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U.S. DEPARTMENT OF LABOR

+ + + + +

ADVISORY BOARD ON TOXIC SUBSTANCES 

AND WORKER HEALTH

+ + + + +

THURSDAY

NOVEMBER 16, 2023

+ + + + +

The Advisory Board met in the Zia 

Boardrooms at the Eldorado Hotel & Spa, 309 W San 

Francisco Street, Santa Fe, New Mexico, at 8:30 

a.m., 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

KIRK DOMINA

DESIGNATED FEDERAL OFFICER

RYAN JANSEN
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ALSO PRESENT

KEVIN BIRD, SIDEM

D'LANIE BLAZE, CORE Advocacy for Nuclear &

Aerospace Workers

AMANDA FALLON, DOL

CARRIE RHOADS, DOL

TONYA TAYLOR, DOL

JOHN VANCE, DOL*

*Present via video teleconference
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CONTENTS

Item Page

Introductions 7

Changes in EEOICP Policies

and Procedures 26

New Issues

Review of Newly Classified IARC

2A Carcinogens 91

Review of Public Comments 97

Follow-up Discussion of Day #1

Topics Board work plan 100

Close of Meeting
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P-R-O-C-E-E-D-I-N-G-S

(8:31 a.m.)

MR. JANSEN: Good morning, everyone. 

My name is Ryan Jansen and I'm the designated 

federal law officer for the Department of Labor's 

Advisory Board on Toxic Substances and Worker 

Health. I would like to welcome you to day two 

of this meeting of the Advisory Board here in 

Santa Fe, New Mexico.

Today is Thursday, November 16th, 

2023. We are scheduled to meet from 8:30 a.m. to 

11:30 a.m. Mountain Time. I am again joined by 

Carrie Rhoads from the Department of Labor and 

Kevin Bird, our logistics contractor. There will 

be no public comment period today.

As I mentioned yesterday, the Board's 

website, which can be found at 

DOL.gov/owcp/energy/regs/compliance/advisoryboard

.htm, is the 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 
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today. There you can also find today's agenda, 

as well as instructions for participating 

remotely.

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, this session is for 

viewing only. Microphones will be muted for nonAdvisory Board members. So the public may listen 

in, but not participate in the Board's discussion 

during the meeting.

A transcript of minutes will be 

prepared from today's meeting. As the designated 

federal officer, I see that the minutes are 

prepared and ensure that they 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. 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 
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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.

I would also ask our transcriber, 

please let us know if you have trouble hearing 

anyone or any of the information that is being 

provided.

As always, I would like to remind 

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.

Please be aware of this throughout the 

discussions today. The materials could be 

discussed in a general way which does not include 

any personally identifiable information, or PII, 
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which is names, addresses, or a doctor's name if 

we are discussing a case.

With that, I convene this meeting of 

the Advisory Board on Toxic Substances and Worker 

Health. I will now turn it over to Dr. 

Markowitz.

CHAIR MARKOWITZ: Good morning. We 

should as a matter of process do introductions 

again. Steven Markowitz, occupational medicine 

physician, epidemiologist at the University of 

New York.

Mr. Key?

MEMBER KEY: Good morning. Jim Key, 

49-plus-year worker at Paducah Gaseous Diffusion 

Uranium Enrichment Facility. I started at the 

inception of this program and EEOICPA.

I represent the labor claimant 

community, and assisting them in getting their 

worker health protection physicals and filing 

their claims. I'm glad to hear the comments of 

other Board members today.

MEMBER VLAHOVICH: Good morning. My 
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name is Kevin Vlahovich. I'm an occupational 

medicine physician, and I'm an assistant 

professor at the University of New Mexico in the 

Department of Internal Medicine.

MEMBER BOWMAN: Good morning as well. 

My name is Aaron Bowman. I am a professor at 

the School of Health Sciences at Purdue 

University. I'm a toxicologist and specialize in 

neurotoxicology.

MEMBER SPLETT: Good morning. I'm 

Gail Splett. I'm retired from the Hanford Site. 

I worked for the Department of Energy for 45 

years with various administrative functions, 

including Records Officer and the EEOICPA Program 

Manager for Hanford.

MEMBER MIKULSKI: Good morning. My 

name is Marek Mikulski. I'm an occupational 

epidemiologist with the University of Iowa 

Occupational and Environmental Health. I direct 

an Iowa Former Worker program for the former 

workers from the State of Iowa.

MEMBER DOMINA: I'm Kirk Domina. I'm 
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a retired Hanford worker. I'm here to represent 

the claimant community.

MEMBER CLOEREN: I'm Marianne Cloeren. 

I'm an Associate Professor of Medicine at the 

University of Maryland School of Medicine, 

occupational medicine and internal medicine 

certified.

I have a lot of experience with 

workers' compensation systems with a focus on 

federal ones, and I'm also the National Medical 

Director for the Building Trades former worker 

program.

MEMBER VAN DYKE: Good morning. Mike 

Van Dyke. I'm an associate professor and 

industrial hygienist at the Colorado School of 

Public Health.

MEMBER CATLIN: And good morning. I'm 

Mark Catlin, retired industrial hygienist.

CHAIR MARKOWITZ: Dr. FriedmanJimenez?

MEMBER FRIEDMAN-JIMENEZ: Good 

morning. I'm George Friedman-Jimenez. I'm an 
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occupational medicine physician and 

epidemiologist at the Bellevue NYU Occupational 

Medicine Clinic, and New York University School 

of Medicine.

CHAIR MARKOWITZ: Okay.

MS. TAYLOR: Good morning. My name is 

Tonya Taylor. I'm with the Department of Labor 

Office of the Ombudsman for the EEOICPA.

MS. FALLON: Good morning. My name is 

Amanda Fallon, and I'm the Ombuds for the Energy 

Program.

MS. BLAZE: Hi. I'm D'Lanie Blaze. 

I'm with CORE Advocacy for Nuclear and Aerospace 

Workers.

CHAIR MARKOWITZ: Okay. Thank you. 

So let's go over -- actually, before we just 

review the agenda today, if Board members could 

just let us know, does anybody need to leave 

before the designated close of business at 11:30?

Aaron? Okay, so 11:00. Okay. That's 

good to know.

Let's just go over what we have from 
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yesterday and what we need to cover this morning. 

We need to just finalize a plan around the 

follow-up on the SEM, what we are going to send 

to the Department and also if there's any 

additional conversation around the demonstration 

that they've offered to provide us. We need to 

come back to the industrial hygiene 

recommendation, our response to it.

We're going to come back to our 

response to the DOL's response on our CMC 

recommendation. We should close out the 

conversation we had about the meaning of 

significance and the various levels of exposure 

designated by the industrial hygienists in their 

report.

We have a brief discussion on the 

claimants who report being terminally ill. We're 

going to just briefly review the request from the 

Department regarding Board review of a newly 

classified 2A carcinogen.

And then I think we can briefly 

discuss public comments. There was one public 
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comment yesterday. We received a couple of 

written comments this morning. I think two are 

actually from the same person. We can briefly 

discuss that.

There is also follow-up, I think, on 

the Parkinson's issue. We were going to request 

to take a look, I think, at the list of agents 

that they have added to the SEM as being related 

to Parkinsonism.

Was there any other follow-up from 

yesterday? I think -- Dr. Cloeren?

MEMBER CLOEREN: Hi, Marianne Cloeren. 

We talked about reviewing recent -- I guess we 

need a plan for reviewing literature on hearing 

loss, what has changed in the hearing loss 

literature.

CHAIR MARKOWITZ: Right. Okay. If 

anything else arises, just chime in. Okay. So 

let's just work our way down the list here.

What's the next step on our discussion 

around the Site Exposure Matrices? Ms. Splett?

MEMBER SPLETT: I think we need to 
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prepare a draft list of questions for the Board. 

And I would be more than happy to commit to 

drafting that and having it out to the other team 

members by the 22nd of December.

CHAIR MARKOWITZ: I'm sorry. 

Questions to the Department?

MEMBER SPLETT: Excuse me. Yes, to 

the Department.

CHAIR MARKOWITZ: Okay.

MEMBER SPLETT: Excuse me. Yes, for 

the subteam. I've got some other specific 

examples that have been provided since yesterday 

from other sites, and I'll get those together. 

And then maybe by the 16th of January, our 

subteam can have the questions finalized for the 

Department of Labor and then schedule the 

demonstration.

CHAIR MARKOWITZ: Okay. So you're 

going to initiate a draft of questions, circulate 

it, get additional comments and questions, 

finalize it by January 16th?

MEMBER SPLETT: Yes.
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CHAIR MARKOWITZ: Okay. And with 

request for a demonstration, which should 

probably be scheduled before -- well, sometime 

during the month after January 16th.

MEMBER SPLETT: I think that seems 

reasonable, if the Department of Labor agrees to 

that.

CHAIR MARKOWITZ: Okay. So if 

demonstration would occur sometime hopefully 

before mid-February, I was thinking ahead whether 

that will give enough time before our next 

meeting for that same working group to do 

additional work, if it wants to.

MEMBER SPLETT: If you want to move 

that schedule up, I'm certainly agreeable to 

that.

CHAIR MARKOWITZ: No, no, I'm just 

thinking out loud whether it's a reasonable time 

frame, that's all. But if it sounds reasonable 

to you, then it's fine.

MEMBER SPLETT: Okay.

CHAIR MARKOWITZ: Any other comments 
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on this? That was easy. So let's discuss the 

industrial hygiene comments. We have a 

PowerPoint, the second slide of the PowerPoint.

Dr. Cloeren, do you want to just walk 

through this?

MEMBER CLOEREN: Yes. Marianne 

Cloeren. The assumption here is that the 

recommendations that were previously made and 

were accepted by the Department still stand, 

including the use of a table to summarize the 

pertinent details whenever an exposure is 

determined to be some level of significant. So 

we didn't add that here.

