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 UNITED STATES DEPARTMENT OF LABOR

 + + + + +

 ADVISORY BOARD ON TOXIC SUBSTANCES

 AND WORKER HEALTH

 + + + + +

 SUBCOMMITTEE ON IH and CMC

 AND THEIR REPORTS (AREA #4)

 + + + + +

 MEETING

 + + + + +

 MONDAY,

 JULY 18, 2016

 + + + + +

 The Subcommittee met telephonically at

2:00 p.m. Eastern Time, Rosemary Sokas, Chair,

presiding.

MEMBERS

SCIENTIFIC COMMUNITY:

MARK GRIFFON

MEDICAL COMMUNITY:

STEVEN MARKOWITZ, Chair of the Advisory Board

ROSEMARY K SOKAS, Chair
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CLAIMANT COMMUNITY:

KIRK D. DOMINA

GARRY M. WHITLEY

FAYE VLIEGER

DESIGNATED FEDERAL OFFICIAL:

CARRIE RHOADS
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 C-O-N-T-E-N-T-S

 Page

Call to Order, Greeting, Roll Call, 4

and Review Call Instructions

 Carrie Rhoads

 Designated Federal Officer

Welcome, Review Charge 9

 Rosemary Sokas

 Chair

Problem Areas and Case Examples 13

 Faye Vlieger

 Kirk Domina

 Garry Whitley

IH Review Issues 37

 Mark Griffon

Medical Review Issues 58

 Rosemary Sokas

 Chair

Discussion: Identify Information Needs 88

Tasks, Assignments, Next Steps 91

 Rosemary Sokas

 Chair
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1 P-R-O-C-E-E-D-I-N-G-S

2 2:02 p.m.

3 MS. RHOADS: Good morning or good

4 afternoon, everybody, depending on your time

5 zone.

6 My name is Carrie Rhoads, and I would

7 like to welcome you to today's conference call

8 meeting of the Department of Labor's Advisory

9 Board on Toxic Substances and Worker Health, the

10 Subcommittee on IH and CMC and their reports. IH

11 is Industrial Hygienist and CMC is Contract

12 Medical Consultant.

13 I'm the Board's Designated Federal

14 Officer, or DFO, for today's meeting.

15 First, I want to note how much we

16 appreciate the time and the work of our Board

17 members in preparing for this meeting and being

18 here today, and for all the work they are about

19 to do.

20 I will introduce the Board members on

21 the Subcommittee and do a quick roll call. And

22 could you please just say "here" or answer for
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1 your name for the transcript?

2 Dr. Rosemary Sokas is the Chair of the

3 Subcommittee.

4 CHAIR SOKAS: Here.

5 MS. RHOADS: And the members are Ms.

6 Faye Vlieger.

7 MEMBER VLIEGER: Here.

8 MS. RHOADS: Mr. Kirk Domina?

9 MEMBER DOMINA: I'm here.

10 MS. RHOADS: Mr. Garry Whitley?

11 MEMBER WHITLEY: Here.

12 MS. RHOADS: Mr. Mark Griffon?

13 MEMBER GRIFFON: Here.

14 MS. RHOADS: Dr. George Friedman15 Jimenez is part of the Subcommittee, but he could

16 not be on the line today.

17 And Dr. Steven Markowitz?

18 MEMBER MARKOWITZ: Here.

19 MS. RHOADS: Who is also the Chair of

20 the Board.

21 Melissa Schroeder from SIDEM is in the

22 room with me.
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1 We are scheduled to meet from 2:00 to

2 4:00 p.m. Eastern time today. Given that the

3 meeting is two hours, we are not scheduling a

4 break at all.

5 Copies of meeting materials and any

6 written public comments are or will be available

7 on the Board's website under the heading

8 "Meetings" and the listing there for this

9 Subcommittee meeting.

10 The documents are also up on the WebEx

11 screen, so everyone can follow along with the

12 discussion.

13 The Board's website can be found at

14 dol.gov/owcp/energy/regs/compliance/advisoryboar

15 d.htm or simply Google "Advisory Board on Toxic

16 Substances and Worker Health," and it will likely

17 be the first link.

18 If you haven't already visited the

19 Board's website, I encourage you to do so. After

20 clicking on today's meeting date, you will see a

21 page dedicated entirely to today's meeting. The

22 web page contains publicly-available material
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1 submitted to us in advance of the meeting. We

2 are going to also publish any materials that are

3 provided to the Subcommittee there. You should

4 also find today's agenda as well as instructions

5 for participating remotely. If you are

6 participating remotely and you're having a

7 problem, please email us at

8 energyadvisoryboard@dol.gov.

9 If you are joining by WebEx, please

10 note that the session is for viewing only and

11 will not be interactive. The phones will also be

12 muted for non-Advisory-Board members.

13 Please note that we do not have a

14 scheduled public comment session today. The

15 call-in information has been posted on the

16 Advisory Board's website, so the public may 

17 listen-in but not participate in the

18 Subcommittee's discussion.

19 The Advisory Board voted at its April

20 26th through 28th meeting that Subcommittee

21 meetings should be open to the public. A

22 transcript and minutes will be prepared from
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1 today's meeting.

2 During Board discussions today, as we

3 are on a teleconference line, please speak

4 clearly enough for the transcriber to understand. 

5 When you begin speaking, especially at the start

6 of the meeting, please state your name, so we can

7 get an accurate record of the discussion.

8 Also, I would like to ask our

9 transcriber to please let us know if you are

10 having an issue with hearing anyone or with the

11 recording.

12 As DFO, I see that the minutes are

13 prepared and ensure they are certified by the

14 Chair. The minutes of today's meeting will be

15 available on the Board's website no later than 90

16 calendar days from today, per FACA regulations. 

17 But, if they are ready sooner, they will be

18 published before the 90th day.

19 Also, although formal minutes will be

20 prepared, we will also be publishing verbatim

21 transcripts which are, obviously, more detailed

22 in nature. Those transcripts should be available
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1 on the Board's website within 30 days.

2 I would like to remind the Advisory

3 Board members that there are some materials that

4 have been provided to you in your capacity as

5 special government employees and members of the

6 Board which are not for public disclosure and

7 cannot be shared or discussed publicly, including

8 in this meeting. Please be aware of this as we

9 continue with the meeting today.

10 With that, I convene this meeting of

11 the Advisory Board on Toxic Substances and Worker

12 Health, Subcommittee on the IH and CMC, and their

13 reports. I will turn it over to Dr. Sokas, who

14 is the Chair of the Subcommittee.

15 CHAIR SOKAS: Thank you, Carrie, and

16 thanks for all the effort that has gone into

17 posting the federal notice and to making this all

18 work out well.

19 And I want to thank all of the members

20 who are able to participate and anyone who is

21 phoning in.

22 The task that we have, which I think
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1 we are all pretty clear about, is trying to help

2 to ensure the quality, objectivity, and

3 consistency of the work and written reports of

4 Industrial Hygienists staff positions and

5 consulting physicians and to make sure that the

6 reports are as helpful as possible.

7 What we are going to do today is have

8 several of the Board members, Faye Vlieger, Kirk

9 Domina, and Garry Whitley, go through some of the

10 challenges that are experienced by the

11 stakeholders and really kind of frame for us what

12 the issues are for the people using the program.

13 We will then, also -- and Mark Griffon

14 is going to do the IH piece and I will do the

15 medical piece -- we are going to assess the

16 questions that were raised by the program itself. 

17 I think we are also going to need to gather

18 information about potential areas for improvement

19 from additional stakeholders, that I would

20 include not only the claimants, but also the

21 Industrial Hygienists and some of the CMCs, just

22 to kind of get their perspective because we have
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1 certainly heard from other perspectives. And

2 then, together we will identify the tasks and the

3 need for additional information and, then, assign

4 those tasks and, hopefully, develop a work plan

5 that we can implement before our next entire

6 meeting in the fall, the entire Board meeting in

7 the fall.

8 Does anybody on the Board have any

9 comments or questions about the scope of today's

10 discussion?

11 MEMBER MARKOWITZ: Rosie, this is

12 Steve Markowitz.

13 My only comment is, as we think about

14 things that we want to do, that we think about

15 the fact that the next meeting is mid-October. 

16 We could have an additional phone call meeting

17 before then, with six weeks' notice needed, but

18 we could achieve that. And then, just think

19 about what the steps are about what we might want

20 to get done between now and the next phone call

21 meeting or between now and the full meeting in

22 October. That's all. It is just to inform kind
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1 of the discussion as we talk through it.

2 CHAIR SOKAS: Right, right. So, we

3 would need a six-week notice if we were going to

4 do another phone meeting. If, on the other hand,

5 we can assign tasks and get to work, basically,

6 we may not need that additional phone meeting.

7 I was also going to ask that, Carrie,

8 when we talk about the IH review issues, if this

9 is all right with Mark, and certainly for when we

10 get to the medical review issues, I would like to

11 pull up just that one-page -- it is actually two

12 pages -- that Jeff Kotsch put together in his

13 presentation that really has the questions

14 related to the program specifically. There are

15 10 questions, I think three of them for the IH

16 and the rest of them seem to be more for the

17 medical. Because that will just let people see

18 in the background what it is we are talking

19 about.

20 MS. RHOADS: Yes, that's fine. I

21 think it is the presentation from the April 28th,

22 I think, meeting.
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1 CHAIR SOKAS: Yes, and it is the top

2 of the page. It says, "CMC Contract Reviews". 

3 But, then, below that, there's the advice and

4 assistance that is underlined and in bold. It

5 says at the bottom "page 6 of 7". So, it goes

6 from page 6 over into page 7.

7 MS. RHOADS: Okay. That's fine.

8 CHAIR SOKAS: I think that is probably

9 the main thing that we will be referencing here. 

10 There probably are other things. And if other

11 Board members would like to pull up anything

12 either before, during, or after that, that would

13 be great. So, just shout it out.

14 All right. I would like to actually

15 move on, then. I think we have got plenty of

16 content to do, and it may be that the duration

17 that I have arbitrarily assigned to each

18 presentation might go a little bit long or a

19 little bit short.

20 But I would like to turn it over to

21 Faye and Kirk and Garry, if they would kind of

22 help us again frame what the major stakeholder
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1 issues are with respect to both the questions

2 that the program itself asked, but also the

3 experiences that people go through and where the

4 trouble spots might be or where we, as a Board,

5 might be most helpful.

6 MEMBER VLIEGER: Okay. Well, the

7 majority of the people on the Advisory Board --

8 this is Faye Vlieger -- don't know the process it

9 goes through. So, you have a pretty dry

10 presentation from what we had at the D.C. meeting

11 in April and, also, the Procedure Manual.

12 The problems arise in the

13 implementation of the use of the CMC and the IH

14 in that the Claims Examiner frames the questions

15 to them. And so, you may have ended up with a

16 broad spectrum of issues that were presented to

17 the CMC, but through the process -- and it even

18 says so in that Industrial Hygiene document that

19 we have, the document on the Industrial

20 Hygienists -- that they are only allowed to

21 answer, the Industrial Hygienists are only

22 allowed to answer the questions that the Claims
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1 Examiner puts to them.

2 And so, you may have actually had a

3 number of toxins that are actually appropriate

4 for the claimed condition, but, then, the Claims

5 Examiner winnows that down to two or three

6 obscure toxins, and then, the Department only

7 analyzes those in their pure form. And so,

8 classically, what happens is the chemicals in

9 their pure state are sent to the Industrial

10 Hygienists, who then opine they could not have

11 been exposed to a sufficient quantity of these

12 chemicals in their pure state to cause the

13 disease.

14 Then, the Industrial Hygienist report

15 is fed back to the CE, and the CE never questions

16 the Industrial Hygienist report, in my

17 experience. The Industrial Hygienist report

18 stands on its own with no other peer review.

