Advisory Board on Toxic Substances and Worker Health, Department of Labor

Revised Recommendations and Comments on Board’s October 2016 and April 2017 

Recommendations and the Department of Labor Responses

Issues for Consideration by the Future Advisory Board on Toxic Substances and Worker Health

Attachments

1. Comments on Recommendation: Incorporating Agency Health Effects Reviews 

Recommended in IOM Report into the SEM

(Originally approved as Recommendation #2 at the October 2016 Board meeting)

2. Comments on Recommendation: Hiring Former DOE Workers to Administer the 

Occupational Health Questionnaire

(Originally approved as Recommendation #3 at the October 2016 Board meeting)

3. Comments on Recommendation: Claimant Information sent to Industrial 

Hygiene and Medical Consultants

(Originally approved as Recommendation #8 at the October 2016 Board meeting)

4. Revised Recommendation: Presumptions for Asbestos-related Diseases

(Originally approved as Recommendation #1 at the April 2017 Board meeting)

5. Comments on Recommendation: Presumptions for Work-Related Asthma

(Originally approved as Recommendation #2 at the April 2017 Board meeting)

6. Revised Recommendation: Presumptions for Chronic Obstructive Pulmonary 

Disease Diseases

(Originally approved as Recommendation #3 at the April 2017 Board meeting)

7. Comments on Recommendation: Revisions of the Occupational Questionnaire 

(OHQ)

(Originally approved as Recommendation #4 at the April 2017 Board meeting)

8. Comments on Recommendation: Enhancing the Science and Technical Capacity in 

EEOICP

(Originally approved as Recommendation #5 at the April 2017 Board meeting)

9. Revised Recommendation: Quality Assessment of Contract Medical Consultants 

and Industrial Hygienists

(Originally approved as Recommendation #7 at the April 2017 Board meeting)

10. Issues for Consideration by the Future Advisory Board on Toxic Substances and 

Worker Health
1

Comments on Recommendation: Incorporating Agency Health Effects Reviews 

Recommended in IOM Report into the SEM

(Originally approved as Recommendation #2 at the October 2016 Board meeting)

ABTSWH response to DOL’s comments

The Advisory Board had recommended that DEEOICP incorporate the disease exposure 

links identified by the sources listed in table 3-1 of the Institute of Medicine report. DEEOICP 

requested that the board narrowed the list to the sources the board believes are most relevant, 

with recommendations as how they could be used in the SEM. DEEOICP reported they found 

the list of 11 sources to be redundant or contradictory

The Board continues to believe that all these 11 sources would be useful, but to make the 

task feasible for DEEOICP we have developed a more limited set of databases that can be 

incorporated. Those recommendations are attached here. The additional sources in the table 

from IOM can be reviewed and added at a future time.

The ABTSWH recommends that EEOICP use IARC as the source for information on 

causal links for carcinogens, use IRIS (EPA) to develop causal links between exposures in the 

DOE complex and non-cancer endpoints, and use NTP as an additional source for both cancer 

and non-cancer endpoints. Although the other databases listed in the Institute of Medicine 

report may contain additional causal links, these three data sources are likely to be the ones that 

are most comprehensive and best supported as causing human health effects. Once the addition 

of hazardous agents identified by IARC, IRIS and NTP to the SEM is complete, the ABTSWH 

can reevaluate the necessity for review of additional databases.

IARC is an agency within the World Health Organization whose mission is to 

continuously assess available evidence and identify which chemicals are known and probable 

human carcinogens.

IRIS is a database maintained by EPA which identifies chemicals that are determined to 

have potential human health effects. Attached is a short description of the process by which 

EPA develops these risk assessments. On the IRIS website, a detailed summary is available for 

each chemical; this includes a discussion of the underlying scientific basis for the health 

assessment. The Board recommends that EEOICP rely upon IRIS because of the extensive 

research and multilayers of review that go into each document. Because EPA has determined 

that every agent listed by IRIS has potential human health effects the board recommends that all 

these agents should be linked in SEM to those health effects.

The National Toxicology Program is an interagency program established in 1978 to 

coordinate toxicology research and testing across the Department of Health and Human Services. 

The program was also created to strengthen the science base in toxicology, to develop and 

validate improved testing methods, and to provide information about potentially toxic chemicals 

to health regulatory and research agencies, scientific and medical communities, and the public.
2

Recommended process

1. DEEOICP should identify a team that will implement these recommendations and 

that includes individuals with competence in toxicology, occupational medicine, and 

epidemiology. 

2. The Board recommends that DEEOICP make this a transparent process, with a report 

to the Board at each semiannual meeting on agents and health effects added to SEM 

and those under review.

3. DEEOICP should review SEM to be sure that all the IARC group 1 (known human 

carcinogens) are included in SEM, and are links to all the specific cancers known to 

be caused by that chemical based on the IARC report.

4. DEEOICP should add the IARC group 2a carcinogens (probable human carcinogens) 

using the same process as above.

5. DEEOICP should add agents identified as causing non-cancer end points based on the 

IRIS database from EPA.

a. Review the list of agents evaluated in IRIS and identify the ones that result in 

non-cancer endpoints. (IRIS has a total of 511 chemicals that have been 

assessed)

b. Match this list against SEM.

c. For those agents in the SEM, add the non-cancer endpoints as causal links. 

Each IRIS assessment identifies which specific health effects are caused by 

that agent. To identify all the health effects, it is necessary to read the entire 

document. The summary may only list the critical health effect (the health 

effect found at the lowest dose which then determines the Rfd set by EPA) but 

the full document lists all the potential health effects. If necessary or helpful 

the reviewers could use the available ATSDR Toxicological Profiles to 

identify health effects for agents in IRIS.

d. As new exposures are added to SEM, repeat this process.

6. DEEOICP should follow this same process for toxic agents identified by the National 

Toxicology Program.
3

Comments on Recommendation: Hiring Former DOE Workers to Administer the 

Occupational Health Questionnaire

(Originally approved as Recommendation #3 at the October 2016 Board meeting)

ABTSWH response to DOL’s comments

DOL’s response indicates that there is clear agreement between the Board and DOL that 

having former DOE workers administer the Occupational Health Questionnaire (OHQ) is 

beneficial in the claims evaluation and decision-making process. The Board also recognizes the 

stated commitment by DOL to encourage the hiring of former DOE workers at the Resource 

Centers. It is encouraging that over one-quarter of contractor Resource Center employees are 

former workers. To clarify the current status and to understand the likely future direction on this 

issue, the Board requests additional information. 