The recommendation would be that the 

Board recommends that the Department of Labor 

modify its exposure assessment and communication 

procedures as follows. The first part is related 

to the IH consultant specifically, that the IH 

consultant specifically address the content of 

what was in the occupational health questionnaire 

in the industrial hygiene report.

And then the second part is that they 
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would be required to describe what exposurerelevant information was found in each of the 

data sources reviewed, including the DAR. And if 

none, that should be explicitly stated.

The rationale for this is to guard 

against the implication that these data sources 

contained information about there not having been 

exposures. Right now the reports tend to group 

the review as these were the sources reviewed, 

without providing detail about what was in them.

And then the second part of the 

recommendation is that the claims examiner would 

share the OHQ itself with any physician that is 

asked to use the IH report for causation 

analysis. So in addition to what's normally 

provided to the physician for causation analysis, 

the OHQ would be another source of data provided 

to the physician.

CHAIR MARKOWITZ: Comments? Dr. 

Bowman?

MEMBER BOWMAN: I agree with this 

recommendation in full. Going back to the 
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rationale that you described, I'm wondering if we 

might edit 1B at the end, the final sentence, to 

be more something explicitly stated to avoid the 

possibility of a false assumption or something 

like that.

CHAIR MARKOWITZ: Our recommendation 

also is accompanied by a rationale. So certain 

things -- I'm not saying this needs to go -- it 

could be put here, but it could also be put --

MEMBER BOWMAN: I'm sorry. I would be 

fine if that concept is just contained within the 

rationale that accompanies this, in which case I 

withdraw my amendment.

CHAIR MARKOWITZ: Dr. Van Dyke?

MEMBER VAN DYKE: Mike Van Dyke. I 

also agree with this recommendation. I would 

just say that the 1A has to be just a little bit 

more specific because just saying address the 

content, that's a big ask. If we say address all 

reported exposures, that might be more specific.

CHAIR MARKOWITZ: There's a thumbs-up, 

Kevin, from the writer of this proposed 
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recommendation to Dr. Van Dyke's added language.

One of the parts of the response from 

the Department was that whatever change they make 

in this process, they were going to run it by the 

CMC contractor, presumably CMCs, to get some 

feedback on any changes that are made and how 

they work.

Do we need to include that in our 

recommendation, that we request feedback on the 

use of any designated? Or do we just assume 

they've made that promise and we'll receive that 

information?

MEMBER CLOEREN: I don't understand 

your question.

CHAIR MARKOWITZ: I'm sorry. Let me 

just quote actually from the Department response. 

Based on the context of -- I'm quoting from 

August 21, 2023. This is a letter from 

Christopher Godfrey to myself, as Chair of the 

Board. The penultimate paragraph quotes:

Based on the context of the Board's 

recommendations, DOL has undertaken action to 
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engage with our CMC contractor to solicit 

information regarding improvements in how 

information is communicated in IH assessments.

This is an opportunity for CMCs to 

provide input on whether any additional metrics 

in an IH report will aid them in making their 

determinations. DOL will share any feedback it 

receives from the Board that further advance our 

shared interest in ensuring the publication of 

accurate and understandable characterizations of 

toxic substance exposures.

End of quote. I think with that 

promise, we probably don't need to repeat that 

here in this recommendation.

MR. VANCE: And Dr. Markowitz, this is 

John Vance.

CHAIR MARKOWITZ: Go ahead.

MR. VANCE: Very quickly, I do have an 

update for you. We did ask our contractor to 

provide any input. They did go out and discuss 

this issue with their CMCs.

The unfortunate response that we got 
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was, no comment. They didn't really want to 

provide any additional specific recommendations 

for improvement or any real thoughts on what 

could be done to improve. Their general 

impression was that the information was 

sufficient for them to inform their opinions, and 

that's where they left it.

So I was going to maybe take that up 

with the director and just see if there was 

anything more that we could do to encourage more 

forthright feedback, but we were not getting much 

of a response from the contractor on that. So I 

thought I'd share that.

CHAIR MARKOWITZ: That's interesting. 

Thank you.

Dr. Bowman?

MEMBER BOWMAN: Just reflecting on 

that, this sounds to me like a case of they don't 

know what they don't know.

CHAIR MARKOWITZ: Dr. Cloeren?

MEMBER CLOEREN: Marianne Cloeren. I 

just wanted to point out that the CMCs are not 
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the only end users of these reports that are 

performing causation analysis.

And so while I think the input of the 

CMCs would be very valuable, we should keep in 

mind that also treating physicians and sometimes 

former worker program physicians and others are 

asked to review and comment. It may be harder to 

get input from that community.

CHAIR MARKOWITZ: Mr. Catlin?

MEMBER CATLIN: Mark Catlin. When 

you're mentioning getting the feedback from the 

CMCs, from the contractor, does that also include 

the industrial hygiene consultant? I'd be 

interested if they had feedback on this 

recommendation and if we can get that, if that 

occurs.

CHAIR MARKOWITZ: I wonder, Mr. Vance, 

whether that's been done at all?

MR. VANCE: The way I can respond 

would be the Department of Labor will consider 

any input that's provided by the Board. So the 

recommendations that you're discussing right now, 
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that would be something that we would engage with 

our industrial hygienist about and see how we 

could facilitate a response that could either 

agree or not with the recommendations of the 

Board.

And we involve our industrial 

hygienists in all of our interactions with the 

Board proposals or recommendations. There are 

even things that we come back to share with them 

about ideas that are discussed during Board 

meetings.

So our industrial hygienists are 

working quite frequently with our contractors to 

try to figure out better ways to accommodate 

recommendations and improvements in the process.

And so what you'll notice with regard 

to the prior recommendation is the result of our 

response to the table issue that was discussed. 

I mean, that was something that we had a 

multitude of meetings and discussions with how to 

best accommodate those improvements in how we 

report the exposure analysis.
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So our industrial hygienists are 

engaged quite rigorously with our process in 

evaluating Board recommendations.

CHAIR MARKOWITZ: That's great. Maybe 

the CMC contractor could learn something from the 

IH contractor.

Dr. Friedman-Jimenez?

MEMBER FRIEDMAN-JIMENEZ: Yes, very 

minor. In 1A, I think it's a little awkward 

seeing the word in twice the way that it is.

What I would suggest is take the best 

four words in the IH report and put it after 

address. So it would read explicitly address in 

the IH report all reported exposures in the OHQ.

CHAIR MARKOWITZ: And I would just add 

that that's what you get when you have professors 

on a board.

MEMBER CLOEREN: It's funny because I 

was about to suggest that too.

(Laughter.)

CHAIR MARKOWITZ: Two professors on a 

board. Thank you, Dr. Friedman-Jimenez. Okay.
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Other comments or questions? We're 

going to vote on this recommendation. Okay.

Do we need to read this out loud or 

can everybody see it clearly enough? Okay.

I think then we can just take a vote. 

How do we do that again?

MR. JANSEN: I will 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?
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MEMBER VLAHOVICH: Yes.

MR. JANSEN: Mr. Key?

MEMBER KEY: Yes.

MR. JANSEN: Ms. Splett?

MEMBER SPLETT: Yes.

MR. JANSEN: Mr. Domina?

MEMBER DOMINA: Yes.

MR. JANSEN: There are 11 yes votes 

and no no votes.

CHAIR MARKOWITZ: Okay. Let's move 

on. If you go to the first slide, this is a 

recommendation. Let me just read it. It's 

regarding the CMC.

The Advisory Board recommends that the 

Department of Labor expand its quality assessment 

of CMC performance by implementing peer review of 

the validity of the content and analysis 

reflected in a quarterly sample of an appreciable 

number of CMC reports. Such peer review would be 

conducted by a small panel, two to three 

physicians, of medical experts in causation 

analysis of occupational diseases.
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Those are multiple: one, to estimate 

the size of the problem of major errors contained 

in the CMC reports; two, to identify and correct 

systemic problems in CMC causation analyses, 

plural; and three, to identify CMCs who 

repeatedly commit major errors in causation.

The floor is open for discussion. Ms. 

Splett?

MEMBER SPLETT: My only question would 

be the terminology of appreciable member. Is 

there any way to quantify that so the Board would 

understand the Department of Labor had completed 

that?

CHAIR MARKOWITZ: Well let me just --

right now the quarterly quality assessment report 

has analyses of 50 CMC or related reports.

Those 50 reports are, the aim is to 

have, as I understand it -- Mr. Vance, correct me 

if I'm wrong. Actually, Mr. Vance, maybe you 

should just explain this to us.

MR. VANCE: All right. Okay, so this 

is John Vance. Very quickly, we have actually 
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supplied to the Board the two most recent 

quarterly reports that are reporting out the 

findings of an analysis that's done on 

qualitative measures of performance by our 

contractor.

And so what we are looking at in those 

reviews is basically the quality of the input 

going into our CMC referral process, looking at 

how well the physician is formulating a response 

to a specific referral question.

As Dr. Markowitz mentioned yesterday, 

the topics that can be reviewed relate to 

anything that a CMC could potentially be opining 

on, specifically: causation, reviewing a file 

based on diagnostic or clinical information to 

help assist with the diagnosis of a particular 

condition, the appropriateness of prescribed 

medical benefits, and referee and second 

opinions.

These are in-person or file reviews by 

second opinions, or referees that are done. So 

we're conducting an analysis event to make sure 
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that the opinions meet the expectations of 

quality for the contract, that they're answering 

the question that has been posed to them, that 

the physician has some reasonable conclusion 

that's based on the facts of the case, and that 

they have some sort of justifiable rationale that 

they apply to arrive at whatever conclusion that 

they reach.

We're not looking necessarily at the 

right or wrong. We're looking at how well the 

doctor formulates the response, and the 

justification that's provided for the conclusion 

offered.

And those reports are available to the 

Board. So you'll see the results of those 

analyses that are performed.