19 Then, the CE, who already is

20 questioning that anything happened in the claim,

21 sends the Industrial Hygienist report to a

22 Contract Medical Consultant, who normally, in my
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1 opinion, is not well-vetted for the opinion that

2 they are making.

3 The CMC, again, is given limited

4 information on the exposures and limited

5 questions to answer, instead of giving them the

6 information on the claim and saying, "Listen,

7 this is what is claimed. This is what they were

8 exposed to. Is there a 50-percent likelihood

9 that this happened?" Because, remember, under

10 this program, the standard is "as likely as not". 

11 So, that is basically 50 percent or better.

12 So, the CMC never goes against the

13 recommendation of the IH. And in very, very few

14 cases is there ever a referee called in on the

15 CMC by the Department of Labor. The referee

16 decision, doctor decision, is called in by the

17 claimant, and the referee normally sides with the

18 Department.

19 So, the claimant really has limited

20 access to these experts that they want these very

21 long decisional letters on. And the doctors that

22 they do see don't have time to do that type of
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1 letter. So, that is kind of it in a nutshell.

2 CHAIR SOKAS: Faye, I have a question. 

3 This is Rosie. I have a question for you. I

4 read in one place where, if the claimant requests

5 it, they can get a copy of the CMC letter. So,

6 it doesn't automatically -- does any of this

7 information automatically get sent to the

8 claimants? Does the claimant get the CE's

9 framing of the question? Does the claimant get

10 the report from the IH? Does the claimant get

11 the report from the CMC?

12 MEMBER VLIEGER: Classically, even

13 when you get a request for the claim file, unless

14 you specifically stated or you knew that these

15 documents existed and asked for them in your

16 request for the claim file, you did not get them. 

17 Many times the only time they see them is after

18 there is a recommended decision to deny, because

19 the Claims Examiner will state that the IH or the

20 CMC said such-and-such.

21 I understand the Department is now

22 going to include them routinely in a document
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1 request, but I have not seen them being presented

2 routinely with the recommended decision to deny. 

3 And that is normally at the point that the

4 claimant knows what those two professionals said. 

5 I am not even going to call them "experts"

6 because they aren't being given enough

7 information to make an expert opinion.

8 It is kind of like -- I don't know if

9 you have ever watched any of the police

10 procedurals, but when the district attorney wants

11 them to answer in a certain way, the question is

12 very leading and there is only one way to answer,

13 and it is usually not the answer that would be

14 accurate. And that is the way these referrals go

15 to the IH and the CMC.

16 I think if you look at the examples

17 that we have seen and what we heard at the

18 meeting in April, that you will see that that is

19 true.

20 CHAIR SOKAS: And is there anything

21 that would prevent the pieces of information just

22 automatically being sent as they are generated to
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1 the claimant?

2 MEMBER VLIEGER: No, it is not part of

3 the Procedure Manual.

4 CHAIR SOKAS: Okay. All right.

5 MEMBER MARKOWITZ: This is Steven.

6 Faye, I have a question that you may

7 or may not know the answer to. In the Procedure

8 Manual, and I'm reading it, it says, quote, "The

9 IH also reviews SEM searches performed by the DO"

10 -- the District Office -- "to determine whether

11 or not they were performed correctly and

12 accurately." End of quote.

13 Does this suggest that the IH is

14 actually not just focusing strictly on the

15 questions posed by the CE, but is also looking at

16 how good the SEM search process was? Do you have

17 any experience with that?

18 MEMBER VLIEGER: My experience is that

19 the CE forms the questions to the IH with a few

20 contaminants. The IH doesn't look beyond what

21 the CE provides to them.

22 And then, if you remember when we were
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1 looking at the Site Exposure Matrix, depending on

2 how you pull it up, it can be very stinted. And

3 then, the disease has to be linked to the Site

4 Exposure Matrix, to a chemical, before that can

5 be verified and sent to the IH.

6 So, when you set up a database to use

7 as your sole source of information, and you

8 discount the input from the claimant in your

9 Occupational History Questionnaire and from their

10 physician, the only evidence that goes to the IH

11 is what the CE sets up. I have not had

12 experience where the IH actually says, "Oh, no,

13 this is wrong. A welder is actually exposed to

14 all of these things, including metal." I have

15 never seen that happen.

16 MEMBER MARKOWITZ: Well, I think this

17 is something that we really need to look at,

18 actually, not just this specific issue whether

19 the IH is looking at the validity of the SEM

20 search, but a number of different aspects, but

21 this is one aspect which ought to be in the

22 documentation of the letter provided by the IH. 
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1 So, we ought to be able to look at this issue.

2 MEMBER VLIEGER: Yes, and I think when

3 we had the IH in front of us in April and we

4 asked him, you know, how long it takes to do this

5 report that they do, if you look at a quantity of

6 the IH reports, you will see most of them are

7 boilerplate.

8 MEMBER MARKOWITZ: Right. Okay. 

9 Thank you.

10 CHAIR SOKAS: Well, I mean, the whole

11 question of doing a quality assessment, quality

12 kind of review of the content of the reports is

13 still open; you know, one of the things we can

14 discuss as one of the requests we might be able

15 to help with.

16 But, again, I am sort of getting at it

17 from the point of view of transparency. So,

18 there is no real reason why the Procedure Manual

19 couldn't say at each step of the process the

20 claimant gets a copy of what is being requested

21 by the CE, what the IH turns up. Because,

22 obviously, that would at least speed things up
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1 and, also, provide some sort of immediate review

2 for potential accuracy.

3 MEMBER VLIEGER: Yes, I think with the

4 new IH contract, I don't know if they wrote any

5 of that into the new IH contract that they

6 awarded, but we did ask these questions. The

7 advocates had a meeting with the Department of

8 Labor and the other parties to the program in

9 December -- excuse me -- in March, and we asked

10 them about this specifically: why is it that the

11 claimant has no input to any of this? And they

12 said they would look into it, but we haven't seen

13 any response to that.

14 CHAIR SOKAS: Okay. Well, that is

15 certainly a question we can raise.

16 MEMBER WHITLEY: Garry here.

17 I think we are onto something because

18 the CEs I think are not sending enough

19 information on up the line. I am going to give

20 you a couple of real quick examples I ran into

21 this week.

22 We had a sheet metal worker who the CE
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1 sent him a form letter back that said that he

2 agreed that a certain chemical caused COPD, but

3 he couldn't say a sheet metal worker used that

4 chemical. Well, I went on the SEM and called up

5 sheet metal worker. There is that chemical. 

6 Called up the building that said sheet metal

7 worker in. There is that chemical. Everything

8 that he needed was right on the SEM, but, you

9 see, he was filing for hearing and COPD.

10 He said he would send the information

11 for the hearing on up to the IH, but he wouldn't

12 send the COPD -- that is what the letter said --

13 the COPD on up because he couldn't find where he

14 used that chemical.

15 And I printed it out for the guy. I

16 said, "Here it is."

17 And today and the past two days, I

18 have had two people call me and say, "I was an

19 instrument technician and I am filing for

20 hearing, and my CE is telling me that they don't

21 cover instrument technicians." Well, when you

22 pull the law, right in the middle of it is the
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1 list of the covered, is instrument technicians.

2 So, I really think the biggest problem

3 is the IH and the Medical Examiners are not

4 getting enough information from the Claims

5 Examiners.

6 CHAIR SOKAS: Uh-hum.

7 MEMBER VLIEGER: Yes, let's just say

8 it is the issue of very channeled, very limited

9 areas that they are allowed to answer to. And if

10 they go outside the box, we don't see those

11 intermediate responses. If there is any

12 discussion between the CE and the CMC, the CE

13 will go back to the CMC and ask them for

14 clarification, but in the file I have never seen

15 that intermediate report from the CMC where the

16 CE disagrees with something that they did.

17 So, that, too, the draft CMC report

18 that the CMC gets before they go back and as the

19 clarification are not showing up, either. And I

20 don't know if that is the internal issue with

21 their records that they get from CMCs. I don't

22 know.
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1 Now the other issue Garry brings up is

2 quite timely. It is that there is a separate

3 Site Exposure Matrix that the Claims Examiners

4 look at that is not public.

5 CHAIR SOKAS: Now, Steve, I'm going to

6 bring you in on this one. Is the SEM Committee

7 looking into that?

8 MEMBER MARKOWITZ: Looking into which

9 aspect?

10 CHAIR SOKAS: To whether or not the

11 information that is available -- I mean, I'm sure

12 they are looking at the SEM, but has the question

13 been raised about whether or not the information

14 is available to the public?

15 MEMBER MARKOWITZ: Well, we are going

16 to look into difference between the private and

17 the public SEM, if that is your question.

18 CHAIR SOKAS: Okay. All right.

19 MEMBER DOMINA: Hey, this is Kirk. I

20 just have a comment.

21 MEMBER MARKOWITZ: I am not exactly

22 sure how we are going to do that, but it is the
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1 intention of doing that.

2 CHAIR SOKAS: Okay. Got it.

3 Kirk?

4 MEMBER DOMINA: If you look at like

5 what we were just talking about what is going to

6 the IH, and whatever, if you look at the example

7 that was provided for us in our April meeting,

8 you will see where, like what Faye just stated,

9 the question that was asked to the IH is -- the

10 individual has worked from '77 until still

11 currently employed, put in for COPD in 2012. 

12 But, when they sent the letter asking the IH,

13 they stopped at 1995, based on the fact of that

14 Circular.

15 CHAIR SOKAS: Right.

16 MEMBER DOMINA: Plus, the individual's

17 work history, there's seven years missing; well,

18 actually, 10 years, 11 now, because the last time

19 they got his work history was in 2005. And so,

20 you don't know; the guy could have been involved

21 in an accident, an incident, or whatever. None

22 of this information gets to them. And so, it is
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1 a jaded report.

2 CHAIR SOKAS: Now we could get

3 explicitly -- one of the very last questions on

4 the list from the program to us is to look at

5 that Circular, the one about the post-1995

6 expectations. And I think that is going to be a

7 real task that we will be able to have input

8 into.

9 So, I think I will be interested to

10 hear what Mark has to say about, you know, when

11 he does his presentation, but I think for sure

12 that is going to be something that we will be

13 taking on as a Subcommittee.

14 I am not clear in my own mind whether

15 or not the inclusion of exposures is required

16 through the most recent, though, and I guess that

17 would be a question I would have, if anybody

18 knows it right now or if that is one of the

19 things we add to our list of questions.

20 MEMBER VLIEGER: Well, the law is

21 quite clear about Part E. The statute states

22 that, in order to be covered under this program,
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1 you only have to have one day of employment to be

2 covered under Part E. And so, the Department

3 administratively made it that, if you had any

4 exposures after 1995, by magic waving of their

5 wand, that they could not have happened.

6 And I did send the Department of

7 Energy's response to me about their input into

8 those memos to Carrie for one of the other

9 Subcommittee meetings. Basically, the Department

10 of Energy did not tell them that that memo was

11 factual.

12 And so, Carrie, do you have that DOE

13 response about what their input was to DOL's 1995

14 post-exposure memo?

15 MS. RHOADS: That is actually on the

16 website for the other Committee meeting. We

17 don't have it up on the WebEx screen, but we can

18 get it up, if you would like, in a few minutes.

19 MEMBER VLIEGER: Well, it is very

20 telling because we are not quite on that topic

21 yet, but the Department of Labor decided to

22 administratively rule out exposure post-'95
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1 because the Department of Energy had written

2 memos to strengthen their toxic exposure to their

3 workers. And just because the Department of

4 Energy wrote a memo and an order to their

5 contractors to stop doing it does not mean that

6 it happened. That memo, that post-'95 exposure

7 memo, is not backed up by any science.

