.

Thank you very much.

(Whereupon, the above-entitled matter 

went off the record at 5:26 p.m.)