 How many of the 17 former DOE workers currently employed at the Resource 

Centers spend at least one-third of their time administering the OHQ to claimants 

during the past year? 

 What percentage of the OHQ’s was administered by former DOE workers during 

the past year? 

 What job titles did the Resource Center-employed former DOE workers have when 

they worked at DOE?

 Are there any Resource Centers where there is a below average number of 

employed former DOE workers or a below average number of OHQ’s administered 

by former DOE workers?

 Do the Resource Center job vacancy notices and recruitment methods specifically 

address the desirability of applications by former workers and reach out to former 

workers to encourage them to apply?

 Does the contract with the Resource Center contractor prioritize the hiring of 

former DOE workers over other applicants?

Such information will be useful to better understand the extent to which former DOE 

workers at the Resource Centers actually participate in the OHQ administration and to serve as 

indicators to assess future changes in these parameters. 
4

Comments on Recommendation: Claimant Information sent to Industrial Hygiene 

and Medical Consultants

(Originally approved as Recommendation #8 at the October 2016 Board meeting)

ABTSWH responses to DOL’s comments

The original Board recommendation is as follows:

"We recommend that the entire case file should be made available to both the 

industrial hygienists and the contract medical consultants when a referral is made to 

either, and not be restricted to the information that the claims examiner believes is 

relevant. The claims examiner should map the file to indicate where relevant 

information is believed to be."

The Department of Labor’s response was to reject the recommendation for the following 

reasons:

1. It is inappropriate and inefficient.

2. The current claims evaluation process relies on the CEs as the finders of fact, 

which would be undermined if the Industrial Hygienist and CMC develop or 

substitute their own facts.

3. Claimants submit voluminous amounts of medical information, not all of which is 

pertinent to the claim.

4. When a claims examiner refers a case to an IH or CMC, they are seeking 

guidance on a particular set of circumstances from which specific questions are 

derived.

5. It is the claims examiners’ responsibility to determine which questions are asked.

6. The contractors doing the work do not want to sift through all of the information.

First, the Board notes that the Board was unanimous in this recommendation. Specifically 

the Board’s industrial hygienists and the physicians all indicated that the professional standard, 

which they apply to the maximum extent possible, is to receive and review all available medical 

and exposure records in conducting reviews and expressing opinions about the work-relatedness 

of health conditions of individuals.

Second, we respond to each reason presented by the Agency in its response:

Issues 1 and 3: are easily resolved with a case index or case map. The contractor 

can review the CE’s findings of accepted facts and then review the case index to see if 

there is any other information they wish to review. The board strongly recommends that 
5

the agency develop a system by which all case files are provided to CE, IH and CMC in 

searchable pdf format to improve searching efficiency.

Issue 2: While the CE’s are well trained to extract information based on agency 

protocol, they are not experts in IH or occupational medicine and may sometimes not 

recognize important links between seemingly unrelated parts of a case. We do not believe 

the agency wishes their experts to form professional opinions based on incomplete or 

inaccurate information. The entire reason for referring to experts is that their expertise 

augments what is known by the CE. Denial of a claim based on CE misjudgment about 

the relevance of medical or exposure information would be unfair to claimants. In 

addition, finders of fact in our legal system are typically not experts, and we do not 

believe that using experts undermines the role of the finders of fact. Finders of fact (like 

judges and juries) often rely on expert evidence. The finders of fact then weigh the 

evidence to determine the facts that they will use in rendering an opinion. 

Issues 4 and 5: These are essentially the same issue. It would be inappropriate for 

the IH or CMC to render an opinion on a specific question when they are not permitted to 

review documents that were not provided to them but are pertinent to the claim. To do so 

creates “tunnel vision” on the part of the expert and a faulty opinion may be the result. 

Again, this is unjust to the claimant. In addition, the Board’s recommendation does not 

affect the CE’s ability to ask specific questions of the IH or CMC. It provides these 

consultants with the opportunity to use their expertise identify information relevant to the 

CE’s questions that was not recognized as such by the CE. 

Issue 6: It should be noted that these same contractors provide expert medical 

opinions to other federal agencies where they are required to receive the entire claims 

folder. It should be the responsibility of the IH or CMC to determine if the statement of 

accepted facts is complete and accurate enough for them to render an opinion, or if they 

need to review additional information in the claims folder.
6

Revised Recommendation: Presumptions for Asbestos-related Diseases

(Originally approved as Recommendation #1 at the April 2017 Board meeting)

Presumptions for Asbestos-Related Diseases

1. All DOE workers who worked as a maintenance or construction worker at a DOE site for 

250 days or more prior to December 31, 1995 and who are diagnosed 15 years (or 10 

years in the case of asbestosis) or more after the initiation of such work with 1 of 5 

asbestos-associated conditions will be presumed to have had sufficient asbestos exposure 

that it was at least as likely as not that asbestos exposure was a significant factor in 

aggravating, contributing to, or causing such asbestos-associated conditions. The five 

asbestos-associated conditions are asbestosis, asbestos-related pleural disease, lung 

cancer, and cancer of ovary and larynx. 

2. All DOE workers who worked as a maintenance or construction worker at a DOE site for 

30 days or more prior to December 31, 1995 and who are diagnosed 15 years or more 

after the onset of such work with malignant mesothelioma of any bodily site will be 

presumed to have had sufficient asbestos exposure that it was at least as likely as not that 

asbestos exposure was a significant factor in aggravating, contributing to or causing the 

malignant mesothelioma. 

3. All claims for one of the six asbestos-associated conditions named above that do not meet 

the exposure criteria described in items #1 and #2 above will be referred to an industrial 

hygienist for exposure assessment and to a CMC for evaluation of medical 

documentation and causation. These six conditions are asbestosis, asbestos-related 

pleural disease, malignant mesothelioma, lung cancer, and cancer of ovary and larynx.

4. Chronic obstructive pulmonary disease may have a contribution from asbestos exposure. 

However, claims for this disease should be evaluated as part of a broader set of 

presumptions for chronic obstructive pulmonary disease.

Rationale

In their response to this Board recommendation, DOL raised several issues:

1. DOL distinguishes between exposure and causation presumptions. 

2. DOL requests documentation to justify expansion of List A job titles to the broader 

categories of “maintenance and construction” titles, as the Board recommended.