8 CHAIR SOKAS: And in addition to that,

9 Faye -- and this is something, Carrie, you might

10 be able to kind of add to the list; I mean, it is

11 the topic of that exposure memo -- but, in the

12 late nineties, I think it was '98-99, OSHA

13 actually did a series of invited visits to

14 several of the DOE facilities. And Oak Ridge I

15 am sure was one of them. I am trying to remember

16 all of the different ones.

17 Because what they did was they were

18 actually looking to see if they were going to be

19 applying for VPP status, basically, which is

20 their high-performing stuff, on the basis of the

21 change in the central office's approach to health

22 and safety. But, in point of fact, there were
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1 slip-ups all over the place, and it was very

2 clear that there were some actual impediments to

3 the implementation of that.

4 One of them, as I recall really

5 clearly, was that they were issuing contracts and

6 renewing contracts on the basis of having an

7 illness and injury reporting number that was

8 quite low. And the problem with that is the

9 minute you tie someone's contract or their bonus

10 or their performance rating to that kind of a

11 single number, you basically invite everybody to

12 cook the books.

13 So, there was a lot of concern around

14 the accuracy of the illness and injury reporting,

15 about the disincentives to reporting, and to the

16 fact that, like any organization, I mean any

17 organization, there's a difference between the

18 central office deciding something and everybody

19 in the field actually performing and having it

20 happen. So, that is true of any organization.

21 So, I think we, as a Committee, are

22 going to have a lot to say about that particular
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1 memo.

2 Kirk, did you have anything else that

3 you wanted to bring up?

4 MEMBER DOMINA: Well, not at this

5 time.

6 MEMBER VLIEGER: I think we need to

7 talk about the correlating memo about hearing

8 loss in toxin exposure post-1995. It follows the

9 same issue where they just summarily decided that

10 that was going to be that way. And the painters

11 didn't change the stuff that they used. The

12 metal workers didn't change the solvents they're

13 exposed to. The instrument technicians still use

14 the same things to clean parts. Yet, the post15 '95 hearing loss memo has the same flaws that the

16 post-'95 toxic exposure memo does.

17 CHAIR SOKAS: So, Faye, I think we

18 should add that to the list then.

19 MEMBER VLIEGER: I would agree.

20 CHAIR SOKAS: Okay, great.

21 And Carrie has the website up. So, is

22 that the DOL memo? The response?
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1 So, Faye, did you want to walk us

2 through the response from DOE?

3 MEMBER VLIEGER: Sure. If you look,

4 I had queries to the Department of Energy what

5 their position was on this post-1995 memo. And

6 they did say that they provide them all kinds of

7 information, but the bottom line on this response

8 is that they did not have, the Department of

9 Labor, that this was a factual memo. They give

10 them information, and the Department of Labor

11 made their own decision to do the post-'95

12 exposure memo basically stating that nobody has

13 any reason to claim toxic exposure post-'95

14 unless it was an incident, accident, or off15 normal occurrence.

16 Well, there is actually a Department

17 of Labor memo. Carrie, did we have the

18 Department of Labor's memo about how they came up

19 with the post-'95 Circular? Was that up on the

20 other page, too?

21 MS. RHOADS: I don't think so.

22 CHAIR SOKAS: No, I think we actually
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1 had that, say, in our original binder from the

2 April meeting. So, there was the original memo,

3 and then, there was that second memo. It is

4 there someplace. But it basically just supports

5 the original memo, I think.

6 MEMBER VLIEGER: Yes, it does. And in

7 countering their logic for this memo -- and Kirk

8 can talk to this -- after 1995, the Department of

9 Energy continually wrote memos about the fact

10 that workers are still being exposed and they

11 were going to improve the workers' situation. 

12 But it still isn't in fruition, and there were a

13 number of documentation requirements that were

14 put in place, that exposure information,

15 monitoring data, incident and accident

16 information would be in personnel records. And

17 Kirk can speak to whether or not those have ever

18 been implemented.

19 Are you there, Kirk?

20 MEMBER DOMINA: Yes. I was eating. 

21 Sorry.

22 MEMBER VLIEGER: All right.
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1 MEMBER DOMINA: No, I mean, the other

2 thing I talked about, too, when we were back

3 there is anytime they put some, quote, "new

4 program" in place, and we are in the middle of

5 contract -- you know, who's running the site --

6 they are going to ask a request for equitable

7 adjustment because they want more money to

8 implement certain things.

9 And so, just because they say they may

10 want to use -- or that things got safer, it is

11 not necessarily so, because if you remember

12 correctly, I think -- or maybe I didn't -- but

13 our latest SEC for construction workers from '84

14 to 1990 came into effect because they were

15 supposed to provide bioassay samples and a

16 bioassay program for the construction workers,

17 and it never happened. Even though DOE says

18 you're going to do this, it doesn't mean it is

19 going to happen. And this is the case with this.

20 And because of how they choose to

21 record incidents, events, or whatever, it is up

22 to them because it still in effect today, on how
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1 things get recorded and what meets a certain

2 level or requirement in their eyes that qualifies

3 as an event when workers are exposed, as what we

4 see going on today, or in the employer's opinion,

5 not exposed.

6 CHAIR SOKAS: Uh-hum, uh-hum.

7 MEMBER VLIEGER: And remember, DOE has

8 specific reporting criteria and requirements for

9 investigation. And if an individual worker gets

10 a chemical exposure, at least during the

11 timeframe I worked at there, it didn't warrant an

12 investigation because three or more people were

13 not involved.

14 And so, the DOE criteria to even

15 investigate is not what people expect. And

16 remember, DOE is not held bound to any NIOSH

17 regulation.

18 CHAIR SOKAS: You know, I think it

19 would be interesting -- and, Carrie, I wish I had

20 a better title to ask you to request, but I am

21 wondering if, within the Department of Labor, you

22 could access the OSHA report. There was a joint
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1 DOE-OSHA activity that included a number of

2 reports based on joint visits to several of the

3 sites in the late nineties. I can try to figure

4 out exactly when that took place, but it would

5 have been '98 or '99, basically. And I can also

6 try to figure out which directorate it would be

7 in, but I think putting the request through the

8 main office in OSHA ought to turn something up.

9 MS. RHOADS: I can do that. Whatever

10 details you have, just send them to me. And

11 then, I will use them in asking about that.

12 CHAIR SOKAS: I sure will. I will

13 track down a little bit more than that. Good.

14 Any other comments, Garry, Kirk, Faye?

15 (No response.)

16 We are moving right along, which is

17 great. I wanted to turn it over to Mark Griffon

18 to talk about the IH review issues. There are

19 some specific questions. Again, if we could go

20 back to those? I think the questions for IH were

21 six, seven, and eight maybe.

22 But, Mark, however you want to handle
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1 this, whatever you want to talk about, the ball

2 is in your court.

3 MEMBER GRIFFON: Okay. Thank you,

4 Rosie. I am not sure just how to go about this.

5 But the main ones I saw -- and I don't

6 know if they are numbered in what I'm looking at;

7 there's a bunch of bullets -- but there is one --

8 CHAIR SOKAS: Uh-hum, many bullets.

9 MEMBER GRIFFON: -- recommendation,

10 standardization of IH reviews that Jeff Kotsch

11 had, I guess, in his presentation.

12 And I think, to me, that alone was

13 very telling, that DOL at this point in the

14 process is asking this Board to help with the

15 definition of exposure levels by employees;

16 recommendations regarding improving IH

17 narratives, and proper assessment of employee

18 toxic substance exposures in the absence of

19 Occupational Safety and Health monitoring data.

20 So, I mean, that last one is pretty

21 broad, I would think. But, as I was thinking

22 about this issue, I am just thinking, you know,
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1 for this Board, for us to look at this issue in a

2 maybe comprehensive fashion -- and I don't know

3 how much -- I think we have to think about what

4 is going to overlap with the other Subcommittees. 

5 But I have been thinking about, you know, we need

6 to review, or at least I do -- some others seem

7 to understand this a little -- they are a little

8 closer to this than I have been, at least on the

9 Part E side.

10 But we need to understand how the

11 procedures are used and other, in those public

12 procedures we have seen, are there other

13 directives or guidance that are given to the IHs

14 or the CEs regarding exposures? Because it seems

15 to me there's a lot of places in the process

16 where a judgment has to be made by someone.

17 If the CE is looking at a claim for

18 the first time, are they including all the

19 exposures that come up on the SEM database or are

20 they saying, based on the job title and my

21 knowledge of what a sheet metal worker does, I

22 think it is unlikely that he would have had any
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1 significant levels of exposure to chemical X? 

2 And then, passing that information on from there.

3 So, who is making the judgments along

4 the process? How are they making the judgments? 

5 How are they making sure they have consistency in

6 the way they are applying these judgments for the

7 various claims?

8 I think we need to look and see if

9 there is QA/QC procedures. Are there peer

10 reviews in IH or are the IHs reviewing the CE

11 claims? I think there are so few IHs, I don't

12 know how that could be happening.

13 And then, another line of questions I

14 had was what is the site-specific expertise of

15 the CEs or IHs that are involved in the process? 

16 Do they know these sites? Do they know the sites

17 over time? Because they have changed quite a bit

18 over the course of history of what has been going

19 on and the potential for exposures over different

20 decades on the sites.

21 Well, I mean, that is just some of the

22 things I have been thinking of, Rosie, in terms
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1 of the IH side of this process.

2 CHAIR SOKAS: So, you are in a

3 position of, I think, being our only IH. So, the

4 question, the way I would kind of frame it, is,

5 which of these do you think you could actually

6 have the time to get a handle on, right? Maybe

7 part of this is to ask the -- because I was

8 having the same response when I was looking at

9 the medical stuff. I'm looking at, oh, my golly,

10 well, maybe if I had a staff of five, you know,

11 and full-time, I could do some of this.

12 MEMBER GRIFFON: Yes.

13 CHAIR SOKAS: So, some of it might be

14 to narrow and to frame it a little bit by asking

15 for more information.

16 MEMBER GRIFFON: Yes.

17 CHAIR SOKAS: So, are there particular

18 scenarios that turn to out to be problematic in

19 terms of inadequate exposure information or would

20 it be helpful for you, for example, to see can

21 examples of IH reviews for accepted cases, and

22 maybe 10 examples for denied claims, and then,
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1 kind of look to see if there's any patterns that

2 you see emerge? Or do you have recommendations?

3 And one of the other things I thought

4 I saw -- and, Steve, a question for you. I don't

5 know if somebody else is going through this, but

6 there was, for example, a question about

7 revamping the Occupational Health Questionnaire,

8 right? So, there is an Occupational Health

9 Questionnaire that, right off the bat, I think

10 you get rid of the family history because I don't

11 actually think that is legal anymore.

12 And people suggested, I think, at the

13 meeting that maybe they could use some of the

14 approaches that, for example, CPWR has taken in

15 terms of collecting information.

16 So, I guess the question is, looking

17 at this, which of these do you think, given time

18 constraints and that you are kind of the IH here,

19 and others on the Committee I'm sure would be

20 happy to help, but what do you think is the most

21 realistic? And what would you need DOL to

22 provide you to be able to start addressing some
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1 of that?

2 MEMBER GRIFFON: Well, I mean, yes, I

3 didn't get to that point yet, honestly. But I

4 think, you know, some questions, certainly some

5 examples. I mean, I have thought about this in

6 maybe a different -- maybe others, like I said,

7 are familiar with this, but, for me, it would be

8 good to see the procedures. In other words,

9 before I can make recommendations on how to

10 improve, I have to sort of better understand how

11 they are doing it right now.