CHAIR MARKOWITZ: Let me just add, I 

think the aim is to do ten of each of five 

different types of medical reports. And if there 

aren't enough reports in any one category, then 

they'll do additional reports in another 

category.
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MR. VANCE: That's correct.

CHAIR MARKOWITZ: I think the Board 

had previously recommended actually that the 

numbers be selected in relation to the proportion 

of overall reports in every category. So the 

categories that from the outset had a much larger 

number of reports, they disproportionately get 

more reviews.

The Department came back to us with, 

no, we're going to do ten of every type. But if 

there's room for fewer than ten and they want a 

given type, then we'll do more of other types.

So my own view is that more than ten 

causation quarterly reports would need to be 

reviewed to accomplish this recommendation. And 

the question is should we come up with a number 

or range of numbers, or should we just leave it 

more general, like appreciable or substantial?

MEMBER FRIEDMAN-JIMENEZ: This is 

George Friedman-Jimenez. I'd like to comment on 

that. I think the whole issue of designing the 

sampling of cases is a relatively technical 
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issue. You know, exactly what are we trying to 

accomplish? That will affect how we sample the 

cases.

For example, we may want to do a 

stratified random sample. The sample size, 

whether we're actually going to do a hypothesis 

test and if we need enough to do that, and what 

statistical analyses are we going to do?

And I would be in favor of doing some 

sort of a correlation or predictive value type of 

analysis similar to the way we do it in 

diagnostic testing theory. And I can give a lot 

more details on that. But I think that this 

whole issue of designing the sampling of the 

cases is beyond what we can discuss right now and 

make a decision.

So I would agree with sticking with a 

more open-ended term, like appreciable or 

appropriate, without specifying that number. I 

think that's something that we should do 

systematically based on what statistical analyses 

we plan to do. And I think we can gain a lot 
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from this.

Another related issue that I wanted to 

comment on is the pool of peers. I think that we 

are doing, in a sense, a peer review, but the 

experts that we're looking for are really experts 

in causation analysis, which may or may not 

include some or all of the CMCs. There are a lot 

of people that are experts in causation analysis, 

in occupational medicine.

And I think it would be a great 

advantage to have an outside panel, i.e. outside 

of the CMCs, because if there is some sort of a 

systematic tendency to make particular judgements 

or errors, this may be obscured by using the CMCs 

as the judges of their own performance in the 

program. And they may feel somewhat defensive.

So I think it should be an external 

panel, i.e. external to those who are making the 

determinations that we're going to be reviewing.

CHAIR MARKOWITZ: That's a good point.

Dr. Cloeren?

MEMBER CLOEREN: I agree with that 
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recommendation that it be an external panel for 

the same reasons.

CHAIR MARKOWITZ: Dr. Bowman?

MEMBER BOWMAN: Just as a counterpoint 

for discussion -- this is Aaron Bowman -- one 

advantage of having it be peer, meaning CMCs, is 

they are perhaps the most knowledgeable about the 

processes in place of what's going on with that.

I wonder could there be -- you all can 

think -- a way to avoid the conflict of interest 

that is the reason to seek for external? Is 

there a way that avoidance of that conflict of 

interest could be used to get sort of the best of 

both?

CHAIR MARKOWITZ: I'm sorry. Could 

you just explicate a little bit? I'm not sure I 

understood.

MEMBER BOWMAN: Yes. So I would imagine 

there is an advantage of using someone who has 

performed the work of a CMC in evaluating the 

quality because they're most familiar with the 

work.
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But we would want to avoid a conflict 

of interest that was mentioned earlier for the 

recommendation for external review, which is also 

important to avoid. And I'm just wondering is 

there some compromise that would allow both of 

those to occur.

CHAIR MARKOWITZ: This is Steven 

Markowitz. Let me just respond. The CMC process 

is not that complicated actually, but the CMC is 

a particular role that's described in the 

procedure manual. And it's described in the 

contract that the Department has.

Quality assessment is something 

different from the CMC process. So I don't -- I 

have a hard time imagining that so-called CMCs 

would also be the peer reviewers because they're 

really separate functions.

Also, in our previous recommendation 

relating to this, we explicitly said this 

mechanism should have sufficient independence of 

the current method of developing and obtaining 

CMC opinions in order to avoid actual or 
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perception of conflict of interest.

End of quote. So we could add that 

certainly to the rationale of this recommendation 

as well.

Dr. Cloeren?

MEMBER CLOEREN: Marianne Cloeren. I 

don't think that the job of the CMC in evaluating 

the data and providing causation analysis is that 

much different from other causation analysis in 

other systems.

So I think I'm agreeing with Dr. 

Markowitz that a peer reviewer would be somebody 

that is an expert in evaluating causation of 

occupational diseases in a variety of different 

system settings.

CHAIR MARKOWITZ: Other comments or 

professorial interest in wordsmithing? By nonprofessors too, by the way. You're welcome.

Dr. Bowman?

MEMBER BOWMAN: Just to follow up on 

my request, I do accept the expert opinion of 

those on the medical side of our Board on that. 
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That sounds reasonable. I only thought that 

because I know when we were given these claim 

packets to review, there is a lot of complexity 

and just figuring out how that all goes together, 

but I accept that notion.

And I would then agree with an edit to 

say by implementing external peer review in this 

recommendation. I would then make that an 

explicit part of this recommendation.

I was wondering, just given -- I guess 

I'll stop there. I've got one more comment, but 

maybe discuss that first.

CHAIR MARKOWITZ: Dr. Van Dyke?

MEMBER VAN DYKE: Mike Van Dyke. You 

invited professorial comments, right?

CHAIR MARKOWITZ: Absolutely.

MEMBER VAN DYKE: Okay.

CHAIR MARKOWITZ: I knew they were 

going to go come anyway, so I wanted to make you 

feel welcome.

(Laughter.)

MEMBER VAN DYKE: So short of this 
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being a really big number that you evaluate, the 

results that you get are going to be a relatively 

small number. If you evaluate 50, maybe you'll 

find five problems.

I'm just throwing it out there. 

That's a lot of work for those five problems. I 

wonder if there is any way to think about how to 

enrich the pool, to make it more likely that 

you're going to find those problems.

So is there any way to think through 

what categories of outcomes, what categories of 

exposures? Because the randomness is just going 

to make it unwieldy in terms of the amount of 

work.

MEMBER FRIEDMAN-JIMENEZ: This is 

George Friedman-Jimenez. I'd like to respond to 

that. Yes, I think you're right.

However, I think that the randomness 

is critically important here, because that's the 

key to interpreting the data. It's the key to 

being able to generalize from our sample of 50 or 

100 or 500 to the whole population of cases that 
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are being evaluated.

So we need some sort of random 

sampling. But that's what I meant by stratified 

random sampling, exactly what you're saying, that 

we randomly sample in a way that will allow us to 

do specific statistical analyses that are the key 

analyses that we want to do.

For example, what is the false 

positive rate? What is the false negative rate? 

Using in lieu of a gold standard the external 

causation analysis experts' gold opinion on 

whether there was causation or not, admitting 

that this is not a true gold standard but this is 

the way that it's done in diagnostic testing when 

there's no gold standard, because the gold 

standard test would be either too invasive, or 

it's not been invented yet.

So there are statistical techniques 

for addressing this by stratified random 

sampling. And I agree with your sentiment.

As far as sample size, I think if this 

is going to be a quarterly exercise, the first 
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quarter and the second quarter are not going to 

give us enough numbers. And you're right. We 

may get one, two, maybe five errors out of 50, if 

we do 50.

However, over a year or two years, I 

think we would have an adequate sample size to 

actually do a hypothesis test that would give us 

a reasonable degree of power to make some 

statistical judgement of whether there is a 

problem or not.

Essentially, we're looking to see: is 

there a problem? And is it big enough to require 

some sort of systemic solution or could it be 

addressed by some minor fixes that we could do, 

some training of the CMCs or something like that?

CHAIR MARKOWITZ: I think -- this is 

Steve Markowitz. This idea of enriching or 

stratifying would be very interesting. I don't 

think it's a first-order issue. It's something 

that if the Department accepts this 

recommendation, we'd be glad to help them figure 

that out. It's a really interesting question.
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For instance, there may be a 

disproportionate number of CMC reports that are 

done by a relatively few number of CMCs. So 

perhaps you'd want to look at that group more 

closely because if there are errors there, it 

could be more meaningful in terms of the number 

of claims that are affected. So that's one way 

of enriching.

Or we could enrich by, say, if we 

suspect there are certain conditions prone to 

problematic opinions -- beryllium disease, COPD, 

or the like -- that's another way of enriching. 

So there are ways of thinking about this.

It's not clear what the solution is, 

but it's an interesting set of questions. But I 

don't think -- I think it's second order. I 

think if they accept this, what we're proposing 

here, and if they want our input into designing 

the assessment, then we'd be happy to provide 

that.

Mr. Domina?

MEMBER DOMINA: Yesterday Ms. Pond 
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mentioned that they're getting 300 claims a week. 

It used to be like 220-230. Over a year's time, 

that's over 4,000 more claims.

To me, if we're going to go down this 

path, there's a percentage, not a finite number 

of 50. You're going to miss basically 25 

percent.

And then with that, she also mentioned 

in the medical benefits part of adding more 

people in that. So is there going to be more 

CMCs? Or you've got the same number doing all of 

the claims? It sounds like it's a problem.

CHAIR MARKOWITZ: Right now it looks 

like the plan is 50 per quarter, but of those 50, 

only ten involve causation. That's 40 per year. 

That's clearly not enough to get at what we're 

trying to figure out here. So that would have to 

be rethought. I agree.

Dr. Cloeren?

MEMBER CLOEREN: Marianne Cloeren. I 

wonder if this -- what we're proposing has room 

for referring potential problems. So if somebody 
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notes that they're getting the same, it seems 

like, erroneous causation analysis over and over, 

that person's reports might never enter the pool 

of random review.

And what might the process -- what is 

the process? Maybe the Department of Labor 

already has a process for reviewing the work if 

something is brought to their attention.