3. DOL requests evidence that 2005 should be a threshold date before which significant 

asbestos exposure can be presumed for selected job titles.
7

 Table: Summary of Recommended Presumptions for Asbestos-related Diseases

Exposure 

criteria

Asbestosspecific 

Diseases

Mesothelioma

Asbestosspecific 

diseases 

Asbestosis,

Asbestosrelated pleural 

disease

Other Asbestos-related 

Cancers

Lung cancer, 

Cancer of ovary 

and larynx

Duration > 30 days > 250 days > 250 days

Job titles

Maintenance,

Construction

Maintenance,

Construction

Maintenance,

Construction

Calendar years < 1995 < 1995 < 1995

Latency

(minimum)

15 years 10 years 15 years

Board’s Approach to DOL Concerns

1. DOL’s distinction between exposure and causation presumptions represents mainly a 

linguistic and procedural difference in approach from the Board’s recommendation. The 

Board’s recommendation essentially modifies DOL’s exposure presumption to define 

sets of exposure conditions that are sufficient to meet exposure requirements of a causal 

standard.

2. The Board and DOL agree on the following time-related exposure parameters: >250 days 

(except for mesothelioma, 30 days) minimum employment; and 15 years of latency, or 

time between onset of work in a listed job title at DOE and the date of diagnosis of N 

asbestos-related disease (except for asbestosis, 10 years). 

3. The Board provides scientific publications in support of including all DOE-relevant job 

titles in the maintenance and construction categories in this presumption (see below). 
8

4. The Board has not yet identified surveillance information that supports use of 2005 as a 

threshold date for presumed significant asbestos exposure. As a default and until such 

information is identified, the Board recognizes that DOE Order 440.1 issued in 1995 

likely served as an important stimulus for change in DOE health and safety policy and 

procedures. The Board, therefore, agrees to the use of 1995 as a threshold date before 

which sufficient asbestos exposure occurred among maintenance and construction job 

titles, assuming the temporal requirements noted above, to meet a presumption of 

asbestos-related disease.

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13

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14

Comments on Recommendation: Presumptions for Work-Related Asthma

(Originally approved as Recommendation #2 at the April 2017 Board meeting)

ABTSWH responses to DOL’s comments

The Board’s April 2017 Recommendation on Presumptions for Work-Related Asthma 

(WRA) contained 4 parts. Each initial recommendation is provided bolded, followed by a 

summary of the DOL’s response, and additional comments of the Advisory Board to the DOL to 

add further clarity or, where indicated, help the DOL implement the Recommendation. 

The OWCP indicated that changes in response to Recommendation #2 have already been 

incorporated into the most recent revision of the Procedure Manual (Procedure Manual 1.1; 

Appendix 1, 9/2017; sections related to WRA). Relevant sections of the Procedure Manual were 

also reviewed to assess how the recommended changes were incorporated. 

Recommendation #2-1

DOL should use the generally accepted unifying term, work-related asthma (WRA) for claims 

evaluation and decision-making. Work-related asthma includes: a) occupational asthma (OA), 

or new onset asthma that is initiated by an occupational agent, and b) work-exacerbated 

asthma (WEA), which is established asthma that is worsened by workplace exposures. The 

recognition of both forms of work-related asthma should be communicated to claimants, their 

physicians and consulting IH’s and CMC’s. 

The Advisory Board appreciates that OWCP agrees with this recommendation and has 

implemented it in the most recent Revision of the Procedure Manual (Procedure Manual 1.1; 

Appendix 1, page)

Recommendation #2-2

Medical criteria for the diagnosis of asthma: The diagnosis of asthma by a treating or 

evaluating physician should be sufficient for the recognition that the claimant has asthma. 

Bronchodilator reversibility of FEV1 and/or a positive methacholine challenge test may be 

helpful but should not be required to accept the diagnosis of asthma, which is made by a 

health care provider. 

The Advisory Board appreciates that OWCP agrees that “a diagnosis of asthma by a 

treating physician should be sufficient, without specific reference to the tests listed” (spirometry, 

methacholine challenge test). The Advisory Board agrees with OWCP that “the physician’s 

opinion should include appropriate medical rationale, based on objective findings, to support the 

diagnosis.”

The Advisory Board also appreciates that OWCP has attempted to implement this 

recommendation in the most recent Revision of the Procedure Manual (Version 1.1). 
15

However, a review of the relevant sections of the Procedure Manual that describe the 

criteria for the diagnosis of asthma reveals sections that are confusing, do not appear to 

incorporate the above recommendation, and do not reflect current clinical practice. For example, 

Procedure Manual 1.1, Appendix 1 (9/2017), page 524 states that: 

“The criteria for accepting a Part E claim for asthma are: 

a. The employee has a period of covered Part E contractor or subcontractor 

employment. 

b. A qualified physician has diagnosed the employee with asthma. A medical diagnosis 

for asthma should be made when the physician is able to identify the presence of 

intermittent respiratory and physiologic evidence of reversible or variable airways 

obstruction including positive methacholine challenge test or post-bronchodilator 

reversibility. However, a physician can also rely on other clinical information to 

substantiate his or her diagnosis of asthma. For example, spirometry for 

measurement of FEV1 and FVC is the most reliable method for assessing airway 

obstruction. The response to inhaled bronchodilator administration has been used as 

a measure of airway hyperresponsiveness. A 12% improvement in FEV1 of at least 

200 mL after inhaled bronchodilator is how the American Thoracic Society defines a 

significant improvement indicative of hyperresponsive airways.”

This wording adds unnecessary confusion, especially the “For example” section. As 

noted in the Advisory Board’s recommendation above the diagnosis of asthma by a treating or 

evaluating physician should be sufficient to recognize that a claimant has asthma for multiple 

reasons. Asthma is a condition that is episodic and variable over time. Spirometry testing is 

generally not performed during symptomatic exacerbations and can be normal when patients are 

not having exacerbations. Bronchodilator testing can be falsely negative, especially if performed 

after a patient has been started on standard asthma treatment such as inhaled steroids or long 

acting beta-agonists. Methacholine challenge testing can also have false negatives (and 

positives), entails risk of inducing an asthma attack, and is not widely available, especially in 

many outpatient office settings. Thus asthma is commonly diagnosed and treated without

documentation of a positive bronchodilator response or methacholine challenge testing. The 

diagnosis is usually based on the patient’s history, clinical presentation, specific symptoms, 

triggers, physical exam findings and response to treatment. 