12 CHAIR SOKAS: Right.

13 MEMBER GRIFFON: And looking at some

14 examples would be helpful, but, also, looking at

15 the procedures or internal guidance that they are

16 using to make some of these judgment calls, or do

17 they have a procedure in place? So, I think to

18 see some of that stuff first --

19 CHAIR SOKAS: Yes.

20 MEMBER GRIFFON: -- to see, for

21 instance, what percentage of claims have been

22 forwarded to the IH if the CEs say, you know,
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1 "This is a technical issue that is beyond our

2 capability. We are referring it to an Industrial

3 Hygienist."? What is the percentage --

4 CHAIR SOKAS: That is a really good

5 data request.

6 MEMBER GRIFFON: Right.

7 CHAIR SOKAS: Again, this is really

8 for Steve and Carrie, because I don't know if

9 others are already doing this. But, for example, 

10 if Mark wanted a list, a number, just a count of

11 what proportion of claims are forwarded to the IH

12 and, then, maybe have a sampling of, a handful of

13 claims that got forwarded, a handful of claims

14 that didn't, because you want to look at both

15 sides. Were there any that should have been that

16 weren't in that little pile, you know, that sort

17 of thing.

18 Maybe you would look at both. I mean,

19 if we wanted to, we could just say, well, let's

20 just look at the denials to see if we find

21 problems with them because we are assuming that

22 the process is specific, but maybe not sensitive. 
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1 I mean, that is, I know, reflection probably.

2 But, Carrie, is that the kind of thing

3 that would be relatively straightforward to get

4 that kind of a redacted series of cases and,

5 then, the numbers across the board? "X" percent

6 get forwarded along.

7 MS. RHOADS: I will ask the program

8 how long would it take them to do that. If you

9 give specific parameters for your request, like

10 maybe for a specific year or something like that,

11 that would --

12 CHAIR SOKAS: Okay. Because, I mean,

13 I think we could do random or we could do the

14 last three months, right, Mark? I mean, I don't

15 think we are looking for a comprehensive thing

16 here. Whatever is easiest for them, if they

17 collect the data monthly, that's great, if they

18 collect it annually. But we want to know, of all

19 the claims coming in, how many were handled

20 entirely by the CE, how many went to an IH. Of

21 the ones handled by a CE only, how many were

22 approved and how many disapproved? Of the ones
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1 that went to the IH, how many were approved and

2 disapproved?

3 MEMBER GRIFFON: Yes, that sort of

4 thing, yes.

5 MS. RHOADS: I will start writing this

6 down, and maybe we can refine. Like I will send

7 some language and you can play with it, or

8 whatever, before we forward it to the --

9 CHAIR SOKAS: Before we ask them,

10 sure.

11 MEMBER GRIFFON: Yes.

12 CHAIR SOKAS: And we are going to be

13 asking to see the actual files at some point, and

14 it could be redacted or however. But I do think

15 that for some of this, for both the IH and for

16 the CMC, I think it is going to be a need to sort

17 of look and see what it looks like. Maybe small

18 samples, maybe five or maybe ten, you know,

19 redacted. And it wouldn't have to be the whole

20 file; it could just be the report, right, the

21 information they receive and, then, the

22 information that they give back.
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1 MEMBER MARKOWITZ: This is Steve.

2 Actually, given the concerns that Faye

3 especially raised about what the CE forwards to

4 the IH or not, if we are going to look at a small

5 number of claims, we shouldn't look just at the

6 IH report, but also what the --

7 CHAIR SOKAS: No, what I was saying,

8 Steve, was that we would look at what they get

9 and what they give back, so what is forwarded by

10 the CE to them and, then, what they return.

11 MEMBER MARKOWITZ: Right, and what I

12 am saying is that could be augmented by, for

13 these small number of claims, also looking at the

14 exposure information that the CE is looking at. 

15 The concern was about some of the things the CE

16 wasn't forwarding. So, if you only look at what

17 the IH gets --

18 CHAIR SOKAS: I see what you are

19 saying. Yes, got it.

20 MEMBER GRIFFON: I think, yes, Steve,

21 I think you're right. This is Mark Griffon. I'm

22 sorry.
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1 I think we should, as we pick out

2 randomly, or however, claims to look at, we

3 should look at the entire claims file and, then,

4 see what the CE looked at, what they forwarded

5 on, what the IH looked at.

6 CHAIR SOKAS: I think that is

7 absolutely right. And it is true for the medical

8 information as well. So, that is right. That is

9 a good point.

10 MEMBER GRIFFON: And then, the other,

11 I mean, I was bouncing around a little bit with

12 what I was talking about, but the other piece of

13 what I am mostly interested in is these guidance

14 or guidelines or internal procedures. You know,

15 it is hard to request them when you don't know

16 what exists.

17 So, I am looking at the one on the

18 website and, for instance, it mentions a

19 questionnaire and it mentions that I think the CE

20 administers -- oh, the Resource Center

21 administers the questionnaire, and they have a

22 script that they follow, but I don't see any
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1 script in the procedure that is on the web,

2 anyway.

3 So, is there a standardized script or

4 is it a site-specific script? I don't know what

5 they are using. So, are there other guidelines

6 that the CEs are using, that the IHs are using,

7 as they assess these claims?

8 Because I think part of the magic that

9 comes into play in this whole process is the SEM

10 says chemical "X" and job "X", or at least jobs

11 to chemicals, but it says nothing about the type

12 of exposure or the level of exposure. And I

13 think that is where people are making, or

14 probably have to make, some judgments.

15 This even comes into play, in my

16 opinion, after '95. These two things we bring

17 up, I don't think it is a magical line where

18 exposures at the site stopped completely. You

19 could definitely make an argument that safety

20 protocols and practices improved, but did toxic

21 exposures suddenly -- you know, toxic exposures

22 were not eliminated in '95. They might have been
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1 greatly reduced in the later years, but not

2 eliminated. So, it is a degree or it is a

3 judgment of how much exposure people got. And

4 the CEs and the IHs and the medical practitioners

5 must be at some point making those judgments. 

6 So, I would like to see even internal guidelines

7 to help in those judgments.

8 MEMBER VLIEGER: One of the things

9 that kind of baffles me about how anybody can

10 make assumptions on how much someone was exposed

11 to is the lack of monitoring data. There is no

12 monitoring data that was done. Yet, the

13 Department of Labor turns around and says to the

14 claimant, "Well, you need to provide us

15 monitoring data for kind, quality, and quantity

16 of exposure." Well, there is none that exists,

17 and this program exists because there is no data. 

18 Yet, the Department of Labor turns it on its head

19 and says, "Well, if you can't come up with it,

20 then we have to rely on our experts." But the

21 experts don't have any exposure data, either.

22 MEMBER GRIFFON: Right, right, right.
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1 CHAIR SOKAS: Well, that gets back to

2 Mark's question about whether the experts have

3 any site-specific experience or training or

4 information, you know, that kind of thing, if

5 there is some ability that they have to get kind

6 of insights into what was going on at a

7 particular location.

8 MEMBER GRIFFON: Right, and --

9 MEMBER VLIEGER: I would be curious

10 to -- I'm sorry, go ahead.

11 MEMBER GRIFFON: I'm sorry. I was

12 just going to say, you know, that, of course, is

13 a double-edged sword, too. We ran into this on

14 the radiation side. The Radiation Board, when

15 you look for experts or consultants to help in

16 this process, if they have some experience, they

17 also could have a conflict. So, you know, you

18 run into this sort of -- but we ended up using a

19 lot of people that, for instance, worked at DOE

20 or at the sites over the years because they had

21 great historical knowledge. I think NIOSH worked

22 hard on developing a policy around that conflict-
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1 of-interest issue and managing the conflicts and

2 making sure, being transparent about them, but

3 also using these people that had a lot of

4 knowledge about historical operations.

5 But I think, yes, it is difficult for

6 me to understand how CIH, if they didn't have

7 much experience, I think the ones that they hired

8 did have experience, at least at some of the

9 sites, but there's so many sites that you

10 couldn't possibly be expert on all these sites,

11 especially over time.

12 MEMBER MARKOWITZ: Right. Yes, and

13 the sites themselves are very complicated things. 

14 Each individual site is very complicated.

15 MEMBER GRIFFON: Right.

16 MEMBER MARKOWITZ: But, you know, the

17 thing about these judgments that the IH makes is

18 that they are inevitable, and partly because of a

19 lack of data, but, in part, because that is just

20 the nature of the work that we do.

21 And my question, then, is how

22 consistent are these judgments across the IHs? 
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1 Actually, that relates to what the charter of the

2 overall Board is. This task of this Committee is

3 to look at the quality, objectivity, and

4 consistency of IH and physician work.

5 Yes, we could look at how consistent

6 the judgments are. And what I am mostly

7 interested in is moving towards -- the question

8 is, can we convert these judgments to

9 presumptions, so that the whole process can be

10 simpler?

11 MEMBER VLIEGER: From my experience --

12 this is Faye again -- from my experience, it is

13 that when there is no monitoring data, the

14 decision goes against the worker. I mean, that

15 is what I have seen historically from the IH and

16 CMC reports that I have requested.

17 And when the CE refers to the CMC with

18 no monitoring data, that is what the CMC hangs

19 their hat on. There is a presumption that there

20 must be data, but it is just not here. And that

21 is an erroneous assumption that no one ever tells

22 them, "By the way, there is no monitoring data
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1 because they did not monitor for this." And that

2 presumption should be changed, that just because

3 it isn't provided to you doesn't mean it was

4 there and not provided. It means it doesn't

5 exist.

6 And we have a request in to the U.S.

7 Department of Energy. They are supposed to be

8 putting a report out from our March meeting with

9 them that the advocates had in Denver with them. 

10 They are supposed to be answering that question,

11 "Tell us if you have breathing space and air

12 monitoring data for the workers. And if you

13 don't, tell us that also."

14 MEMBER MARKOWITZ: Well, you know,

15 that is actually an empirical question that we

16 can look at, the decisions the CMCs are making

17 and the extent to which what Faye is saying is

18 true or not.

19 CHAIR SOKAS: So, again, that really

20 kind of implies that we will have data. That is

21 part of the data request, basically. And we can

22 certainly construct a way to look for that if we
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1 have got all the records, you know, the complete

2 records. We have to decide how many we want to

3 look through and maybe how we are going to do it

4 to be able to come up with those numbers.

5 MEMBER MARKOWITZ: This is Steven. I

6 have a question.

7 If we are tasked with looking at the

8 quality, objectivity, and consistency of the IHs

9 and the CMC and the other physicians' work here,

10 aren't we eventually going to have to look at a

11 broad sample of reports and claims and look at

12 those specific factors? And if that is true,

13 what do we need to get there to better inform our

14 request around those things? What initial

15 information do we need?

16 And I think we are getting some of

17 this down on the table, you know, some of the

18 current reports on quality assurance or whatever

19 they have produced, and, also, looking at a

20 limited number of claims to understand the

21 process.

22 But I keep thinking of, what do we
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1 need ultimately to answer this question of

2 quality and objectivity and consistency and,

3 then, how do we get there?

4 CHAIR SOKAS: This is Rosie.

5 I am thinking there are two parts to

6 that question. One is, what are the mechanisms

7 through DOL? And then, the other is, again, what

8 is the sample size we need, right? So, would we

9 need to look at maybe all of the denials for a

10 month throughout the country? I don't know what

11 that number would be. Again, because that is

12 where the concern is; it is with denials, not so

13 much with acceptances.

14 And I guess, Carrie, that might be a

15 question for you. I mean, even having us being

16 able to read through five charts or ten charts

17 apiece, or something like that, if we divvied up

18 how we wanted to handle this, we would need to

19 have both access to the charts, which obviously

20 is challenging -- and the question for you guys

21 is, we have taken an oath. So, does that mean we

22 could look at them with the person's identifying
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1 characteristics, which, of course, then, ratchets

2 up the level of security for maintaining those

3 charts? Or would it require DOL staff to redact

4 all that information, right, which would be a lot

5 of work?