CHAIR MARKOWITZ: Comments? Further 

comments? Dr. Bowman?

MEMBER BOWMAN: Yes. This is Aaron 

Bowman. In regards to the implementation, we 

talked about any variety of ways it could be 

implemented.

And that we would, as a Board, of 

course be willing to advise on that 

implementation with the addition of a final 

sentence to the recommendation saying that the 

Board requests feedback on how a recommendation 

will be implemented and its outcomes once active, 

just to make it clear that we are interested and 

willing to provide input on implementation.
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CHAIR MARKOWITZ: I don't think we 

need to -- Steve Markowitz -- express our 

interest in the outcome, because generally we do 

get feedback over time.

However, expressing interest and our 

willingness to assist in implementation or in 

further steps, design, et cetera, we could 

include that in the recommendation or in the 

rationale. We could put it in the 

recommendation. So if you want to give Kevin 

some words to put in?

MEMBER BOWMAN: Sure. I'll put the 

first half of what I said and then we can 

wordsmith afterwards. The Board requests 

feedback on how our recommendations will be 

implemented. Is that sufficient? Or the Board 

would be happy to participate in the 

implementation.

CHAIR MARKOWITZ: Offers assistance.

MEMBER BOWMAN: Yes. The Board offers 

our assistance in the implementation of this 

request and planning for the implementation.
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CHAIR MARKOWITZ: You got that, Kevin?

(Laughter.)

MEMBER BOWMAN: And planning for the 

implementation of this request.

CHAIR MARKOWITZ: If accepted.

MEMBER BOWMAN: Okay. Thank you. 

Perfect. While we're editing, do we want to add 

external in front of the words peer review?

CHAIR MARKOWITZ: Which line is that? 

Is that the fifth line?

MEMBER BOWMAN: The third line down.

CHAIR MARKOWITZ: The third line.

MEMBER BOWMAN: Implementing external 

peer review.

CHAIR MARKOWITZ: It's not obvious 

what that word would mean in this context. What 

you mean is other than CMCs?

MEMBER BOWMAN: Other than CMCs, yes.

CHAIR MARKOWITZ: Yes.

MEMBER BOWMAN: Is there a better word 

for that? Or do you think it -- independent peer 

review?
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MEMBER VAN DYKE: I think you need to 

remove peer if you're going to put external.

CHAIR MARKOWITZ: The word peer is 

important because right now the assessments are 

done, as far as we know, by non-health providers.

MEMBER BOWMAN: Right. Yes.

CHAIR MARKOWITZ: The peer is an 

important concept here.

MEMBER FRIEDMAN-JIMENEZ: Well, 

analogous to the NIH peer review system, peers 

are all investigators in that field. So that 

doesn't necessarily have to include the person 

that's applying for the grant. So in that way, 

the peer is assumed to be external or 

independent. I think independent is a good word 

here.

MEMBER BOWMAN: I agree.

CHAIR MARKOWITZ: I think the 

rationale can get a little bit into this.

MEMBER BOWMAN: Yes. And then of 

course, since we're in it, the typo of the 

apostrophe, CMC's. We're trying to eliminate the 
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apostrophe.

MEMBER FRIEDMAN-JIMENEZ: So it would 

be CMCs' and then causation analyses with an E. 

Is that correct, Professor Bowman?

MEMBER BOWMAN: I will defer to you on 

this, George.

(Laughter.)

MEMBER CLOEREN: Well, in the line 

above, just get rid of the apostrophe-S. CMC 

causation analysis, I think, works.

MEMBER FRIEDMAN-JIMENEZ: Yes.

MEMBER BOWMAN: I think that could 

work too.

CHAIR MARKOWITZ: So the analysis 

should be plural, analyses with an E, S-E-S, not 

S-I-S.

MEMBER CLOEREN: Just make it CMC. No 

S and no apostrophe.

MEMBER FRIEDMAN-JIMENEZ: Right.

MEMBER CLOEREN: There you go.

CHAIR MARKOWITZ: That was easy. Any 

further comments?
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MEMBER CATLIN: Yes. I'd just make 

one.

CHAIR MARKOWITZ: Go ahead.

MEMBER CATLIN: In the last line, I'd 

replace request with recommendation.

CHAIR MARKOWITZ: Good point.

Dr. Cloeren?

MEMBER CLOEREN: Well, I think what I 

said -- this is Marianne Cloeren -- what I said 

before about if somebody is identified outside 

this process where the reports might need review. 

Maybe what I'm requesting is information from 

the Department about how that is addressed, 

what's the mechanism for bringing that to 

attention so that there could be a review.

CHAIR MARKOWITZ: Steve Markowitz. 

Could you just -- I don't quite understand the 

comment or question.

MEMBER CLOEREN: Marianne Cloeren. 

Yesterday Ms. Pond said that from our previous 

meetings, the examples that we had given of a 

particular CMC that repeatedly made errors in 
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causation analysis related to asbestosis not 

being possible without pleural plaques, that was 

an example where they did take that information 

and did some reviews and addressed it.

It's not at all clear to me what the 

process is for bringing such kind of situations 

to the attention of the Department.

CHAIR MARKOWITZ: Steve Markowitz. We 

don't have a bunch of claims that we're looking 

at or the Board is looking at. So what are the 

circumstances where that problem would arise?

MEMBER CLOEREN: Marianne Cloeren. I 

imagine that advocates and former worker programs 

may get word about or may have the opportunity to 

be reviewing opinions that have the same analysis 

that appears to be erroneous and needs to be 

looked at. And I'm just concerned that this 

process might never capture that in the random 

assignment.

I'm not saying the Board would be 

making the referral. I'm saying what is the 

process for referring a possible problem 
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consultant for evaluation.

CHAIR MARKOWITZ: But wouldn't that 

input from the advocate or from the former worker 

program or whatever provider, wouldn't that be in 

the context of a specific claim, right?

MEMBER CLOEREN: Or ten claims. It's 

not a pattern if it's one claim.

CHAIR MARKOWITZ: I see. Okay.

Mr. Vance, do you want to address that 

if you're still here?

MR. VANCE: I'm not really sure how I 

can respond to that. The program is always going 

to be responsive to issues as they're brought 

forward. We have to consider how to best 

approach each kind of situation.

So what Ms. Pond was talking about 

yesterday -- and I'm not familiar with the full 

context -- I don't think that we were looking 

specifically at the question of -- the plural 

plaque question in asbestos. I think that there 

was some other issue or concern brought to our 

attention about a qualitative issue with regard 
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to one of the CMCs.

And when we went back and looked at it 

-- there can always be differences of opinion 

about how certain things are addressed with 

regard to causation opinions, but it was deemed 

that the manner in which the doctor was doing his 

work was not cause to take any kind of corrective 

action. And we have taken corrective actions in 

the past with training, and going back and 

reiterating the responsibilities of the 

contractor to manage their process well.

That's the purpose of the CMC crossprocess, which is that quality assurance thing. 

So we are constantly engaging with a contractor 

to identify flaws and how doctors do impairment 

ratings or whatever aspect of the work that 

they're doing.

So it's -- we're responsive as much as 

possible to issues that are brought to our 

attention, but that's a matter of weighing and 

deciding, is this a matter that is warranting 

action by the program or is it just some other 
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issue of concern about the process that has to 

bear out during a case adjudication process.

CHAIR MARKOWITZ: Thank you.

Other comments? Okay. Then we're 

ready to take a vote. We're looking at the 

recommendation. I don't really think there's a 

need to read it, so maybe we can just move to the 

vote.

MR. JANSEN: I will 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?
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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: Mr. Domina?

MEMBER DOMINA: Yes.

MR. JANSEN: There are 11 yes votes 

and zero no votes.

CHAIR MARKOWITZ: Okay. So our next 

topic is significance, really just to close out 

the discussion from yesterday.

This is about the industrial 

hygienists' use of six different categories to 

categorize exposure, including three levels of 

significance and three additional levels. From 

our discussion yesterday, it wasn't as if there 

was any consensus, or even a particular problem 

that was identified and agreed upon.

So the question is, do we simply want 
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to drop this topic? Or do we want to somehow 

continue the conversation? And not necessarily 

today. It'd be in a working group or otherwise.

Dr. Bowman?

MEMBER BOWMAN: This is Aaron Bowman. 

With our current recommendation relating to the 

IH reports, I would be okay with the sunsetting 

of that subcommittee until some later time.

It seems very complex. I'm not sure 

what else we can do. Maybe with the 

implementation of that recommendation, some of 

those issues will resolve.

CHAIR MARKOWITZ: Dr. Cloeren?

MEMBER CLOEREN: Marianne Cloeren. I 

overall agree with what Dr. Bowman just said.

I wonder if it might make sense to 

solicit -- if there is a mechanism for soliciting 

the input of the IH consultants about any 

struggles or just feedback on how the system, 

especially the low-moderate-high, works for them 

in the incidental -- not significant, but more 

than incidentally.
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I think it would be useful to get 

feedback from or input from the people that are 

asked to use the system before making any kind of 

changes. And I agree, it's very complex. Such a 

-- that could be obtained possibly through some 

kind of a focus group, just as an idea.

CHAIR MARKOWITZ: Other comments? So 

let's just explore that. Your idea is that the 

program or the contractor would identify two 

willing industrial hygienist consultants either 

from the contract and/or the national office to 

meet with a few interested Board members and 

discuss how this works in practice.

I think more than incidental but less 

than significant is a new-ish category. So to 

understand how that actually is used in practice 

and how it's helpful or not, that's what you're 

driving at?

MEMBER CLOEREN: Correct.

CHAIR MARKOWITZ: Okay. Do any Board 

members have --

MEMBER CLOEREN: But I also think it 
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could wait because we are making some other 

recommendations right now. And if those are 

implemented, it might make sense to wait for a 

while.

CHAIR MARKOWITZ: Do you think that if 

accepted, the implementation recommendation is 

going to have a significant impact on the use of 

these categories?