Documentation of specific asthma symptoms (e.g. wheeze, cough), symptom triggers, 

and physical exam findings (e.g. wheezing) are objective findings that are used to identify the 

presence of reversible airflow obstruction, and would be better examples of “other clinical 

information to substantiate his or her diagnosis of asthma” than those provided (spirometry, 

bronchodilator and methacholine challenge testing). 

Suggested alternate wording (major changes are underlined) to the current Procedure 

Manual 1.1 (pages 524-5) is as follows:
16

“A medical diagnosis for asthma should be made when the physician is able to identify 

the presence of intermittent respiratory and physiologic evidence of reversible or 

variable airways obstruction including post-bronchodilator reversibility on spirometry or 

a positive methacholine challenge test. However, a physician can also rely on other 

clinical information to substantiate his or her diagnosis of asthma, such as the findings 

from a detailed medical history and physical examination. Documentation of recurrent 

symptoms of airflow obstruction or airway hyper-responsiveness, such as episodic cough, 

chest tightness or shortness of breath, or symptomatic improvement following treatment 

for asthma (e.g. inhaled bronchodilator or steroids) supports a diagnosis of asthma. 

Physical examination findings such as wheezing on lung examination, nasal swelling and 

drainage, or use of chest muscles to breath also support a diagnosis of asthma. 

The response to inhaled bronchodilator administration has also been used as a measure 

of airway hyperresponsiveness. A 12% improvement in FEV1 of at least 200 mL after 

inhaled bronchodilator is how the American Thoracic Society defines a significant 

improvement indicative of hyperresponsive airways. However, a negative bronchodilator 

test does not rule out a diagnosis of asthma, especially if the patient is on medical 

treatment for asthma.” 

Recommendation #2-3. Work-related asthma, whether OA or WEA, is defined as the 

presence of medically-diagnosed asthma that is associated with worsening of any one or 

more of the following in relation to work: asthma-related symptoms, asthma medication 

usage or asthma-related health care utilization temporally related to work, or change in 

peak expiratory flows associated with work. Such a history should be documented by a 

treating or evaluating health care provider, or addressed by a CMC if consulted in a claim 

evaluation. 

The Advisory Board appreciates that OWCP agrees with this recommendation. The 

Advisory Board recognizes that implementation of the recommendation by the DOL will likely 

be challenging, as it will require education of claims examiners and treating and consulting 

physicians about WRA, including causative substances and diagnostic criteria.

Recommendation #2-4. The same criteria for WRA should be used in evaluating asthma 

claims whether the claim is made contemporaneous with the period of DOE employment or 

after the end of that period of employment. A specific triggering event causing onset of 

WRA may occur but is not typical or necessary. Inciting exposures such as dusts, fumes, 

heat or cold or others should be specifically identified when possible, but should not be 

required for the diagnosis of WRA. 

OWCP’s response to this recommendation notes that “The policy (=updated Procedure 

Manual) differs slightly from Recommendation #2-4 by requiring a triggering mechanism that 

occurred to cause, contribute to, or aggravate the condition. Legally, OWCP must require 

evidence that the toxic substance was the likely trigger for the condition because a condition can 

only be accepted as a compensable “covered illness” if “it is at least as likely as not that the 

exposure to such toxic substance was related to employment at a Department of Energy facility. 
17

A mere temporal association, without identification of a toxic substance, would not satisfy the 

statutory requirement for eligibility. In addition, neither “heat” nor “cold” can be defined as a 

“toxic substance” under this definition.”

The Advisory Board understands that under Part E of the EEOICPA, an illness can only 

be accepted as a compensable covered illness if “exposure to a toxic substance at a covered 

DOE facility was “at least as likely as not” a significant factor in aggravating, contributing to 

or causing the illness.” The Advisory Board also acknowledges that heat and cold should not be 

considered causative exposures for work-related asthma.

However, a review of the updated Procedure Manual 1.1 (see below) indicates that 

OWCP’s current criteria for WRA differ more than “slightly” from the Advisory Board’s 

recommendation and are not consistent with current knowledge and clinical practice regarding 

WRA. The primary area of discrepancy relates to the criteria regarding the physician’s 

documentation of the exposure that likely caused the claimant’s WRA. 

A better understanding of what is meant by the phrase “a toxic substance” and also what 

is known about the causes of WRA provides greater clarity and should resolve this discrepancy. 

The U.S. National Institute of Health (NIH) (and others) define a toxic substance as: 

“A toxic substance is simply a material which has toxic properties. It may be a discrete 

toxic chemical or a mixture of toxic chemicals. For example, lead chromate, asbestos, 

and gasoline are all toxic substances. More specifically:

 Lead chromate is a discrete toxic chemical. 

 Asbestos is a toxic material that does not consist of an exact chemical 

composition but a variety of fibers and minerals. 

 Gasoline is also a toxic substance rather than a toxic chemical in that it 

contains a mixture of many chemicals. Toxic substances may not always have 

a constant composition. For example, “the composition of gasoline varies 

with octane level, manufacturer, time of season, and other factors.”

https://toxtutor.nlm.nih.gov/01-002.html

There are numerous other examples of well-known toxic substances that are mixtures of 

many chemicals, particles or fumes, such as cigarette smoke, coal dust, diesel exhaust, 

degreasing solvents, combustion products or dust from the World Trade Center attacks. These 

exposures are well recognized to be toxic, even though they are not a single specific toxic 

chemical or a mixture of chemicals with unvarying composition. Stating that EEOICPA Part E 

requires identification of a specific exposure or exposure event in order to consider a condition to 

be compensable is a misunderstanding of the EEOICPA statutory requirement. Rather EEOICPA 

requires identification of work exposure(s) that on an at least as likely as not basis were a 

significant factor in aggravating, contributing to or causing the illness.

Multiple different potentially toxic substances can cause or exacerbate WRA, including 

various irritants, allergens, dusts, fumes, vapors and gases. This is acknowledged in the current 

Procedure Manual page 524: “The CE does not apply a toxic substance exposure assessment to a 
18

claim for work-related asthma, including the application of the SEM or IH referral process,

because any dust, vapor, gas or fume has the potential to affect asthma.”

Most cases of WRA result from repeated inhalational exposures over months to years, 

rather than a specific exposure incident. In the great majority of cases of WRA diagnosed in the

US, a single specific causative agent or specific exposure event is not identified, nor a triggering 

mechanism, even when patients are evaluated by occupational lung specialists. Commonly 

identified exposures that contribute to WRA include dusts, fumes, chemicals, cleaning products, 

and pyrolysis products.(1-5) Also of note, the mechanisms by which most exposures cause or 

exacerbate asthma remain poorly defined.