6 And, Steve and Mark and Faye and Kirk

7 and Garry, I guess the question for us is, how

8 much of this do we need to see? And then, how

9 much of this could we, then, ask for

10 specifically, look at this diagnosis? I mean, to

11 me right now, unless I missed it, I don't think

12 we have the list yet of what are the most

13 frequent diagnoses that are approved, what are

14 the most frequent that are denied, you know, that

15 level of what are the reasons for denial, that

16 level of looking at every chart and just checking

17 up the numbers. But, then, what would we want to

18 look into more in-depth, and could DOL do that

19 for us or do we? I mean, I think initially at

20 least, we need to look at them ourselves

21 probably.

22 Mark, I apologize. My computer just
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1 went down. Did you have anything else that you

2 wanted to raise right now or ask for information

3 about?

4 MEMBER GRIFFON: No, I think that was

5 the main things for my part of it. I mean, I

6 don't know if it is in line with what Steve was

7 just raising, but, I mean, that is exactly what I

8 was thinking of, was this question of

9 consistency, quality and consistency.

10 I mean, here's the other question: if

11 you get a sampling of cases to review, to what

12 extent can our Board do this without some help?

13 CHAIR SOKAS: Right.

14 MEMBER GRIFFON: I mean, I think an

15 independent review is something that people have

16 asked for for quite some time, but that would be

17 more of sort of an audit of a percentage of cases

18 or something like that. So, I don't know if that

19 is something that is an option, but --

20 MEMBER VLIEGER: Mark, are you

21 thinking of somebody like SC&A to help with the

22 review of this stuff?
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1 MEMBER GRIFFON: Yes, well, that is

2 the model on the NIOSH side. The Board had to

3 ultimately have a contractor to help with this

4 review. Now there was perhaps a larger number

5 that we were reviewing and pretty technical dose

6 calculations, and things like that, that were

7 involved. So, maybe it doesn't have to be to

8 that extent, but something like that, yes.

9 CHAIR SOKAS: That is a great example

10 to have, I mean to kind of frame what we are

11 looking for. I think that might be the next step

12 after we figure out what we can get from DOL

13 originally, and looking through that, I think

14 that will help us shape that request.

15 MEMBER GRIFFON: I agree, that is

16 something perhaps down the line, but I think we

17 need to get a handle on what is there ourselves

18 first. And I, myself, have to -- maybe others

19 know better -- but I have to get a better handle

20 on sort of the internal process, how this all

21 works behind the scenes. That will be useful.

22 CHAIR SOKAS: This is Rosie.
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1 I agree with you, and I just think

2 that is going to be the hardest to thing to get. 

3 But it will be at least interesting to see. 

4 Following a couple of charts I think will help

5 with that.

6 MEMBER GRIFFON: Right, right.

7 MEMBER WHITLEY: Garry here.

8 I think you guys have that number

9 down. Let's just say, for example, we ask for 20

10 cases in the past three months that have been

11 denied.

12 CHAIR SOKAS: Uh-hum.

13 MEMBER WHITLEY: And let's just look

14 at them and see. I think it will jump out at us. 

15 I really think it looks like we will have some

16 real questions: why was this done? And then, we

17 could ask some specific questions about those

18 cases, and it will give us a clue. I'm like

19 everybody else, I have got to see more of how

20 past workers have -- the Claims Examiner I think

21 is part of the whole problem.

22 On their behalf, I am using Oak
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1 Ridge. It is 500 miles to Jacksonville. So,

2 there is not a very good chance that one Claims

3 Examiner down there has ever seen inside one of

4 these plants in Oak Ridge, Tennessee. So, they

5 really have no way to understand.

6 CHAIR SOKAS: So, just to follow up on

7 that, I mean, what about if we each take -- I

8 think we could do it in a way, if we each took

9 maybe five cases and, then, have access to the

10 others, I mean this might be a time when we might

11 need to have a closed conversation, and we would

12 have to discuss how and if that could happen.

13 But I think that doing that, and then,

14 being able to discuss it across our group might

15 be very helpful. I know it would be incredibly

16 helpful for me for the medical stuff, and I am

17 sure for the IH as well. It is just necessary

18 really.

19 MEMBER WHITLEY: I agree.

20 CHAIR SOKAS: So, I like that idea. 

21 I think that we can move that forward before the

22 end of today with specific numbers to request,
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1 and just whatever Carrie can find out for us

2 would be very helpful in that.

3 I don't want to cut this off. So, I

4 think we should keep talking about all of these

5 issues, but I would like to take us through the

6 questions starting from the top.

7 Carrie, if you wouldn't mind? Because

8 I think that first one was more of a medical

9 question. Okay, great.

10 So, I did sort of number these, but

11 Mark is right, they are just bullets.

12 The first one, this is a request from

13 the program. It is for new presumptive criteria

14 to be applied in eliminating the need for medical

15 review. And the first piece that they mention is

16 the diagnosis plus a toxin, plus a latency, time

17 of exposure, equals causation.

18 Now I immediately had some concerns

19 about the request even a little bit. I mean, I

20 think there are examples that we have seen about

21 -- I can't remember now if it is renal and

22 trichloroethylene. There are some specific
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1 guidances that have come out where the real

2 question is, how do you figure the sensitivity

3 versus specificity of all of this? And what's

4 five years versus ten years versus two, you know,

5 that kind of stuff?

6 So, I think it is possible there may

7 be low-hanging fruit. What I would do, I would

8 turn this around. And then, the other question,

9 of course, is this whole concern we have

10 currently about the quality of the evaluations

11 that are going on. So, before you would want to

12 turn any more to that, we would want to go

13 through the rest of these discussions.

14 But I would ask DOL -- and, Carrie, I

15 think should be an easy request -- but I really

16 think that, for them, it would be relatively

17 straightforward for them to be able to provide

18 us, again, with a list of the top diagnoses that

19 they make, both for denials and acceptances, the

20 main reasons why they get denied or accepted. 

21 And this would be for the past year probably. I

22 mean, this is just numbers-crunching.
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1 And then, if there are particular ones

2 that they suggest or that they are concerned

3 might be routine enough that we could do that

4 for, right? So, I would kind of put it back on

5 them because some of these questions really seem

6 to be asking for the universe of possibilities,

7 and that is a little too broad for us. So, if we

8 can nail it down to are there a couple of

9 diagnoses that you think could be turned into

10 something presumptive if we had this, this, and

11 this information?

12 Steve, I know that you kind of

13 mentioned that a little bit. Again, I am a

14 little concerned with this whole question when it

15 gets to be too specific. I think that whole

16 being able to do the 50/50, as likely as not, is

17 going to be our challenge when we do that.

18 But I would like more information from

19 the program on which specific diagnoses are they

20 really looking at that they would like to try to

21 do this for.

22 And then, the second piece of that,
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1 again, for the matrix of consequential illnesses,

2 that can be accepted once the primary work3 related illness is accepted, again, I think that

4 rather than to try to imagine all the different

5 possibilities, it would be very helpful to have

6 like the three major diagnoses where this comes

7 up, and then, what are the examples, both

8 accepted and denied, of the kinds of

9 consequential illnesses that people wanted to

10 claim based on the main diagnosis?

11 So, if they could come up with what

12 are your top three and what have you see and what

13 have you accepted and what have you not accepted,

14 you know, just to give us something to figure out

15 what their main concerns are, I think we could

16 work on that. But I don't want to promise to

17 imagine the universe and, then, provide it. So,

18 that is how I would handle that. It is just

19 really at this point asking them to frame the

20 questions based on their experience with priority

21 in both categories.

22 Then, the next bullet down --
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1 MEMBER MARKOWITZ: Rosie, can I just

2 add something?

3 CHAIR SOKAS: Sure.

4 MEMBER MARKOWITZ: Yes, it's Steve

5 Markowitz.

6 We have seen this now on a few of the

7 Subcommittees, this issue of presumption and

8 DOL's interest in presumption. I mean, because

9 they have moved in that direction, right? We

10 learned, I think, a little bit about asbestos and

11 asthma and maybe even COPD.

12 CHAIR SOKAS: Yes, and I think I liked

13 the asthma one. I thought they did a good job of

14 that.

15 MEMBER MARKOWITZ: And those

16 presumptions have been claimant-friendly. I

17 mean, my interpretation of how they set up the

18 criteria is that they are on the generous side to

19 claimants rather than on the other side.

20 CHAIR SOKAS: I thought that was true

21 for asthma. I was not so sure about the

22 trichloroethylene. I mean, I didn't look into it
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1 really carefully, but it raised a little concern

2 with me. Especially because of the latency for

3 that one, I had a little concern that they were

4 being too specific.

5 MEMBER MARKOWITZ: Right. Well, so

6 yes, and presumptions in and of themselves aren't

7 necessarily generous or not. It depends on what

8 you use as the criteria --

9 CHAIR SOKAS: Uh-hum.

10 MEMBER MARKOWITZ: -- where you set

11 the limit. For instance, they have solvent12 induced hearing loss which a person has to have

13 10 consecutive years of exposure prior to 1990 to

14 one or more of a select group of solvents in one

15 or more of a select number of occupations. So,

16 that is a set of presumptions, but that is too

17 restrictive.

18 CHAIR SOKAS: Right.

19 MEMBER MARKOWITZ: So, it is not

20 specifically generous, but it depends on where

21 you set the bar. But presumption is an approach

22 which can be very claimant-friendly. And so, I
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1 think that their interest in moving on

2 presumption I regard as a very useful kind of

3 opening.

4 CHAIR SOKAS: Okay. I mean, you are

5 giving it a more positive interpretation than I

6 was kind of. So, I think that is fair. I think

7 that is good.

8 I still think we need to restrict them

9 to maybe their three biggest issues because it is

10 hard for me to imagine we are going to pull

11 together more than that in the next year at

12 least.

13 MEMBER MARKOWITZ: No, no, I agree

14 with you. The most frequent things that people

15 make claims for are --

16 CHAIR SOKAS: Right.

17 MEMBER MARKOWITZ: -- the things that

18 we should help them with. I mean, that would

19 both help DOL, help a lot of claimants, and would

20 be a real contribution.

21 CHAIR SOKAS: Okay. So, taking your

22 perspective, which I think is a really good one
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1 because you're right, I mean, the asthma one was

2 really good, I will say it in a more positive

3 way; that we would like to kind of move forward

4 on that, but we want to restrict it. We want the

5 information about what their top priority areas

6 are.

7 And I think the same is equally true

8 for the matrix of consequential illnesses. I

9 mean, I think that there probably are about three

10 or four that come up all the time, and that would

11 be fairly easy. My concern is that we could come

12 up with a list of 10 consequential illnesses and

13 just not think of the 11th or 12th, and that

14 would be used to exclude people.

15 So, as long as it is done in the

16 spirit of this is what we have so far, that is

17 not the entire universe necessarily. I think

18 those are two things that we could actually move

19 forward on in Committee, and I am perfectly happy

20 to assign that to George since he is not here

21 today. I am teasing on that part.

22 But, Carrie, so that is a request for
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1 both of those sub-bullets for additional

2 information on their big priorities based on the

3 number of requests that they get.

4 MEMBER MARKOWITZ: No, but, I mean --

5 this is Steven -- I think, is your request that

6 we learn the frequency of different diagnoses

7 that people make claims for, both on the claims

8 side and on the consequential illness side? It

9 is the frequency?

10 CHAIR SOKAS: Right. It is the most

11 frequent requests for both of those. And then, I

12 think it would be useful to also know, of those

13 most frequent requests, how many are denied and

14 how many are approved and are there problem areas

15 that pop up.