The question is, things take time when 

we interact with the Department. And if we do it 

in sequence, then it could take a lot of time.

Dr. Bowman?

MEMBER BOWMAN: I would be interested 

in hearing from some IH consultants that are 

happy and willing to talk to the Board. I think 

that could be very informative. Any time maybe 

prior to the next Board meeting would even be 

fine.

I don't know if they'd be willing to 

speak to us virtually at the next meeting as 

well. We could just have a conversation. I'm 

good either way.
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CHAIR MARKOWITZ: All right. If we're 

going to -- Steve Markowitz -- make a specific 

request to the Department, then we should 

probably specify whether it's done in a smaller 

group interaction or whether in appearance at a 

Board meeting. Those are going to serve 

different functions, I think.

Also, if the contractor's IHs aren't 

available, we're limited to the national office's 

industrial hygienists. Would that be helpful?

Let me ask the Board members who are 

not industrial hygienists. Would you have 

interest in participating in this interaction 

where you hear directly from industrial 

hygienists how they use -- for those of you who 

aren't around the table, Dr. Friedman-Jimenez, 

I'm seeing a bunch of heads nodding yes.

MEMBER FRIEDMAN-JIMENEZ: Yes. I 

think also I agree with Dr. Cloeren's suggestion 

that the users of the IH report be questioned 

also. And I think it would be very interesting 

to hear how the CMCs process a rating of 
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incidental or greater than incidental but not 

significant.

Does incidental essentially rule out 

causation? Do they make an exception for 

substances that may have an allergic or 

sensitization type of a dose response rather than 

a toxicant type of a dose response?

How do they think about this 

incidental category as opposed to greater than 

incidental, less than significant, or 

significant? So yes, I think that would be of 

great interest to see how these categories are 

used in making the decision.

CHAIR MARKOWITZ: Dr. Vlahovich?

MEMBER VLAHOVICH: Kevin Vlahovich. 

Yes, I agree. Knowing how the IH goes through, 

evaluates the evidence, and comes to a conclusion 

would be helpful in formulating a medical opinion 

on the case.

CHAIR MARKOWITZ: Steven Markowitz. I 

think we would have to do that through looking at 

CMC reports and claims because we heard at the 
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beginning of today's meeting from Mr. Vance that 

the CMC contractor expressed a disinterest really 

in just giving basic feedback on any change to 

the industrial hygiene form.

So we're unlikely to get any further 

with that contractor. Plus even if we assembled 

a few CMCs, I'm not sure how representative it 

would be of the totality. We could more directly 

look at that issue by looking at some claims and 

how the CMCs are interpreting the IH reports.

Dr. Van Dyke? Sorry, I was thinking 

for a moment.

MEMBER VAN DYKE: Mike Van Dyke. 

Sorry, I didn't know if you saw that. I think 

we're talking about two problems. We're all 

assuming that since there's no definition of 

terms, that there's no calibration among the 

people that are doing the assessments.

And then the other problem we're 

talking about is really, we're unsure how the 

results of an IH assessment are interpreted by a 

CMC. And I think we could talk to these IHs to 
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figure out how they go through their process, but 

I'm not sure that that's really going to be 

productive in changing anything.

Would it be helpful to come up with a 

series of questions where we can give an example 

and say, how would you interpret this? And then 

we could distribute a questionnaire to a broader 

group of CMCs and industrial hygienists and get 

responses to those.

And then I think that will answer our 

question to say, are they miscalibrated? Are 

they interpreting this different? And the 

questions would probably be different for the 

CMCs versus the industrial hygienists, but it 

would be a way of getting a broader response. It 

would be a way of asking more specific questions 

to get at what we've been talking about for a 

long time.

And I think the other thing is, is 

when you ask somebody, do you have any 

improvements, versus you ask somebody a very 

specific question, I think that your response is 
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much different.

CHAIR MARKOWITZ: Mr. Key?

MEMBER KEY: I agree with the basic 

context you just stated. But as we've seen, we 

cannot get any voluntary suggestions from the 

CMCs to improve as a response to us. So how do 

we as a Board mandate and dictate that they fill 

out these forms and review them?

CHAIR MARKOWITZ: Steve Markowitz. We 

can't. That would be a voluntary survey. If the 

program can't do that with a contractor, that's 

one thing. If a contractor is not interested, 

that's another thing. It's possible the IH 

contractor might be interested to cooperate with 

such a survey, but it certainly sounds like the 

CMC contractor wouldn't be interested.

Was that an idea that we want to 

explore in a smaller group, sort of brainstorm it 

a little bit and see if we can articulate an idea 

that we want to pursue?

Dr. Friedman-Jimenez?

MEMBER FRIEDMAN-JIMENEZ: Yes. I'm 
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just thinking about Dr. Cloeren's comment that 

maybe we should wait on some of this. And I'm 

wondering, maybe the contractor would respond 

more positively if we had a focus for what is the 

problem.

We haven't yet demonstrated in a 

convincing way or transparent way that there is a 

problem. So if we do this review of the 

causation analyses and we don't find a problem, 

then this is really moot.

If we find that there's a particular 

kind of problem that is systemic or seems to be 

repeated and could be potentially correctable 

that's related to exposures, an exposure 

assessment, then that could, I think, change the 

contractor's view toward collaborating with us 

and participating in more exploration of what the 

exposure assessment process is.

CHAIR MARKOWITZ: What's our goal 

here? Our goal is to try to understand how the 

industrial hygiene process is using its various 

categories of exposure.
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The ideas are we could ask to meet 

either in a smaller group or as a Board with a 

few of the industrial hygienists and national 

office contractor. Another idea is that we put 

together a survey to get the input from a broader 

number of industrial hygienists.

Dr. Van Dyke?

MEMBER VAN DYKE: Mike Van Dyke. I 

think I'm persuaded by Dr. Friedman-Jimenez. 

We've made several recommendations. They've 

accepted some changes on how the report gets 

done. I think the implementation of that table 

for the significant exposures might start to 

really enlighten the thinking of the industrial 

hygienists in terms of exposure.

So maybe in terms of -- I've heard 

some people say maybe we should wait a bit on 

this. But in the meantime, maybe we should ask 

for some of the redacted IH reports over the next 

six months that really use this table so we can 

have some more data to evaluate that, and then 

make a decision from there.
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CHAIR MARKOWITZ: Okay. Mr. Catlin?

MEMBER CATLIN: I think I support that 

from Dr. Van Dyke. I would also be interested if 

maybe our small group, the working group, could 

have just a discussion with some of the 

industrial hygienists.

I feel like there might be some real 

benefit to just having that conversation. I'm 

not making an assumption that's there's problems, 

but it'd be really good to hear the thinking of 

the folks who are doing the program so that we 

could hear that directly, if that's possible.

CHAIR MARKOWITZ: All right. Those 

two suggestions aren't mutually exclusive.

Other comments? How do we want to 

proceed? What do we want to do? One proposal is 

that we request either a subset of the Board or 

ask the full Board meet with a few industrial 

hygienists to basically discuss how they work, 

how they implement changes, problems they face, 

et cetera.

Dr. Cloeren?
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MEMBER CLOEREN: I think I was preempting you. I think the second one, what was 

discussed earlier was the possibility of 

appearing to the Board, I would be against that 

one. I think that's too formal and too highpressure, but I think an informal discussion 

would be great. I'm not sure what the mechanism 

is for requesting that.

CHAIR MARKOWITZ: I'm sorry. So not 

the full Board, but a subset of the Board?

MEMBER CLOEREN: Not a formal 

appearance at the next Board meeting. I don't 

think it matters how many of the Board are there.

CHAIR MARKOWITZ: Actually, if the 

full Board --

MEMBER CLOEREN: It probably has to be 

a subset because if it's the full Board, then 

it's formal.

CHAIR MARKOWITZ: Right. If it's the 

full Board, it's going to look like this. So 

anything short of the full Board. If it's ten 

people, not 11 Board members, then that's a 
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subset of the Board.

I agree that format, if we can achieve 

it, would be more fruitful. And I'm sure there's 

a volunteer from the Board who would volunteer 

not to participate in that and hear about it 

secondhand.

MEMBER CLOEREN: I volunteer as 

tribute. The Hunger Games. I had to get the 

Hunger Games thing in.

CHAIR MARKOWITZ: Okay. So this is 

not a recommendation. This is a request to the 

Department. We have to write up our request.

It doesn't have to be extensive, but 

who would like to do that? Dr. Cloeren?

MEMBER CLOEREN: I'm willing to take 

the lead on writing that up.

CHAIR MARKOWITZ: Okay.

MEMBER CLOEREN: You don't need it 

right now, do you?

CHAIR MARKOWITZ: No.

MEMBER CLOEREN: Okay.

CHAIR MARKOWITZ: There's a form to 
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fill out. It's easy. I'll send it to you and go 

over it. Okay. That's that piece of it.

Then the second idea that came up was 

to actually see some industrial hygiene reports 

over the next period of time and to see how 

changes are actually used in practice. I think 

that's a pretty good idea, personally.

Dr. Friedman-Jimenez, there is various 

positive nodding of heads around the table.

MEMBER FRIEDMAN-JIMENEZ: I have to 

unmute myself every time. Yes, I agree. I think 

it's a good idea. We'll see how they accept or 

don't accept the table, what parts they fill in, 

if there's parts that they don't fill in or don't 

like to fill in.

And then we can get some response from 

them on how they like it, if they feel it helps 

them or it's a pain in the neck, or it's invalid 

or parts of it are very important. This kind of 

feedback, qualitative feedback would be very 

useful. I agree.

CHAIR MARKOWITZ: So we need someone 
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to write up that request with a little bit of 

specificity, including calendar time from when 

the reports should be drawn. I don't know 

whether accepted versus denied claims.

Dr. Bowman?

MEMBER BOWMAN: On the request, I 

think the two requests are related and can 

probably be in a single document. And then in 

terms of what we'd review, I think we'd want to 

review the ones that have actually utilized the 

table.