The criteria to diagnose WRA that are described in newly revised Procedure Manual 1.1, 

Appendix 1, pages 524-5 (noted below), differ more than slightly from Recommendation #2-4, 

are not reflective of current knowledge and practice regarding WRA, and contain internal 

inconsistencies:

“Asthma: Work-related asthma includes: a) occupational asthma; or new onset asthma 

that is initiated by an occupational agent, and b) work-exacerbated asthma, which is 

established asthma that is worsened by work place exposures. The CE does not apply a 

toxic substance exposure assessment to a claim for work-related asthma, including the 

application of the SEM or IH referral process, because any dust, vapor, gas or fume has 

the potential to affect asthma. Given the scope of potential occupational triggers that can 

affect asthma, the CE relies exclusively on the assessment of the medical evidence by a 

qualified physician to arrive at a determination of compensability. The criteria for 

accepting a Part E claim for asthma are: 

a. The employee has a period of covered Part E contractor or subcontractor 

employment. 

b. A qualified physician has diagnosed the employee with asthma ...... (see above).

c. Once having established covered Part E contractor or subcontractor employment 

and a diagnosis of asthma, the following criteria are available to demonstrate 

that the employee has work related asthma (as defined above): 

i. A qualified physician, who during a period contemporaneous with the 

period of covered Part E employment, diagnosed the employee with workrelated asthma or; 

ii. After a period of covered employment, a qualified physician conducts an 

examination of either the patient or available medical records and he or 

she concludes that the evidence supports that the employee had asthma 

and that an occupational exposure to a toxic substance was at least as 

likely as not a significant factor in causing, contributing to or aggravating 

the condition. The qualified physician must provide a well-rationalized 

explanation with specific information on the mechanism for causing, 

contributing to, or aggravating the conditions. The strongest 

justification for acceptance in this type of claims is when the physician 

can identify the asthmatic incident(s) that occurred while the employee 

worked at the covered work site and the most likely toxic substance 

trigger. A physician’s opinion that does not provide a clear basis for 
19

diagnosing asthma at the time of covered employment or the physician 

provides a vague or generalized opinion regarding the relationship 

between asthma and occupational toxic substance exposure will require 

additional development including the CE’s request for the physician to 

offer further support of the claim. If the CE is unable to obtain the 

necessary medical evidence from the treating physician to substantiate the 

claim for work-related asthma, the CE will need to seek an opinion from a 

CMC. If a CMC referral is required, the CE will need to provide the CMC 

with the relevant medical evidence from the claim file and provide a 

detailed description of the employee’s covered employment which must 

include each covered worksite, dates of covered employment, labor 

categories, and details about the jobs performed.” 

The above criteria for WRA would more accurately reflect the medical literature and 

current practice if the sections that are bolded were eliminated. 

Also of note, the updated Procedure Manual refers to Exhibit 18-1; Matrix for 

Confirming Sufficient Evidence of Non-cancerous Covered Illnesses; Asthma, Occupational 

(page 568) for further guidance. This Table (page 568; dated 9/2017) summarizes the criteria to 

diagnose Asthma and WRA. It does not reflect the Procedure Manual text, contains inaccurate 

medical information, and requires revision.

The Advisory Board, which has substantial expertise in WRA, is willing to provide the 

DOL additional guidance on updating the Procedure Manual and implementation of the WRA 

Presumption. 

Additional References:

1. Jajosky RA, Harrison R, Reinisch F, Flattery J, Chan J, Tumpowsky C, Davis L, Reilly MJ, 

Rosenman KD, Kalinowski D, Stanbury M, Schill DP, Wood J. Surveillance of work-related 

asthma in selected U.S. states using surveillance guidelines for state health departments--

California, Massachusetts, Michigan, and New Jersey, 1993-1995. MMWR CDC Surveill Summ 

1999; 48: 1-20.

2. Mazurek JM, Filios M, Willis R, Rosenman KD, Reilly MJ, McGreevy K, Schill DP, Valiante 

D, Pechter E, Davis L, Flattery J, Harrison R. Work-related asthma in the educational services 

industry: California, Massachusetts, Michigan, and New Jersey, 1993-2000. Am J Ind Med 2008; 

51: 47-59.

3. White GE, Seaman C, Filios MS, Mazurek JM, Flattery J, Harrison RJ, Reilly MJ, Rosenman 

KD, Lumia ME, Stephens AC, Pechter E, Fitzsimmons K, Davis LK. Gender differences in 

work-related asthma: surveillance data from California, Massachusetts, Michigan, and New 

Jersey, 1993-2008. J Asthma 2014; 51: 691-702.
20

4. Talini D, Ciberti A, Bartoli D, Del Guerra P, Iaia TE, Lemmi M, Innocenti A, Di Pede F, 

Latorre M, Carrozzi L, Paggiaro P. Work-related asthma in a sample of subjects with established 

asthma. Respir Med 2017; 130: 85-91.

5. Anderson NJ, Fan ZJ, Reeb-Whitaker C, Bonauto DK, Rauser E. Distribution of asthma by 

occupation: Washington State behavioral risk factor surveillance system data, 2006-2009. J 

Asthma 2014; 51: 1035-1042.
21

Revised Recommendation: Presumptions for Chronic Obstructive Pulmonary Disease 

Diseases

(Originally approved as Recommendation #3 at the April 2017 Board meeting)

ABTSWH comments on OWCP’s response regarding the causal link between COPD and VGDF

OWCP did not accept the Board’s recommendation to add a section on reported exposure to 

vapors, gases, dust, and fumes (VGDF) based on the following reasoning:

1. EEOICPA specifically states that a condition can only be accepted as a compensable 

covered illness if it is at least as likely as not that exposure to a toxic substance was 

related to employment at a Department of Energy facility.

2. The program has defined a ‘toxic substance” -- as “any material that has the potential to 

cause illness or death because of its radioactive, chemical, or biological nature”.

3. VGDF lexicon is a broad reference that encompasses many different toxic substances that 

exist in either occupational or non-occupational settings. 

4. The current presumption for COPD requires 20 years of exposure to asbestos while the 

Board recommended that five years of exposure to VGDF should be sufficient in a 

presumption. OWCP stated that this recommendation conflicts with the literature on 

which OWCP developed its presumption and requested additional documentation.