16 MEMBER MARKOWITZ: "Requests," you

17 mean claims, the most frequent type --

18 CHAIR SOKAS: Right. Right, that is

19 what I mean, claims.

20 So, then, the next item is

21 clarification/recommendation regarding the

22 assessment of a medical opinion regarding the,
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1 quote, "rationalization" -- wait a minute; let me

2 just pull it back down; people can read that on

3 the screen there -- supporting a conclusion.

4 And then, there is a circle up there

5 about standardized triggers. Okay. And I am

6 just going to go into a grumpy, old lady mode

7 right now on this one.

8 So, the clarification of the

9 assessment of the medical opinion, I think there

10 is a communications issue for the medical and

11 probably for the IH that kind of threads

12 throughout all of this. I think the overall

13 challenge is that there is a need to have things

14 fit into boxes and to be able to be assessed by

15 someone who is not technically-trained, on the

16 one hand, and on the other hand, to have that

17 information presented when there is a need for

18 expertise in a way that is clear enough to give

19 that kind of almost a computerized response to

20 it, right?

21 And there was 217-15 memo, I think or

22 217-16. It is a 217 memo that we are not
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1 supposed to share or discuss that was describing

2 a, quote/unquote, "informal audit". But, in it,

3 there were complaints about people providing too

4 much information. They didn't want to hear it

5 all. And I think we heard about some of that in

6 our face-to-face meeting.

7 So, I think some of this is a

8 communication issue. I had a problem on my end

9 with the communication with words like "opine"

10 because I think of opine as you opine about the

11 weather, right? For some reason, it is like

12 chalk on a blackboard to me. "Rationalize,"

13 which is in quotes here, but the idea of

14 rationalizing, I realize that what the program

15 means is to make something rational. But, again,

16 what physicians might hear is, you know, one of

17 the Webster definitions is -- and I am going to

18 quote this because "rationalization" is something

19 we don't want to attempt -- "to attribute one's

20 actions to rational and credible motives without

21 adequate analysis of the true, and especially

22 unconscious, motives." I mean, the whole term,
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1 quote/unquote, "rationalize" is subject to two

2 very different interpretations.

3 And then, there was another place

4 where they were asking for opinions, suspicions,

5 or diagnoses, which, again, the word "suspicions"

6 is like "OMG". So, I think there is kind of

7 this, in the same way that there is kind of a

8 legal/medical disconnect, there is sort of a

9 bureaucratic medical disconnect in some of the

10 communications. And it goes in both directions.

11 One of the questions I had, so in our 

12 task we are talking about getting guidance to

13 staff physicians. Now I don't know if that was a

14 typo, but I did want to know more about the role

15 of staff physicians. I mean, I know there have

16 been staff physicians in the past. I don't know

17 if there is a staff physician currently who is

18 engaged or if they are in the process of looking

19 for somebody. I think they might be looking for

20 somebody, is what is going on.

21 But it just seems that some of this

22 communication problem is pretty profound. And
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1 the way this question is asked makes it hard to

2 be precise in figuring that out. But I do agree

3 that one of the responsibilities we can take on

4 as a Board or as a Subcommittee might be to help

5 figure out ways to foster better communication. 

6 So, that I think is a realistic request.

7 When they talk about standardized

8 triggers, I am a little more reluctant and I

9 would wonder if maybe all denials should be

10 reviewed. And so, the question is whether or not

11 that is feasible or whether or not that is an

12 easy thing for them to do. So, I would just ask

13 that in the form of a question, whether they have

14 considered reviewing all denials and making that

15 the trigger.

16 When we go down to the next --

17 MEMBER MARKOWITZ: This is Steven. If

18 I could just chime-in here?

19 CHAIR SOKAS: Sure.

20 MEMBER MARKOWITZ: This

21 clarification/recommendation, what I interpret

22 this as meaning is how do we tell a good report
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1 from a bad report from the doctor. And what

2 criteria can we use, whether it is a CMC report

3 or a personal physician? What criteria can we

4 use to assess those opinions or the decisions, as

5 they describe their reasoning behind those

6 decisions? I don't know really what the answer

7 to that question is, but I think that is what

8 they are asking here.

9 CHAIR SOKAS: I agree, I think that is

10 what they are asking, but I think the issue is

11 probably more upstream than that.

12 MEMBER MARKOWITZ: What do you mean?

13 CHAIR SOKAS: I think they are talking

14 apples and oranges sometimes. For example, one

15 of the complaints in that informal audit was

16 that, on the one hand, the physician went through

17 like very precisely what the toxic exposure was

18 and the expected health outcome. But, then, they

19 seemed to waffle on the language. Well, waffling

20 on the language is what scientists are taught to

21 do, basically, right?

22 So, there is that kind of
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1 communication stuff. It is a matter of

2 translation almost. I don't know. I mean, maybe

3 there are things that we can say. I think they

4 already have sort of the basics. If you don't

5 have good diagnoses, then that doesn't matter. I

6 mean, you have to have clear diagnoses. You have

7 to have some clear connection between the

8 exposure and the outcome.

9 Maybe, again, we can find out more

10 once we look at a handful charts. Because I did

11 not interpret that question to be that

12 straightforward. I thought they meant that they

13 had that in place, but were having trouble with

14 it. But that is a question.

15 And, Carrie, I thought I looked

16 through this stuff, but I didn't see anything. 

17 And there are very clear recommendations to the

18 CE, to the Claims Examiner, that they need to

19 have this, this, this, and this.

20 I think that pretty much explains what

21 it is they need and how they are to interpret it,

22 but if there is additional guidance that we
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1 haven't seen already, that would be helpful.

2 MEMBER VLIEGER: This is Faye.

3 Econometrica did a report about the

4 most common diseases, and the Department of Labor

5 implemented some of them and, then, kind of

6 strayed from the Econometrica report. That

7 report the Department of Labor actually

8 contracted to do, and they came up with the most

9 common diseases based on their review from the

10 former Worker Screening Program. So, some of

11 this work has already been done, and the

12 Department of Labor is asking again. And I don't

13 know whether it is like when you are ask your

14 mother and she tells you no, and then, you go ask

15 your dad to see if he will say yes.

16 CHAIR SOKAS: Oh, interesting. That

17 might be something, Carrie, to ask, if there are

18 previous reports that address some of these

19 questions, what is their take on them?

20 This next one, again, so the

21 methodologies, they are looking for ways to

22 improve physician responsiveness to data
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1 requests. Again, I have a clarification

2 question. Is this a question for both the

3 treating physician as well as for the CMC,

4 because it seems like there would be different

5 mechanisms for either one of those?

6 Again, I didn't get a real sense --

7 and maybe I just missed it -- of what the current

8 procedures are in place to get this information. 

9 So, what are they currently doing would be

10 helpful.

11 MEMBER MARKOWITZ: Rosie, can I just

12 jump in here? Steven.

13 This same issue was addressed to

14 another Committee, the Medical Evidence

15 Committee --

16 CHAIR SOKAS: Okay.

17 MEMBER MARKOWITZ: -- which is where

18 it actually belongs.

19 CHAIR SOKAS: Okay. So, we will just

20 delete that one.

21 MEMBER MARKOWITZ: Because these are

22 IHs and doctors contracted by DOL. So, if they
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1 are not responsive, they ought to have a way of

2 dealing with them.

3 CHAIR SOKAS: That's right. I thought

4 they were talking maybe about the treating

5 clinician. But that's fine. That's great. So,

6 we will skip that one, and we will just say that

7 is not part of our purview.

8 MEMBER MARKOWITZ: Right.

9 CHAIR SOKAS: You're right. I mean,

10 there was a series of these questions that was in

11 the earlier part of that same day, and some of

12 them are verbatim repeated. So, as long as we

13 know the other Committee is doing that, we can

14 just take it off of our list. So, that is off of

15 our list.

16 The next one is, what sources of

17 information exist that describe the synergistic

18 effects of chemical-radiologic interventions and

19 resulting health effects? I would ask if that is

20 actually on one of the other Committees because

21 that seems to have more to do with lungs than

22 anything else, but I don't know.
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1 MEMBER MARKOWITZ: Well, no such luck.

2 (Laughter.)

3 CHAIR SOKAS: It was worth a try. 

4 Okay.

5 Again, we can look around. I mean, I

6 would, then, ask, well, where have you looked

7 already? Have they identified any sources? I

8 think the answer is going to be you do a PubMed

9 search or you do a research search for each

10 particular individual where it happens.

11 But, if the DOL has anything already,

12 that would be helpful to know. Otherwise, we can

13 take a look at it. I don't think we are going to

14 come up with a magic bullet, but certainly we

15 could search and look.

16 MEMBER VLIEGER: This is Faye.

17 I just sent the link from the U.S.

18 Department of Labor site on the Econometrica

19 report to Dr. Sokas, Dr. Markowitz, and to you,

20 Carrie.

21 CHAIR SOKAS: Thank you.

22 MS. RHOADS: You sent that to the
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1 Advisory Board inbox?

2 MEMBER VLIEGER: I sent to you, Dr.

3 Markowitz, and Dr. Sokas.

4 MS. RHOADS: Okay. Thank you.

5 CHAIR SOKAS: Thank you, Faye.

6 So, the next question on this -- I am

7 just going to kind of run through these now --

8 training resources for improving the quality of

9 medical reviews of medical evidence in weighing

10 conflicting evidence. I think that is another

11 one that is a repeat, Mark? Steve? I'm sorry.

12 MEMBER MARKOWITZ: I'm sorry, I'm

13 trying to get this back on my screen.

14 CHAIR SOKAS: This is the one about

15 they want training resources -- and it is not

16 clear to me for whom -- for improving the quality

17 of medical reviews of medical evidence in

18 weighing conflicting evidence. So, is that for

19 the CE? Is that for the physicians? It is kind

20 of not clear to me, but I thought that was a

21 repeated question.

22 MEMBER MARKOWITZ: Yes. Well, you
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1 know, this ought to go to the Medical Evidence

2 Committee.

3 CHAIR SOKAS: Okay, great. And,

4 Steve, I am assuming you are sitting in on all of

5 those and you will just let them know?

6 MEMBER MARKOWITZ: Yes, but,

7 hopefully, Carrie is getting this down.

8 CHAIR SOKAS: And Carrie will get the

9 notes down. Okay, great.

10 MEMBER MARKOWITZ: My memory is almost

11 perfect, but not --

12 (Laughter.)

13 But, just to look at this for a moment

14 to see whether it really does relate to IH and

15 the CMC and the CCOP and all that, this would be

16 training resources really relevant to this

17 Committee would be training of the CMCs, although

18 it is to make sure that their medical reviews are

19 of sufficient quality.

20 But in the "weighing conflicting

21 evidence," you know, I don't know whether that

22 applies to the CE who is sitting there trying to
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1 figure out what is going on when he or she gets

2 conflicting reports or whether that is the

3 problems faced by the CMC. I don't know what to

4 think.

5 CHAIR SOKAS: Yes, I mean, it is

6 unclear who they are referring to. Again, it is

7 a repeat question, I'm pretty sure.

8 MEMBER VLIEGER: Just so you know, the

9 CE and their supervisor, if they ask for the

10 input, are the ones who decide whether or not the

11 medical evidence is sufficient. I'm not aware

12 that there is a physician in every district

13 office looking at every claim where they have

14 questions about the medical evidence.

15 MEMBER MARKOWITZ: Right.

16 CHAIR SOKAS: So, that is a really

17 interesting point. There is a place -- and I

18 can't remember where it is -- it is in some

19 document; I wrote down what they said in it,

20 though. It was there is a place where it talks

21 about when a CMC referral may not be needed,

22 right? It is when they are telling people when
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1 to refer for a CMC and when not to refer.