CHAIR MARKOWITZ: Right, but the 

Department is unlikely to look at the claims and 

see which ones have used the table. So if we 

define it by calendar period, we're more likely 

to actually get some results, I think.

By the way, when we write up this 

information request, maybe what we should do is 

we'll circulate it among Board members for input 

to see if there's anything else to be included.

Mr. Catlin?

MEMBER CATLIN: I was just going to 
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volunteer on that second task and do the first 

draft or work with Dr. Cloeren and others.

CHAIR MARKOWITZ: Okay. I think that 

could be a single information request. Again, I 

can show you some previous ones. If there are 

any residual questions, they'll come back with 

clarifying questions.

MEMBER FRIEDMAN-JIMENEZ: This is 

George Friedman-Jimenez. I'd like to volunteer 

to work with this group to help with designing 

the sampling strategy, what exactly do we want to 

find out, and what case sampling do we need to do 

in order to get there.

CHAIR MARKOWITZ: So is this the 

industrial hygiene feedback effort that --

MEMBER FRIEDMAN-JIMENEZ: Is this the 

case review for the -- okay. Maybe I'm getting 

this wrong.

CHAIR MARKOWITZ: No. We accept your 

willingness to volunteer. I was just looking for 

a name, what to call this.

MEMBER FRIEDMAN-JIMENEZ: We're 
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consolidating the two, the industrial hygiene 

feedback and the causation review in one? Or are 

we --

CHAIR MARKOWITZ: No, we're not.

MEMBER FRIEDMAN-JIMENEZ: -- combining 

industrial hygiene feedback and the users of the 

industrial hygiene report?

CHAIR MARKOWITZ: No. What we've been 

lately discussing is restricted to industrial 

hygiene, either looking at recent reports that 

have used a modifying table or speaking with 

industrial hygienists who are using this. This 

does not include the CMCs.

MEMBER FRIEDMAN-JIMENEZ: Okay. I 

misunderstood that.

MEMBER BOWMAN: Sorry. This is Aaron 

Bowman. If I'm following, what we're talking 

about is sunsetting the significance working 

group and having it roll into an IH working 

group.

CHAIR MARKOWITZ: Yes. That's what 

we're doing, yes. Okay.
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So we've got Mr. Catlin, Dr. Cloeren, 

Dr. Friedman-Jimenez, and Dr. Bowman, who raised 

his hand, and Dr. Van Dyke. Okay. I think we've 

closed that out.

So I want to just follow up on a brief 

discussion we had yesterday about an issue that's 

come up before before the Board, either in public 

comments or in Board conversation.

We decided just to formalize this into 

a simple communication to the Department that the 

Board recommends that the program designate a 

single program staff person as an initial point 

of contact for claims that involve people who 

report that they are terminally ill.

We've heard from the program that they 

addressed this problem, and yet we continue to 

get feedback about this as being an issue. This 

is kind of a de minimis recommendation, a minimal 

recommendation about a process suggestion that 

there would be a single person who is responsible 

for attending to the requests that come in around 

this.
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We understand it's a thorny issue. 

It's a challenging issue. Nonetheless, this at 

least would simplify how it's addressed by 

claimants, by their representatives, advocates 

and the like.

Comments? Mr. Key?

MEMBER KEY: Yes. This issue has been 

brought up previously. At our last meeting, I 

questioned Mr. Vance. He said to raise the 

issue.

When we contact CEs, they are unaware 

or uninterested or don't know who to contact 

within the Department that we can get this case 

fast-tracked. And since I brought the issue up 

at the last Board meeting, we've had three 

individuals who have passed away as a result of 

never getting their claim adjudicated, approved, 

and moved through the process.

I would recommend with our 

recommendation that we add a time frame for the 

Department to designate this staff person and 

provide us with the initial point of contact, a 
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contact number where we can alleviate some of 

these. And this is not only happening at one 

site. It's across the entire program.

CHAIR MARKOWITZ: So if I understand 

that correctly, you want to add a few words here, 

line 2, designate a single program staff person 

within -- how many days? What did you say; how 

many days? Within 30 days, okay. Within 30 days 

of the date of this recommendation.

Okay. Ms. Splett?

MEMBER SPLETT: Would it make more 

sense to have one DOL staff person at each of the 

district offices who would have the direct access 

to the claims examiners in that office?

CHAIR MARKOWITZ: Mr. Key?

MEMBER KEY: That's a good idea, but 

do they have the power to fast-track? That's the 

unknown. Who within a program can pick up a 

phone and make something happen within a matter 

of one to two days?

MEMBER SPLETT: I guess my sense is it 

would be someone relatively high up in the 
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district office. And I'm going to only speak 

from my experience at Hanford, and that's 

somewhat dated, but all the Hanford claims went 

to Seattle. I spoke routinely to the district 

director, who had that ability to fast-track.

We also came up with a little 

different of a designation. We had terminal 

claimants and we had imminently terminal 

claimants, which meant we just had a few days to 

do things. Both offices knew exactly what that 

meant.

I never had that issue, but I do 

understand in the last four years when the claims 

are now diversified throughout the country, it's 

a lot different. And those personal 

relationships are not nearly as strong.

CHAIR MARKOWITZ: I think the 

rationale could make the point that the person 

should be in the position of actually influencing 

the process. And if that ends up meaning that 

there's more than one, but a very limited number, 

that that would be a more effective way of doing 
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it, that would certainly seem to comply with the 

spirit of the recommendation.

Is that right, Mr. Key? Okay.

Dr. Cloeren?

MEMBER CLOEREN: Marianne Cloeren. I 

am not familiar enough with the procedure manual 

to know if there is currently a procedure for 

fast-tracking. There's certainly precedent for 

it in other programs, such as Social Security.

That's a much bigger ask, that there 

be a procedure established for fast-tracking with 

parameters, putting somebody in that track, but I 

think that's what's really needed. A contact 

person is a good start, but if there's not a 

procedure, what's that contact person supposed to 

do?

CHAIR MARKOWITZ: Ms. Splett?

MEMBER SPLETT: Could Mr. Vance answer 

that, whether there is a procedure? I know that 

operationally, we worked it and it worked very 

well, but I do not know whether there is an 

actual procedure. And I think Mr. Vance should 
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be able to answer that.

CHAIR MARKOWITZ: So Mr. Vance, in the 

procedure manual now, is there some procedure 

that addresses this issue?

MR. VANCE: This is John Vance. Yes, 

there is. I'll just explain the process as it 

exists right now.

When we do have notification that we 

do have someone that is terminal, that is open to 

a very wide interpretation of what that means. 

Generally what is going to happen is that we are 

going to look for medical documentation that 

clearly defines or can be interpreted as being 

supportive of a terminal designation.

So that would be indications that 

someone is going into hospice or someone is in a 

hospital setting with a very limited life span. 

We will identify that case and it will be 

evaluated by the district director of each 

office.

They will then identify that case with 

a designator in their energy compensation case 
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management system. That will then fast-track the 

case. So an identifier in our energy 

compensation system that identifies the case as 

terminal. That will then move the case through 

our process as quickly as we can.

Now, that being said, we are still 

obligated to ensure that if we are even 

expediting the case, that means we still must 

overcome whatever claim hurdles exist that we 

must go through as far as our process is 

concerned.

So we will try to obtain expedited 

industrial hygienist reviews, CMC reviews. We 

will try to process the steps involved with 

getting a decision out the door, getting any kind 

of waiver, getting final decisions issued.

And then processing as quickly as we 

can expedited payments. We can do a bypass of 

the routine payment process to do same-day or 

next-day payments. Again, those are all steps 

that need to occur in these cases.

There is a procedure for it, but keep 
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in mind that even if you identify someone as 

terminal status and you have someone that's 

shepherding you through the process, in some 

instances we're still going to be reliant on 

getting documentation that supports a case 

adjudication outcome for that claim.

So even if we would want something to 

happen fast, if we don't get a document from the 

claimant or their family, that could slow things 

down.

So there is a process. I'm very 

familiar with a lot of the efforts that we take 

in the program and try to prioritize terminal 

payments for individuals that are due money. But 

again, a lot of those require a lot of steps to 

make happen.

So there is a process. We do work 

very actively to make these cases move along very 

quickly. Unfortunately that doesn't always work 

out, but we do try to do what we can to make 

those things happen quickly.

CHAIR MARKOWITZ: Thank you.
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Mr. Key?

MEMBER KEY: Yes. As Mr. Vance 

stated, the process is through each separate 

division office or district office. So we need a 

listing of those people, names and contact 

numbers associated with each district office.

CHAIR MARKOWITZ: Ms. Splett? And 

then we'll get back to Mr. Keys' idea here.

MEMBER SPLETT: I do have to say also 

that not only did DOE inform DOL that we had a 

claimant that we felt was terminal or imminently 

terminal, but they did the same. Sometimes we 

would be processing a claim and not realize that 

there was an end-of-life issue.

The Department of Labor would reach 

out to us and say, put this in the front of your 

list because we've got to get moving on this one. 

So it was bilateral notifying if one agency or 

the other knew that the claimant was terminal.

That happened routinely that they 

would call me and say, you've got a claim on the 

way in. This is the name. Go ahead and start 
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working on it. And we'd start pulling their 

records immediately.

CHAIR MARKOWITZ: The system seems to 

work well in Hanford, but perhaps in one or more 

other places it's not working so well. So what's 

the difference?

MEMBER SPLETT: It did used to work 

that way. My understanding now is all Hanford 

claims don't all go to Seattle any longer.

There was that personal relationship 

where we would call one another. It was not 

uncommon to talk once or twice a week. I would 

get calls at 10:00 on a Friday night that, you've 

got an imminently terminal claim coming in.

Once I retired, I understood that 

claims go all over the country. So those 

relationships no longer exist, I believe, from 

Hanford to Jacksonville or Cleveland. That just 

doesn't work in the same way any longer.