5. OWCP also requested clarification of the labor categories, which is being addressed in 

response to recommendation #1 from April 2017.

Regarding (1) and (2) above: The Board agrees that VGDF exposure can contain a range of 

different individual toxic agents. The Board notes that OWCP does accept claims for disease 

resulting from exposure to complex mixtures such as welding fume and wood dust, and from 

work processes that do not contain one specific toxic substance, such as: Blast, drill, remove, or 

crush rock; Dry clean with organic solvents; Clean equipment with solvents; Paint or varnish, 

oil-based. The Board notes these examples to point out that OWCP has found ways to 

accommodate exposure to complex mixtures.

Regarding (3), to be responsive to the request to provide a narrower list of toxic exposures, 

we have added a list to the presumption recommended in October 2016; see below

Regarding (3) above, the intent of the Board’s recommendation is to have OWCP 

compensate workers with occupational exposure to VGDF that occurred during their work in the 

DOE weapons complex, not from more general non-occupational exposure. The Board stands 

behind the opinion that the literature provided to OWCP shows a clear causal link between 

VGDF exposure and COPD in an occupational setting, and this causal link is accepted by the 

American Thoracic Society, the premier US organization of professionals in the area of 

respiratory disease.
22

Regarding (4) above, the Board would need to review the research referenced by OWCP. 

However, that review would not change the recommendations made here, since OWCP’s 

references presumably are specific asbestos. 

Revised Recommendation: Presumptions for Chronic Obstructive Pulmonary Disease Diseases

The Board recommends that DOL adopt the following:

1. A determination by DOL that chronic occupational exposure to toxic substances or 

vapors, gases, dusts, or fumes (VGDF) at DOE sites where toxic substances were or are 

used can cause, contribute, or aggravate COPD,

2. Presumption of Chronic Exposure to Toxic Substances

Claimants will be presumed to have had chronic occupational exposure to one or more toxic 

substances at a Department of Energy facility that was sufficient to aggravate, contribute to, 

or cause COPD if they meet any one of the following conditions:

a. 5 years of work at a DOE site with exposure to one or more of the following toxic 

substances, as identified on the EE-3 or the OHQ: asbestos; silica; cement dust; 

engine exhausts; acids and caustics; welding, thermal cutting, soldering, brazing; 

metal cutting and grinding; machining aerosols; isocyanates, organic solvents, wood 

dust, molds and spores; and particulates not otherwise regulated (PNOR1), or

b. 5 years of work in any one of the maintenance or construction job titles at a DOE site 

if the claimant’s job title(s) is linked to one or more toxic substances in the SEM, or

c. 5 years of exposure to VGDF during DOE employment as reported in a revised OHQ 

that assesses VGDF exposures and the SEM shows that his/her job title or tasks are 

linked to agents in one or more of the following SEM toxic substance groups:

i) Acids/caustics/reducing and oxidizing agents

ii) Dusts and fibers

iii) Gases

iv) Metals

v) Solvents

 

1

PNOR includes all mineral and inorganic “inert or nuisance dusts” without specific individual U.S. Occupational 

Safety and Health Administration Permissible Exposure Limits (PEL). See OSHA. Chemical Sampling Information: 

Particulates Not Otherwise Regulated (Total Dust) Washington, DC. 2015; NIOSH Pocket Guide to Chemical 

Hazards: Particulates not Otherwise Regulated. Atlanta, GA, 2015.
23

3. Timing of exposure: Because exposures to toxic substances continue to take place at 

DOE sites and many of them are unregulated, it should be presumed that reported 

exposures to toxic substances that cause, contribute to or aggravate COPD at any period 

of employment covered by EEOICPA, up to the present time, are contributory exposures. 

4. Duration of exposure. Based on the evidence presented in the Dement 2015 study, a 

cumulative duration of 5 years of reported exposures to VGDF can be presumed to 

aggravate, contribute to, or cause COPD. 

5. Time since last exposure: The committee does not recommend specifying any minimum 

or maximum time since last exposure to a toxic substance. COPD is a slowly progressive 

disease and individuals are often not diagnosed until the disease is advanced, or an 

intervening infection makes the diagnosis more apparent. Since it would not be possible 

to determine in retrospect when a case of COPD could have been first diagnosed, and 

since exposure to VDGF involving toxic substances is a contributory cause to COPD, it is 

reasonable to assume that VGDF exposure contributed to any diagnosed case even if the 

disease is diagnosed after the worker has left employment

6. Additionally, claims examiners should not deny claims for COPD if the worker had fewer 

than 5 years of exposure; for example, a claimant who has experienced high intensity 

exposures to VGDFs involving toxic substances during work in a covered facility would 

have an equivalent exposure. Claims that do not meet the requirements set forth here but 

do have reported exposure to VGDF should be sent for IH and/or CMC review under the 

policy established in Bulletin 16-03.

Scientific Rationale 

Substantial medical literature has investigated the etiology of COPD among general 

populations in the U.S., Italy, New Zealand, Poland, Australia, Spain, and elsewhere (see 

reviews in ATS Statement, Balmes 2003; ATS Statement, Eisner 2010). 

In 2003, the American Thoracic Society, which is the preeminent respiratory disease 

organization in the United States, published the enclosed paper concluding that occupational 

exposures were responsible for a substantial fraction of COPD in the United States (Balmes 

2003). Another paper from the American Thoracic Society published in 2010, with Eisner as 

the lead author and the title “An Official American Thoracic Society Public Policy Statement: 

Novel Risk Factors and The Global Burden of Chronic Obstructive Pulmonary Disease,” (Eisner 

2010) describes that there is a very strong and well accepted relationship between occupational 

exposures to vapors, gases, dusts and fumes (VGDF) and COPD; [see the section starting on 

page 704]. This document states that it is a strong causal relationship and describes other 

literature that has identified some specific agents that are part of the overall occupational 

exposures to vapors gases dust and fumes. Table 5 in this paper lists some studies that have 

identified specific agents, including asbestos and quartz (quartz is another name for as crystalline 

silica).
24

Other primary research studies have defined the causative occupational exposures as a 

combined exposure VGDF. These large studies of varying study designs have consistently 

shown that occupational exposures defined as “gases, dusts, vapors, and fumes” increase the risk 

of COPD. A dose-response relationship has been seen (Weinmann 2008, Mehta 2012), and the 

effect is observed among both smokers and non-smokers (Blanc 2009, Dement 2010). The effect 

of smoking and occupational exposures appears to be additive. A recent study by Dement et al 

looked at COPD and occupational risks in DOE facilities specifically, and found that VGDF 

significantly increased the risk for COPD (Dement 2015). 