2 So, one of the times not to refer was

3 if there is no exposure documented. Well, okay,

4 you know, that probably makes sense not to refer

5 to a CMC if you don't have an exposure. But,

6 then, the next clause was if there is no

7 plausible scientific association between the

8 toxin and the diagnosed illness. And my question

9 was, well, based on what? I mean, that is

10 exactly why you would refer to a CMC, I would

11 think, right? Because unless you are using the

12 SEM or something else to dismiss potential

13 relationships, or unless you have kind of

14 searched the research publications, how would you

15 know? And that would be exactly when you would

16 want to have this.

17 So, I think one of the questions for

18 us is maybe we just want to encourage people, if

19 you don't know, that is when you should be having

20 a CMC evaluation. Again, based on that informal

21 audit, the problems were when they forwarded for

22 CMC where they had treating physician information
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1 that didn't get included accidentally, you know,

2 that kind of stuff. So, that informal audit

3 seemed to do nicely to look at procedural

4 deficiencies, but it did absolutely nothing to

5 look at quality of the content. So, that is a

6 whole issue in and of itself, and whether or not,

7 in addition to this informal audit, they plan to

8 have a formal audit, I think we are going to be

9 the formal audit or we are going to be shaping

10 the formal audit.

11 MEMBER VLIEGER: I just want to throw

12 one more piece of information to you about the

13 CEs. Many of them are attorneys, and many of

14 them are basing their decision on their legal

15 training. And so, when we use specific

16 definitions in what they are supposed to do, many

17 of them are going to adhere strictly to the legal

18 definition, irregardless of what the Procedure

19 Manual says.

20 CHAIR SOKAS: Right. Right, right,

21 right. That's very interesting. Well, again,

22 hopefully, if we get the full charts, we will be
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1 able to see some of that. So, that would be very

2 helpful.

3 Carrie, can you move that down to the

4 next page, page 7 of 7?

5 MEMBER MARKOWITZ: And while she is

6 doing that -- Steve Markowitz -- can I just make

7 a comment?

8 So, the CE, then, is looking at

9 conflicting evidence and making a decision with

10 or without the help of her supervisor or his

11 supervisor. And DOL is asking for help on,

12 presumably, training the CE and supervisor in

13 this. But we are not sending him to medical

14 school --

15 CHAIR SOKAS: Right.

16 MEMBER MARKOWITZ: -- or epidemiology

17 school.

18 And I say this as a kind of a

19 rhetorical thing, but is the answer here to have

20 more of those go to a referee, to a third person

21 who is qualified to settle this dispute?

22 MEMBER VLIEGER: Are you asking about
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1 the application of the referee?

2 MEMBER MARKOWITZ: I'm asking, when

3 you have a CE who is sitting there looking at

4 what the personal provider does or says, and it

5 is sent off to the CMC. And the CMC contradicts

6 what the person's own provider says. The CE is

7 sitting there and they are inclined to accept the

8 CMC report probably, right?

9 MEMBER VLIEGER: That's correct.

10 MEMBER MARKOWITZ: That's why they

11 have CMCs. But there is some doubt. And so,

12 what DOL is saying here, "weighing conflicting

13 evidence," right, and how are they supposed to

14 make a decision? What DOL is requesting is, what

15 training resources can we inject into this to

16 help them? What I am saying is I am not sure

17 training is going to do it. Is the answer for

18 that case to go to a referee physician, so

19 that --

20 CHAIR SOKAS: For an opinion.

21 MEMBER MARKOWITZ: Right.

22 MEMBER VLIEGER: Yes. However, there
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1 is some bias for the referee because it is the

2 same contractor that did the initial --

3 MEMBER MARKOWITZ: Right.

4 MEMBER VLIEGER: -- that did the CMC

5 report. And so, the referee reports that I have

6 seen seldom stray from the initial. So, I would 

7 love to see referee reports that actually go a

8 different direction, but the referee is a

9 different doctor within the same contract of the

10 Contract Medical Consultant.

11 MEMBER MARKOWITZ: Right.

12 CHAIR SOKAS: Is the Contract Medical

13 Consultant national or regional?

14 MEMBER VLIEGER: The contract is

15 vetted. It is owned by QTC at this point. And

16 that is the same people that do the VA disability

17 ratings. And so, QTC vets the doctors.

18 If you wanted to talk to Dr. Welch

19 about a particular issue that she had with one of

20 the CMC doctors, if we wanted to talk to her on

21 the side, the CE discounted her expert opinion

22 letter and, then, went with the CMC's report that
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1 was not fully rationalized or using current

2 medical science, and the claim was denied.

3 CHAIR SOKAS: Wow. That's

4 interesting.

5 MEMBER VLIEGER: And so, she did write

6 another, a five-page response to a CMC report for

7 a claim that is in the posture to deny, where she

8 refuted the CMC. She also questioned the CMC's

9 CV, whether or not the CMC was actually qualified

10 to be opining on the case at all.

11 I don't know what she looked at. I

12 don't know how she looked him up, but I saw the

13 letter. I saw the five-page letter.

14 So, is that something that you wanted

15 to bring her in on a Committee discussion and

16 have her discuss her experience? That is

17 something where you could talk to her with the

18 former Worker Program and her providing medical

19 opinion for the workers.

20 CHAIR SOKAS: Well, and the other

21 thing, I mean, I think we can probably do -- I am

22 not sure how to do that with a Subcommittee
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1 Working Group, but, for sure, when we get to our

2 next face-to-face meeting, we could pull her in

3 for that conversation.

4 I am also wondering if we could

5 explicitly request to see the number of cases

6 that go to the second review or the referee

7 rather and the number of times that it is

8 overturned, and maybe review some of those, the

9 ones on both sides, the ones that are overturned

10 and the ones that aren't.

11 So, Carrie, that is another request

12 for specific cases. Again, it would be nice to

13 have those kind of total numbers of, out of so

14 many cases evaluated every year, "X" number go

15 for this referee, require a referee, and how many

16 of those does it change the CE determination? 

17 But, also, to see a handful of those, so we can

18 look through them.

19 And, Steve, I think the bigger

20 question is, again, it is hard to almost

21 mechanize some of this stuff as opposed to trying

22 to deal with it -- oh, I don't know.
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1 Let me just go to the next question. 

2 So, the next couple were for industrial hygiene. 

3 But, then, when we get down to the last two,

4 there is a question there that I really could not

5 interpret. I think I might have just spaced out

6 on it. So, I am going to ask everybody.

7 It is generalization of prior IH and

8 CMC findings pending adjudication actions. And I

9 am just having a hard time figuring out what that

10 means.

11 Mark, how did you interpret that?

12 MEMBER GRIFFON: I had trouble with

13 that question, too, actually. I wasn't sure

14 exactly what they were trying to get at, either.

15 CHAIR SOKAS: Steve?

16 MEMBER MARKOWITZ: Yes, this is my

17 thought about that. I don't know if it is right

18 or not.

19 So, IHs and CMCs write reports, and

20 some of those reports are going to cover the

21 similar issues. And the question is, can I

22 aggregate some the finding from the CMC and IH
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1 reports and generalize from those decisions, from

2 those opinions, judgments, to use them for

3 things, other cases, presumably, so that all of

4 them don't have to be sent to IHs?

5 CHAIR SOKAS: Gotcha. I mean, I think

6 in order to even begin to answer that question,

7 we would really need to do the quality assessment

8 that we have been talking about.

9 MEMBER MARKOWITZ: Yes.

10 CHAIR SOKAS: Okay. So, I think we

11 can skip over that.

12 This last item I think is really

13 needed, and Faye has already suggested adding to

14 this. I think we could probably divvy this one

15 up and clearly be able to come up with some

16 response. So, individually, we could take our

17 own work together to respond.

18 So, Circular 1505 is the Occupational

19 Exposure Guidance Relating to Asbestos. I am

20 happy to work on that. Steve, I don't know if

21 you are interested in that, if the other team is

22 actually doing that already.
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1 MEMBER MARKOWITZ: No, it hasn't been

2 claimed yet, Rosie. So, I would be happy to work

3 with you on that.

4 CHAIR SOKAS: Okay. Terrific. So,

5 that is easy.

6 And then, the next one I think we

7 would all have concerns about. So, I would like

8 to suggest whoever is the most passionate about

9 it. This is that 1506, post-1995 Occupational

10 Toxic Exposure Guidance.

11 Faye, I am assuming you are going to

12 be interested, and Garry and Kirk. And, Mark, is

13 this something that you would be interested in as

14 well?

15 MEMBER VLIEGER: Sure.

16 MEMBER GRIFFON: Yes, sure, I can work

17 with it. I think they are very familiar with it,

18 but I can definitely work with it. And I am

19 familiar with some of those OSHA reviews that you

20 mentioned earlier, too.

21 CHAIR SOKAS: Oh, great. Okay.

22 MEMBER GRIFFON: I think I actually
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1 have those reports somewhere in my office.

2 CHAIR SOKAS: Oh, Mark, that's

3 awesome.

4 MEMBER GRIFFON: Yes. So, I can work

5 with them on that, sure.

6 CHAIR SOKAS: That's terrific.

7 And then, Faye, you had a third one

8 which was similar, which was the post-'95 hearing

9 loss. Would you be willing to kind of include

10 that in that group activity?

11 MEMBER VLIEGER: Yes, they go hand-in12 glove. There was the same rationale for both

13 Circulars.

14 CHAIR SOKAS: Okay, great.

15 So, for at least our last question, we

16 should have some nice draft responses.

17 This is a question for Carrie in terms

18 of keeping us on the straight and narrow here. 

19 When we sub-subdivide into actual getting tasks

20 done, I am assuming we can communicate with each

21 other. Like I can communicate with Steve as long

22 as I keep you in the loop?
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1 MS. RHOADS: That's right, yes.

2 CHAIR SOKAS: Okay, great.

3 So, we have got at least one task, and

4 we probably are going to need to plan for more

5 tasks, obviously. But I would like to propose

6 that we, as a group, plan to have something that

7 we are happy with internally, and maybe can share

8 it with the others in the group or just with the

9 people directly working on it?

10 Carrie, for example, if the group

11 working on the post-'95 Circulars wanted to share

12 that with Steve and me, is that something we

13 could do now or would that need to wait until the

14 next meeting?

15 MS. RHOADS: No, I think you can do

16 that within the Subcommittee. Just keep the

17 DFO --

18 CHAIR SOKAS: The draft?

19 MS. RHOADS: Yes, keep the draft. 

20 Keep the DFO email included.

21 CHAIR SOKAS: So, I would like to

22 propose, then, that we set ourselves a timeline,
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1 and maybe by the end of August the individual

2 groups have a draft that we can share with the

3 other half, you know, the other groups.

4 MEMBER MARKOWITZ: Clarification,

5 Rosie? It's Steven.

6 CHAIR SOKAS: Sure.

7 MEMBER MARKOWITZ: Draft of what? 

8 What are you --

9 CHAIR SOKAS: So, they are asking us

10 to do policy guidance review for these two, and

11 now we are going to make three, Circulars. 

12 Basically, we might say, "Oh, this is great as

13 is," although it is unlikely, or "We find this

14 Circular to have the following problems and we

15 would recommend changing it to the following

16 language." And maybe give the reasons why and

17 cite information.

18 But I think what we should propose to

19 give back to DOL is a review, kind of a written

20 review of what we find in those Circulars and

21 what we think might be an improvement. Does that

22 make sense?
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1 MEMBER MARKOWITZ: Sure.

2 CHAIR SOKAS: And then, for the other

3 things --

4 MEMBER GRIFFON: Pardon me, Rosie. 

5 Just one subtle thing here. I think that we, as

6 a Subcommittee, putting together some findings

7 and possible motion for the Board as a whole to

8 consider --

9 CHAIR SOKAS: Right, right.

10 MEMBER GRIFFON: Because this Board is

11 making recommendations; the Subcommittee is not

12 making recommendations directly to the

13 Department.

14 CHAIR SOKAS: Thank you. That's a

15 really good point. Thank you, Mark.