So I do want to make that distinction. 

We're talking four years ago it worked very 

well. I do not believe from what I'm hearing 
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from others on-site that it works out that well 

any longer.

CHAIR MARKOWITZ: Mr. Key, getting 

back to you, your request is for each district 

office to learn the name of the person who's 

responsible for this?

MEMBER KEY: Yes. As Mr. Vance says, 

the process is through each district office. 

They have those people designated. We need the 

names of each district office person and their 

contact number so that the advocate or whoever 

can pick up the phone, make the contact, and 

fast-track it as well as possible.

CHAIR MARKOWITZ: Okay. It seems like 

a reasonable request. Does the Board need to 

turn that into a written information request? Or 

can this occur as a result of the minutes of the 

meeting? I'm looking at Ms. Rhoads for a way in 

here.

MS. RHOADS: If it's just an 

information request, I think we can pass it on.

CHAIR MARKOWITZ: Okay. We'll write 
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it up. We'll write it up just for clarification.

Mr. Key and then Dr. Cloeren.

MEMBER KEY: Yes. I'd rather submit 

it as a Board request officially so it would be 

on document and record.

CHAIR MARKOWITZ: Okay. Good idea.

Dr. Cloeren?

MEMBER CLOEREN: From what I heard of 

the process, I'm a little fuzzy on the first step 

of flagging it as terminal and fast-tracked. It 

sounded to me like it might sit in the same pool 

of claims of everybody else before somebody gets 

to it. I'm not sure who does the first pass, 

like the triage.

I think what I'm asking is, is there a 

triage process that will quickly identify that 

this is one that needs to be expedited, 

understanding that you still need to get all the 

information?

CHAIR MARKOWITZ: I'm sorry. Is that 

a question for Mr. Vance?

MEMBER CLOEREN: Yes.
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MR. VANCE: Let me get into the 

details of how it works. So generally, what 

you're talking about is a claims examiner who is 

responsible for case adjudication.

As part of their daily activity, what 

they're looking at is their daily inventory of 

newly imaged information coming into the VOIS 

system. This is where new mail is recorded as an 

image. They will get a flag that they have a 

certain amount of time to review that 

information.

Now, if an authorized representative 

or a claimant or some indication is coming in on 

one of these newly submitted documents that 

identifies that an individual is terminal or that 

there's a need to prioritize the case because of 

the status of the employee, the CE will conduct 

an evaluation of the case.

What they're going to do according to 

procedure is look for medical documentation that 

supports that the information that's being 

reported to them is accurate.
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We have a lot of folks that will try 

to identify terminal cases to expedite cases 

without any corresponding medical documentation. 

And that's just something that we have to work 

through. But they're going to try to seek out 

medical documentation from the claimant or their 

representative that affirms and testifies to the 

terminal status of the employee.

That information, once that's been 

received, will then be transmitted to the 

district director or designated manager in that 

district office who is responsible for then 

identifying whether they agree that there is 

sufficient justification to identify that case as 

a terminally flagged situation.

Once that occurs, that then transmits 

to the claims examiner and others involved in the 

process that steps need to be taken to try to 

move this case along as quickly as possible. So 

it's generally going to be notification from an 

authorized representative that is somehow getting 

into the case file requiring a review by the 
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claims adjustor or claims examiner.

Sometimes we will get emergency phone 

calls and you can just gauge from the interaction 

with the caller. I've had these calls where the 

circumstances are such that we need to move this 

case very quickly based on the circumstances that 

are being described to us from the authorized 

representative or whomever.

So it's a judgement call, but we also 

tend to try to rely on getting good information 

about the status of the employee, the survivor, 

or whoever it is that we're trying to get through 

the process as quickly as possible.

And you can imagine there's a lot of 

instances where we have to look at it because we 

get a lot of representatives who like to say a 

lot of their clients are terminal to try to move 

those cases to the front of the line.

So there is this bifurcation where we 

have to look at, okay, is it truly a terminal 

situation or what is it that we're getting here? 

That's just the reality of the claims process. 
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But it generally is going to start with some sort 

of notification that we've got to look at someone 

because of their status.

CHAIR MARKOWITZ: Thank you.

Dr. Cloeren, your name tag is up.

MEMBER CLOEREN: Can I ask one more 

clarifying thing? When a claim is submitted, is 

there a way for the system to -- it sounded to me 

like it depends on somebody giving a heads up.

I'm wondering if there's a system 

method for flagging a claim that this is terminal 

and maybe prompting what information is going to 

be needed for the claims examiner to act on that 

really quickly so that at the time the claim is 

sitting in the queue for the claims examiner, 

it's already tipped that this is one that needs 

to be prioritized, and the person submitting it 

hopefully has a chance to have submitted whatever 

is needed to triage it.

MR. VANCE: This is John Vance again. 

It's going to rely on someone at some point 

taking a look at something that has come in.
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That can be a phone call that's been 

recorded into our telephone management system. 

It could be a document identifying someone as 

petitioning the program to treat the case as a 

terminal status. It could very well be medical 

documentation that we receive that the CE screens 

to identify someone as potentially terminal.

Any of those triggers have to be made 

by someone looking at case file information and 

making a judgement that this has got to be 

processed through that referral mechanism to the 

district director to make sure that's there's a 

sufficient justification to treat this as a 

terminal case.

The key thing to understand is when 

you treat someone in a terminal situation, you're 

taking claims examiner staff and contract 

resources away from the routine cases to try to 

prioritize these terminal situations. So it 

really does rely on some mechanism that triggers 

that review.

And it does mean somebody has got to 
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be looking at something and saying, you know 

what? Here it is. I've got a situation that we 

need to evaluate for a terminal designation.

CHAIR MARKOWITZ: Go ahead, Dr. 

Cloeren.

MEMBER CLOEREN: Just one more 

question. I promise this is the last one.

How long does the claims examiner have 

to get to -- what's the time expectations for 

getting to a case in the queue? What's the 

maximal time that something might be sitting 

there before the claims examiner looks at it and 

says, oh my gosh, this is one that needs quick 

action?

MR. VANCE: It's going to depend on 

the circumstances of what it is that you're 

looking at, but generally they have a limited 

amount of time looking at incoming new OIS images 

that are registered as unreviewed.

So if we get some documented into a 

case file, the claims examiner has a limited 

amount of time -- I don't know what the exact 
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standard is, but it's not a significant period of 

time -- to review and classify. They call it 

indexing where they have to go in and categorize 

this document as being -- this is what this 

information is and this is how it's being 

characterized.

When they do that and they're looking 

at something that's talking about this person 

entering a terminal status, or their situation is 

medically dire or whatever it is, they have to 

trigger that mechanism. So it's not that it's 

going to sit for a while on that initial 

screening. It's going to then move through that 

process.

Now, how long it takes once that 

terminal designation exists, how long is it going 

to take for all the steps needed to get to a 

positive outcome, that's where you end up with 

some of these -- we want to move it quickly, but 

we can't do anything if we're asking for 

information that we need and we're not getting 

that response in a timely manner. So you're kind 
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of dependent on that.

But I do know that in many situations 

that we encounter, once we have the information 

and are able to make the decision, especially if 

it's an affirmative one that's going to pay 

money, we've done those kinds of outcomes in a 

matter of a day or several days.

It's just a matter of getting the 

decisions out the door, getting the necessary 

paperwork back from the family, and getting the 

payment into the account of the payee. So those 

things can move quickly when we have all the 

necessary documentation.

CHAIR MARKOWITZ: Okay. Thank you.

So we have a pending recommendation. 

It's combined also with an information request, 

which the Board will make regarding the names of 

the people at each of the district offices who 

are responsible for this.

Are there further comments or 

questions? Ms. Splett?

MEMBER SPLETT: I would recommend 
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after the single program staff person, add each 

district office within 30 days.

CHAIR MARKOWITZ: Okay. Mr. Key?

MEMBER KEY: Yes. Specific to the 

district office director or who they appoint at 

that level, because our experience with the a 

claims examiner on one recent case of terminal 

illness -- a gentleman was in the hospital dying.

The CE said that he was not eligible 

for SEC, having worked at the Paducah Gaseous 

Diffusion Plant, one of the original four 

contained SECs within the legislation. So 

clearly, the CE either was not well-trained, not 

well-informed, or didn't know what they were 

doing.

CHAIR MARKOWITZ: Thank you.

Dr. Bowman?

MEMBER BOWMAN: Just for clarity in 

reading this, I wonder if after the words within 

30 days of the date of this recommendation, the 

words to serve would make this make more sense.

CHAIR MARKOWITZ: That's an 
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acceptable, friendly amendment.

Any other suggestions?

Okay. We should take a vote.

MR. JANSEN: I will 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: Yes.
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MR. JANSEN: Ms. Splett?

MEMBER SPLETT: Yes.

MR. JANSEN: Mr. Domina?

MEMBER DOMINA: Yes.

MR. JANSEN: There are 11 yes votes 

and zero no votes.

CHAIR MARKOWITZ: Okay. It's roughly 

10:10. Let's take a ten-minute break and then 

we'll come back. I don't think we have any more 

votes, but we do have some other work that we 

need to consider.

(Whereupon, the above-entitled matter 

went off the record at 10:07 a.m. and resumed at 

10:20 a.m.)

CHAIR MARKOWITZ: Okay. We're going 

to resume. The Department has requested that we 

review some work on carcinogens. You may recall 

a couple of years ago, maybe in the previous 

Board term -- I think it was -- we had a working 

group on carcinogens.

We looked at the IARC probable human 

carcinogens, the 2A carcinogens. IARC is the 
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International Agency for Research on Cancer, part 

of the World Health Organization.

We made some recommendations to the 

program that they add certain toxic substance 

links in the SEM to selected cancers. That was 

accepted by the Department.

PTS, Paragon Technical Services, has 

conducted a review of the IARC 2A Carcinogens 

that have been determined to be 2A over the past 

period of time. I can't recall what the period 

is. They have produced a report for us.