The specific agents listed in 2(a) have been shown to cause COPD with these studies:

asbestos [ATS, 2004; Dement et al., 2010; Glencross et al., 1997]; 

silica [Dement et al., 2010; Hnizdo and Vallyathan, 2003; Oliver and Miracle-McMahill, 

2006; Rushton, 2007b; Tse et al., 2007]

cement dust [Abrons et al., 1988; Dement et al., 2010; Fell et al., 2010; Mwaiselage et 

al., 2004; Rushton, 2007a]

diesel exhausts [Hart et al., 2009; Hart et al., 2006; Tuchsen and Hannerz, 2000; 

Ulvestad et al., 2000; Weinmann et al., 2008]

welding and cutting gases and fumes [Balmes, 2005; Bradshaw et al., 1998; Dement et 

al., 2010; Hunting and Welch, 1993; Koh et al., 2015; Mastrangelo et al., 2003; Szram et 

al., 2013]

metal cutting, grinding, and machining aerosol, paint-related aerosols [Glindmeyer 

et al., 2004; Hammond et al., 2005; Mastrangelo et al., 2003; Pronk et al., 2007]\

organic solvents [Ebbehoj et al 2008; Heederik et al 1989; Melville 2010; Post et al 

1994; Suadicani P, 2001; Valcin M, et al. 2007; Alif et al, 2017]

wood dust [Jacobsen et al., 2008; Dement et al., 2010]

molds,spores and biological aerosols [Matheson et al., 2005; Dement et al., 2010; Sunyer 

et al., 1998]

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Balmes JR. Occupational Contribution to the Burden of Chronic Obstructive Pulmonary Disease. 

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Bergdahl IA, Toren K, Eriksson K, Hedlund U, Nilsson T, Flodin R, et al. Increased mortality in 

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Blanc PD, Iribarren C, Trupin L, Earnest G, Katz PP, Balmes J, et al. Occupational exposures 

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Dement JM, Welch L, Ringen K, Bingham E, Quinn P. Airways obstruction among older 

construction and trade workers at Department of Energy nuclear sites. Am J Ind Med 2010 

Mar;53(3):224-40.

Dement J, Welch L, Ringen K, Quinn P, Chen A, Haas S. A case-control study of airways 

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symptoms, and pulmonary function in welders in New Zealand. Occup Environ Med. Mar 

1998;55(3):150-154.

Dement JM, Welch L, Ringen K, Bingham E, Quinn P. Airways obstruction among older 

construction and trade workers at Department of Energy nuclear sites. Am J Ind Med. Mar 

2010;53(3):224-240.

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Eisner MD, Anthonisen N, Coultas D, Kuenzli N, Perez-Padilla R, Postma D, et al. An official 

American Thoracic Society public policy statement: Novel risk factors and the global burden of 

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Fell AK, Sikkeland LI, Svendsen MV, Kongerud J. 2010. Airway inflammation in cement 

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26

Heederik D, Pouwels H, Kromhout H, Kromhout D. Chronic non-specific lung disease and 

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Hammond SK, Gold E, Baker R, et al. Respiratory Health Effects Related to Occupational Spray 

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Hunting KL, Welch LS. Occupational exposure to dust and lung disease among sheet metal 

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Jacobsen G, Schlunssen V, Schaumburg I, Taudorf E, Sigsgaard T. 2008. Longitudinal lung 

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Glencross PM, Weinberg JM, Ibrahim JG, Christiani DC. 1997. Loss of lung function among 

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Glindmeyer HW, Lefante JJ, Jr., Rando RJ, Freyder L, Hnizdo E, Jones RN. Spray-painting and 

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Melville AM, Pless-Mulloli T, Afolabi OA, Stenton SC. COPD prevalence and its association 

with occupational exposures in a general population. Eur Respir J. Sep 2010;36(3):488-493.

Mastrangelo G. Ascertaining the risk of chronic obstructive pulmonary disease in relation to 

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Abramson MJ. 2005. Biological dust exposure in the workplace is a risk factor for chronic 

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Comments on Recommendation: Revisions of the Occupational Questionnaire (OHQ)

(Originally approved as Recommendation #4 at the April 2017 Board meeting)

ABTSWH responses to DOL’s comments

The Advisory Board made several specific recommendations for revision of the current 

occupational history questionnaire at the April 2017 meeting. The DOL response to the 

Advisory Board’s recommendation contains the following specific points:

1. OWCP has already developed a revised OHQ that: 

 Provides space for workers to provide free text descriptions of how they were 

exposed.

 Provides space to record union membership and participation in a Former Worker 

Program.

 Reduces the lists of toxic substances and instead lists categories under which the 

claimant may provide specific toxic substances.

2. OWCP did not accept the Board’s recommendation to add a section on reported exposure 

to vapors, gases, dust, and fumes (VGDF) based on the following reasoning:

 EEOICPA specifically states that a condition can only be accepted as a 

compensable covered illness if it is at least as likely as not that exposure to a 

specific toxic substance was related to employment at a Department of Energy 

facility.

 The program has defined a “toxic substance” - as “any material that has the 

potential to cause illness or death because of its radioactive, chemical, or 

biological nature”.

 VGDF lexicon is a broad reference that encompasses many different specific 

toxic substances that exist in either occupational or non-occupational settings.

The Advisory Board discussed the OHQ recommendations and the OWCP response in 

detail at the meeting held in November 2017. The Board’s recommendation to add questions 

concerning VGDF exposures is tied to the recommended presumption for COPD and will be 

addressed in the responses to the COPD recommended presumption. 

The Advisory Board’s recommended OHQ revisions are closely tied with other 

recommendations intended to improve the quality of claimant-provided exposure information 

and use of this information during claim adjudication. These other Advisory Board 

recommendations include: 
29

1. Use of former DOE workers to assist claimants in completing the OHQ, and 

2. Providing industrial hygienist the opportunity to speak directly with claimants to 

clarify information provided in the OHQ.

The Advisory Board was provided and did review the revised draft of the OHQ in the 

process of developing its specific OHQ recommendations. The Board believes that there 

remains considerable room for improvement in the draft OHQ. The draft OHQ is largely a form 

that allows the claimant space for recording free text descriptions of their exposures. While 

recording free text descriptions of work performed is helpful, the draft OHQ does not provide 

sufficient structure and ‘memory triggers’ to help claimants recall specific tasks and exposures at 

DOE sites. Experience gained through the Former Worker Programs including the Building 

Trades National Medical Screening Program (BTMed) has shown that listings of materials and 

tasks on the OHQ provide memory triggers often useful in stimulating recall of exposures that 

may have occurred decades in the past. Furthermore, industrial hygienists use tasks and 

materials collectively as indicators of exposure and exposure intensity. In addition to asking 

about materials and tasks, the Advisory Board recommended that a scale of task frequency be 

included the OHQ. The BTMed program has found that tasks and task frequency by job, in 

combination with job duration, can be used to generate exposure indices that are indicative of 

risk for occupational diseases such as pulmonary fibrosis and COPD.

The Advisory Board acknowledges that the BTMed list of tasks is largely specific to 

construction and maintenance workers. A similar list is not available for production workers and 

production tasks are likely to differ substantially by DOE site. Acknowledging this limitation, 

the Advisory Board recommended that the OHQ provide space to record free text descriptions of 

tasks associated with recorded exposures. This would allow industrial hygienists reviewing the 

claimant file better information to assess the likely range of exposure intensity. Additionally, 

this free text description could provide a useful flag to industrial hygienists when the task 

description is insufficient and discussion with the claimant for clarification is needed.
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Comments on Recommendation: Enhancing the Science and Technical Capacity in 

EEOICP

(Originally approved as Recommendation #5 at the April 2017 Board meeting)

ABTSWH responses to DOL’s comments

The Board recommended that the DEEOICP enhance its scientific and technical 

capabilities to address selected gaps in current capacity, namely, to implement the 

recommendations developed in the 2013 IOM report on the SEM; to update and keep current the 

exposure-disease links based originally on Haz-Map in the SEM; to ensure that that program 

policies reflect state-of-the-art science; to address the continuing challenge of evaluating claims 

for diseases for which knowledge is actively evolving; and others. The Board acknowledges the 

current in-house and contracted expertise that OWCP has at present in the EEOICP. However, 

the issues that the IOM report raised remain relevant, and the problems that the Board itself has 

identified in its work on selected issues such as occupational asthma, asbestos-related diseases, 

occupational hearing loss, and chronic obstructive pulmonary disease, illustrate that OWCP 

needs additional organizational expertise in disease causation, epidemiology, and occupational 

medicine that can participate in the OWCP on a sustained and regular basis. The Board remains 

willing to assist on an ad hoc and advisory basis, but the program need is too multi-dimensional 

and ongoing to rely on the Board to fulfill this function. 
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Revised Recommendation: Quality Assessment of Contract Medical Consultants and 

Industrial Hygienists

(Originally approved as Recommendation #7 at the April 2017 Board meeting)

ABTSWH responses to DOL’s comments

The Board takes note that the EEOICP Medical Director conducts audits of 

approximately 40 CMC reports on a quarterly basis and that follow-up is conducted on problems 

that are thereby identified. However, the Board raises the concern that the audit process itself is 

flawed and fails to address major questions concerning quality. The Board recommends the 

following three changes in the process as relatively straightforward ones that could be 

implemented immediately to improve quality assessment:

1. The initial question for the medical reviewer to address is whether the CE included all 

relevant information in the information sent to the CMC/IH. Note that this 

recommendation is not necessary if the Board’s overarching recommendation to 

provide the entire file to CMC and IH consultants is approved.

2. The main quality question for the medical reviewer is whether the CMC’s written 

medical opinion was based on established DOL guidance and on the latest scientific 

evidence.

3. A review process in which reviews are conducted by two medical experts with 

subsequent comparison of results should be implemented.

The Board takes the position that it cannot properly advise the Secretary regarding the 

fourth task of its mission concerning “the work of industrial hygienists and staff physicians and 

consulting physicians of the Department and reports of such hygienists and physicians to ensure 

quality, objectivity, and consistency’ without conducting an independent review of a substantial 

number of claims. In the second half of 2016, the Medical Director found problems in 13 of 82 

reviewed CMC reports, representing 1 of every 6 (16%) CMC reports. This finding represents a 

significant proportion of reports with errors, reinforcing the Board’s desire to take an 

independent look at a large number of claims. In addition, the Medical Director’s review did not 

address the issue of consistency across reports, an issue that is key to quality and fairness of 

EEOICP. The Board has not been provided of a quality assessment of the IH reports.

Revised Recommendation

Given the number of CMC’s and IH’s, the different types of their evaluations, the 

different types of claims, and other factors, the Board requests that it oversee the review of CMC 

and IH reports that were developed in several hundred claims. The exact number awaits a fuller 

understanding of the variation in the factors identified above. 
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Issues for Consideration by the Future Advisory Board on Toxic Substances and Worker 

Health

The following is a number of issues raised by Board members in its last two meetings 

that might be considered by the next appointed Board. They are not ordered in priority and are 

not intended to be comprehensive.

1. How to interpret and apply the standard: aggravated, contributed to, or caused by an 

exposure.

2. Revisit the SEM at a broad level and assess and monitor DEEOIC’s relationship with 

HAZ-MAP. In addition, making sure that exposure assessment in the claims process 

continues to improve, including a focus on tools that are outside the SEM. How to ensure 

that the employment history of claimants is well-documented.

3. Look more deeply at the available claims data – particularly continuing with the analysis 

that Member Dement did of the data relating to pat B claims. 

4. Look at the topic of durable medical equipment authorization. 

5. Examine EEOICP’s performance on impairment ratings.

6. The new Board should look at the list of conditions for the most commonly denied 

claims, and, additionally, neurologic illnesses, cancer, and endocrine conditions. 

7. More interaction with physicians from DOL would be helpful. 

8. It would also be helpful for the next Board to have refresher presentations from DOL and 

the NIOSH Board. 

9. Be involved in evaluating the pilot data from the re-drafted OHQ questionnaire. 

10. Follow up on Board recommendations.

11. Monitor the outcomes of changes made by DOL in response to Board recommendations, 

including the claims process and outcomes.

12. Examine and encourage additional continuing education, credentialing, and career 

progression for Claims Examiners and other staff.

13. Ensure that public comments are appropriately tracked and subsequently integrated into 

Board discussions.

14. Review of the latest procedure manual, circulars, bulletins, and training materials for 

accuracy and consistency.