The Department has asked us to review 

this report. I think the report was sent to 

everyone a week or so ago. The request to us is 

to review their determination. They recommended 

that there are 2A carcinogens --

trichloroethylene, that that be linked to 

multiple myeloma in the SEM, and also antimony be 

linked to lung cancer.

So I think this is a useful use of the 

Board, for us to weigh in here. Ninety percent 

of the work has been done, maybe more. And I'm 
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looking for a subset who is willing to take a 

look at this report from PTS and basically weigh 

in on its conclusions.

We had a carcinogen subcommittee. I 

only remember two members. I think it was Rose 

Goldman.

MEMBER FRIEDMAN-JIMENEZ: Rose Goldman 

and I.

CHAIR MARKOWITZ: Dr. FriedmanJimenez, I think, was prominent in that effort. 

Were you part of that?

MEMBER FRIEDMAN-JIMENEZ: I think 

Marek Mikulski, were you on the group too?

CHAIR MARKOWITZ: I think he was on 

Parkinson's duty at the time.

In any case, are there any Board 

members who would like to work on this? I 

volunteer as one, but are there others?

MEMBER FRIEDMAN-JIMENEZ: Could I ask 

how long is the report? I don't think I got this 

report.

CHAIR MARKOWITZ: I'm looking at it on 
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my phone so I can't tell how many -- oh, seven 

pages.

MEMBER FRIEDMAN-JIMENEZ: Okay. I'll 

volunteer.

CHAIR MARKOWITZ: Okay. We have Dr. 

Friedman-Jimenez. We have Dr. Cloeren. We have 

enough but if others wish to join, you're 

welcome. Thank you.

MEMBER BOWMAN: If it would be 

helpful, I could join.

CHAIR MARKOWITZ: Okay, yes. Now we 

have Dr. Bowman.

MEMBER BOWMAN: I also don't think I 

received the report. I looked for it.

CHAIR MARKOWITZ: Okay. I hope I'm 

not misportraying it as only being seven pages 

long, but I think that's all it is. In any case, 

it's finite.

A follow-up on Parkinsonism. We heard 

that the SEM has been altered and 111 toxic 

substances have been linked to Parkinsonism. 

That resulted from Board recommendation. We had 
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a working group about that a couple of years ago. 

So I think we discussed receiving that 

information, which substances are now linked in 

the SEM, and taking a look at that.

Did I recall that correctly? I'm 

looking for volunteers who might be willing to do 

that. We have Dr. Mikulski and Dr. Bowman.

MEMBER BOWMAN: Yes. This definitely 

falls well within my area of expertise. On the 

cancer one, because I served on the IARC review 

with that, I'm happy to continue that because I 

learned a bit about the process.

CHAIR MARKOWITZ: Okay.

MEMBER BOWMAN: But probably my 

expertise is better suited with Marek's on the 

Parkinson's.

CHAIR MARKOWITZ: Okay, great. We 

talked about hearing loss, re-looking at some 

hearing loss literature to see whether the 

minimum number of years used by the program, ten 

years, to look at the issue of whether 

consecutive exposure up to ten years was 
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necessary.

Could it be interrupted and cumulative 

up to ten years or whatever? And so we thought 

we should take a look again at that topic for 

those specific subjects.

Dr. Cloeren?

MEMBER CLOEREN: I think if we're 

going to be looking at the recent literature on 

toxic effect and hearing loss, we should also be 

open to additional agents that are not on the 

list. I mean, if there is evidence for it.

CHAIR MARKOWITZ: It sounds like a 

good idea, especially if we have volunteers who 

are willing to do that.

MEMBER FRIEDMAN-JIMENEZ: This is 

George Friedman-Jimenez. I will volunteer for 

this group also.

CHAIR MARKOWITZ: Okay. Thank you.

Dr. Bowman?

MEMBER BOWMAN: The sensorineural 

component would make sense.

CHAIR MARKOWITZ: And I'll volunteer 
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to help with that. So we have enough. Again, 

we're open to additional volunteers should you 

have a change of mind or a change of heart, 

whichever.

So public comment. We had a single 

public commenter yesterday.

I think that the comment on the Santa 

Susana -- Ms. Splett, in your questions to the 

Department and you're going to provide certain 

examples, are you intending to include that?

MEMBER SPLETT: I am.

CHAIR MARKOWITZ: Okay. There was a 

public comment that came in this morning, a 

written public comment, which you all should take 

a look at. It was fairly long, I guess. It had 

to do with CMCs.

It claimed that many reports are done 

by relatively few CMCs, that there is not an even 

distribution across the pool of CMCs. And then 

there was other discussion about exactly how the 

CMCs were chosen.

It made me realize, actually, I don't 
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know if the Board has ever requested any sort of 

profile of the CMCs and whether the Department 

has it or the contractor can produce it. So what 

I'm thinking is: how many are there?

What's their specialties? How many 

are in occupational medicine? How many 

orthopedics? How many oncology? How many 

pulmonary medicine?

And then what's the distribution of 

reports in a given time period? So you take a 

given 12-month period, how many are done by what 

discipline? How do they break down in terms of 

the individual CMCs? Are there a relatively 

small number of CMCs who are doing a lot of 

reports?

There's nothing wrong with that, but 

it would be interesting to know, particularly if 

you move ahead and look at the quality assessment 

process with that. So just basic data, 

distribution data on the CMCs and the reports.

My question, Mr. Vance, is that kind 

of information that the program and the 
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Department already has? If not, is that 

something that we can reasonably expect the 

contractor to produce?

MR. VANCE: I would think that would 

be something that we could reasonably produce.

CHAIR MARKOWITZ: Okay. Thank you.

Aside from what I just mentioned about 

the distribution of disciplines, the numbers, the 

reports, the distribution of who's doing the 

reports, is someone willing to write up an 

information request and send it around? Are 

there any other aspects of this off the top of 

your heads that you think would be useful?

MEMBER BOWMAN: Potentially the length 

of service to get a sense for the turnover.

CHAIR MARKOWITZ: Dr. Cloeren?

MEMBER CLOEREN: Would it make any 

sense to also look at the proportion of denials 

versus approvals?

CHAIR MARKOWITZ: They don't deny.

MEMBER CLOEREN: I know they don't, 

but the decisions to deny are produced that may 
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have hinged on the causation analysis. I know 

there are other factors that are at play.

CHAIR MARKOWITZ: Also the condition, 

actually, what condition the issue is about.

Dr. Van Dyke?

MEMBER VAN DYKE: Given we go around 

the country and look at all these different 

sites, it would be nice to know the particular 

site too, especially in light of hearing that 

there's an increase of claims from CANEL.

CHAIR MARKOWITZ: Yes, right. I mean, 

this is subject to how the program and how the 

contractor keep the data, but we can certainly 

ask for these things.

I'll send around a draft. You may 

think of some other useful ones. We're not 

asking for a lot of work here. This is a basic 

profile of CMCs and the reports that they write 

that would give us a better sense of the 

activity.

Okay. So nothing further on that 

topic. I don't have anything else on my list 
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here.

Dr. Bowman?

MEMBER BOWMAN: I just recalled when 

we were going through this that we mentioned 

yesterday a request for an update on the report 

of the case distribution by disease category.

CHAIR MARKOWITZ: Right.

MEMBER BOWMAN: I don't know if that 

needs to be a written request.

CHAIR MARKOWITZ: So Ms. Rhoads makes 

an action list from the discussion of our last 

day and a half. That will be on the action list. 

I'm sure she caught that.

Mr. Key?

MEMBER KEY: Yes. Ms. Carrie 

yesterday sent the Board members responses to the 

926 questions. And in opening those, from my 

side there are some questions that I have.

Who do I submit these questions to? 

Do I submit them to Carrie? Do I submit them to 

Ryan, Mr. Dan, who?

CHAIR MARKOWITZ: These are follow-up 
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questions regarding the SEM?

MEMBER KEY: Yes.

MS. RHOADS: They can be sent to you 

as the Chair. And then we can decide where to 

send them after that.

CHAIR MARKOWITZ: Okay. You can send 

them to me. I personally was hoping it was a 

different answer.

MEMBER BOWMAN: Gail, aren't you 

preparing the summary of questions? Wouldn't 

those be just part of that?

CHAIR MARKOWITZ: They'll make their 

way around to the other Board members.

MEMBER BOWMAN: Yes, okay.

MEMBER SPLETT: If you want to send 

them to me, I'll route them to everybody.

CHAIR MARKOWITZ: Yes.

MEMBER SPLETT: Unless you want them, 

Dr. Markowitz, directly.

CHAIR MARKOWITZ: You can send them to 

me and CC everybody else. How about that?

This is November. We'll meet again in 
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roughly May. Right now the Board is scheduled to 

end its existence, I think, in December of 2024 

unless Congress changes the date, extends it. I 

think that is part of legislation. Maybe a 

decision will be made by the end of December, but 

who knows. It's Congress. So we'll see. We'll 

just continue our work.

This particular Board term is over in 

July of 2024. So we should try in the meeting to 

the extent we can to close out on certain issues 

that we can come to a conclusion about or 

otherwise pass it along to the next Board that 

serves.

Does anybody see any need for a 

telephone meeting before our next in-person 

meeting in six months? I haven't heard of 

anything that would require a vote.

As usual, there will be a very careful 

deliberative process about where we meet next. 

We'll see where that is. I'm trying to shoot for 

a place where we can get a pretty good tour. 

That's a little bit of a challenge at the labs. 
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That's why in general we haven't been to the 

labs. We'll work with Greg Lewis and see what we 

can use.

Are there any other issues, comments, 

closing thoughts? Okay.

Mr. Jansen, I think you officially 

adjourn the meeting.

MR. JANSEN: Thanks, everyone. The 

meeting is adjourned.

(Whereupon, the above-entitled matter 

went off the record at 10:36 a.m.)