16 MEMBER MARKOWITZ: But let me just

17 offer a friendly amendment not to bring a motion

18 to the full Board because I think these same

19 topics, there are going to be other members of

20 the Board who are going to want to weigh-in. So,

21 I think it would be better to portray these as

22 discussion pieces --
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1 CHAIR SOKAS: Okay.

2 MEMBER MARKOWITZ: -- for further

3 discussion.

4 CHAIR SOKAS: Okay, good.

5 MEMBER GRIFFON: Right, and then,

6 maybe it can be made into a motion at the Board

7 meeting.

8 CHAIR SOKAS: At the Board meeting,

9 right, if everybody is onboard with it. Good.

10 MEMBER GRIFFON: Yes.

11 CHAIR SOKAS: Okay. So, the other

12 questions, we can go through. One of the

13 questions was -- and, Mark, you are going to

14 think about this because you are sort of flying

15 solo on this right now in terms of the questions

16 targeting industrial hygiene, you know, the

17 quality measures and all of that.

18 Before you get into any of that, there

19 were requests for information that Carrie is

20 going to get about current procedures for quality

21 improvement or any forms they have to complete

22 regarding quality improvement.
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1 And then, I think both for that piece

2 of it and for these other issues about whether we

3 can do presumptive diagnoses, which we are going

4 to look favorably on trying to do that, but we

5 need the information, Faye it sounds like stands

6 as the source of information on that, but, again,

7 we kind of want to know what the major ones are

8 from the DOL perspective.

9 The same thing for the matrix of

10 consequential illnesses, we will get the list of

11 the main questions that pop up or the main claims

12 that are made and what the concern areas are.

13 I think we are not responding yet on

14 this clarification of medical opinion or

15 rationalization, and all of that, just because,

16 well, I think our question is right now some of

17 this may be language-related; some of it may be

18 more than that, but what is the status of the

19 Department's internal occupational medicine,

20 occupational physician capabilities, right? So,

21 who are they using and do they have somebody who

22 is in charge of that at this point? That is more
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1 of a question than anything, but we can certainly

2 ponder it in the future, but it is not going to

3 be an easy answer.

4 The next question, oh, here we go. 

5 This is where I am going to talk George into

6 doing it. The source of information for

7 synergistic effect between -- so, I am going to

8 suggest that all of us look to see, spend maybe

9 an hour or two kind of looking around to see if

10 we have any good examples of sources of

11 synergistic radiation and chemical effects. All

12 right. So, that will be on all of us. We will

13 just report back at our next face-to-face

14 meeting.

15 It probably wouldn't hurt to have a

16 little opportunity to touch base before the large

17 meeting, but I am wondering if we could actually

18 do that in the face-to-face meeting.

19 Steve, what are you looking at in

20 terms of the agenda for that next meeting?

21 MEMBER MARKOWITZ: I am not looking at

22 anything yet.
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1 CHAIR SOKAS: Because, again,

2 realistically, I mean, are we going to get

3 something scheduled for us in August? Probably

4 not. Does it make sense to try to do it in

5 September? I'm not so sure.

6 MEMBER MARKOWITZ: Are you talking

7 about a telephone meeting?

8 CHAIR SOKAS: I am talking about a

9 telephone meeting. It took us from April to

10 today to get one that we could all make, and

11 then, it turned out one of us couldn't make it

12 afterwards.

13 MEMBER MARKOWITZ: Right, right.

14 CHAIR SOKAS: So, I am not optimistic

15 about being able to schedule a realistic other

16 telephone meeting.

17 MEMBER MARKOWITZ: This is Steven

18 Markowitz.

19 Actually, the other three

20 Subcommittees I think are meeting by phone.

21 CHAIR SOKAS: That's because they are

22 the only good ones. And I'm willing to try it if
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1 others on the phone really feel that it would be

2 necessary or helpful. I think it would be

3 helpful for us to get together as a group, but I

4 think we could do it for 30 minutes during coffee

5 at the next meeting.

6 MEMBER MARKOWITZ: But the question

7 is, well, listen, we could try to find a

8 telephone meeting time and, then, if we fail, we

9 fail. If we succeed, we succeed.

10 The question is whether we have

11 something we want to achieve by having another

12 phone call like this. And if there is something

13 we think we can achieve, then let's try. And if

14 it fails, then we will resort to something else.

15 CHAIR SOKAS: So, my question, I

16 guess, to all of us was this business about are

17 we going to be able to help them figure out

18 synergistic effects, right? Do we need to do

19 something on that before the face-to-face meeting

20 because we are probably not going to do that?

21 MEMBER VLIEGER: This is Faye.

22 There were a number of studies done,
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1 and I would have to go and look and see if they

2 are up-to-date or not, but I thought IARC had

3 done a large study of synergistic effects of

4 radiation, radioactive materials, and chemicals. 

5 If I can find those links, I will forward it to

6 you. It has got to be on one of my computers. 

7 But there was a large database done, large

8 studies, and they may not be completely up-to9 date. Or they may be did they roll through them

10 to update kind of like they do with other

11 programs? But I thought IARC was the one that

12 had done that. Let me see if I can find them.

13 CHAIR SOKAS: Okay. I think that is

14 wonderful, Faye. I think that is probably the

15 best thing I have heard so far.

16 And I was thinking that if each of us

17 dedicated a small amount of time to trying to

18 find -- you know, if that answers the question,

19 then we don't need to go further. But if each of

20 us wanted to take on trying to find sources of

21 information, preferably peer-reviewed sources of

22 information, that might be useful. But the
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1 question is whether we need to try to pull that

2 together again before the October meeting.

3 MEMBER MARKOWITZ: This is Steve

4 Markowitz.

5 My personal view is not that we don't

6 need to, but that is not a time-dependent

7 request. Frankly, I think that request is also

8 outside of the purview of the entire Board, but,

9 you know --

10 CHAIR SOKAS: Okay.

11 MEMBER MARKOWITZ: -- we're eager to

12 help. That's fine.

13 CHAIR SOKAS: Okay.

14 MEMBER MARKOWITZ: I want to bring

15 something back to an earlier part of the

16 discussion. We talked about looking at a certain

17 number of claims.

18 CHAIR SOKAS: Right.

19 MEMBER MARKOWITZ: And the question

20 is, at the end of this meeting right now, are we

21 going to submit a request to DOL for "X" number

22 of claims where we get to see the IH medical
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1 report and the data?

2 CHAIR SOKAS: Right. So, this is a

3 request for Carrie. We talked about it a little

4 bit, but you're right, we need to formalize it.

5 And, Steve, it kind of depends. I am

6 assuming you want to do this as well. So, it

7 looks like we have six members of the Committee,

8 right, you know, including George?

9 MEMBER MARKOWITZ: Right, right.

10 CHAIR SOKAS: So, I would like to

11 propose to Carrie -- and again, this is going to

12 take some legwork within the Department to figure

13 out what all the possibilities are for doing

14 this -- but we would like to have five records

15 apiece. So, there would be a total of 30 records

16 that we would individually be responsible for

17 reviewing, but, then, would want to be able to

18 have access to the other, to the total 30.

19 So that we could actually have a

20 conversation where I could say, "Oh, I think this

21 was a problem in these three." And then, Mark

22 could say, "Oh, wait a minute. Let me take a
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1 look at that because maybe you missed something,"

2 right? Or, "Yes, I've seen the same thing in two

3 others," right? And then, Faye could say, "Yes,

4 and we have got this third thing going on here."

5 So, we could all make use of the

6 original 30. That would, then, help us inform

7 what we really thought we needed to look at for

8 quality assurance, and maybe then somebody else

9 could do it, right? There could be a subcontract

10 where people could look at X, Y, and Z.

11 But we need to do that amount first to

12 really understand it. So, the question is going

13 to be, can we get 30 charts? Can we get trained

14 on how to look through those charts? Are we okay

15 with access without compromising -- you know what

16 I mean? So, do we have to be able to get onto a

17 secure site, all of that stuff?

18 I think the goal would be to have that

19 happen and to have us be able to look at those

20 charts between now and October. It is one of

21 those things where I think it is going to be

22 challenging to have the conversation. I think it
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1 is a Working Group conversation, but that is

2 going to be challenging to have that public

3 because, obviously, this is going to be the most

4 sensitive stuff, right? I mean, this is

5 personal, this might be personal information.

6 MS. RHOADS: Can I just ask, are you

7 asking or would you be asking the program to look

8 at the entire case file or certain pieces of it?

9 CHAIR SOKAS: So, we are looking for

10 cases that have been referred both to an IH and

11 to a CMC, I think. Correct? Anybody else jump

12 in here if I'm overstating this. And we would

13 like the entire case file.

14 But we would like to see what the CE

15 had available to them, what they sent forward to

16 the IH, what happened. In fact, if a couple of

17 these -- maybe these could be ones that actually

18 had to go for -- I mean, I don't want to skew it

19 entirely, but a subset of these could actually be

20 ones that had to go for a referee.

21 So, we are looking for the more

22 complicated cases that had to go someplace, and
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1 we would like to be able to review both the IH

2 and the CMC on all of them, and then, maybe a

3 second opinion on some of them or a referee on

4 some of them.

5 So, we are going to need to access to

6 these. I am sure these charts are huge and with

7 a lot of scanned information into them. And I

8 don't know; I mean, I am assuming there is a

9 secure website that we would be able to get

10 permission to access these particular charts

11 rather than somebody redacting everything and

12 sending us hard copies. I mean, I doubt that

13 that is going to be -- so, however DOL can work

14 that out and what we would need to do in order to

15 be able to access that information. But we want

16 all of us to be able to have done that.

17 That I think actually might be a

18 useful reason to have a phone call, Steve, now

19 that I think about it. I don't know how anybody

20 else feels. But if we could get that done -- I

21 don't know if that is going to work out by the

22 end of August, I mean, again, how challenging it
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1 is going to be to actually get access to it. But

2 if we could have that done by August, then we

3 could certainly have a September phone call. Or

4 we could meet, again, for an hour at Oak Ridge.

5 And, Steve, I think the only challenge

6 for that would be your participation in all these

7 different groups. But in a lot of these meetings

8 it is useful sometimes to have time set aside for

9 the Working Groups to have a little bit of face10 to-face time.

11 MEMBER MARKOWITZ: Carrie, do you know

12 when the Advisory Board meets whether the rules

13 permit us to meet in Subcommittees, spend part of

14 the time meeting in Subcommittees? I say that

15 because, you know, obviously, that is probably

16 impossible to work remote public access.

17 CHAIR SOKAS: Right.

18 MS. RHOADS: Yes, if you want to have

19 Subcommittee meetings along with the main

20 Committee meeting, we would have to publish that

21 fact in The Federal Register.

22 MEMBER MARKOWITZ: Right, but, then,
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1 not just publish it, but, then --

2 MS. RHOADS: Right.

3 MEMBER MARKOWITZ: -- provide the

4 technical access to Work Groups.

5 MS. RHOADS: Right, right.

6 MEMBER MARKOWITZ: Yes.

7 CHAIR SOKAS: Well, and I think that

8 it has got to be a question raised about when we

9 have this conversation about the chart audits

10 that we are going to be conducting, do we need to

11 have an exemption to our public discussion? So,

12 we need Rob Sadler, or somebody like that, to

13 tell us about the confidentiality requirements of

14 this particular task.

15 MS. RHOADS: Right. I'm writing that

16 down.

17 MEMBER MARKOWITZ: In the other

18 Subcommittees, two of them have requested claims. 

19 The assumption has been that it would be redacted

20 of all identifying information. And DOL hasn't

21 told us that they can't do it or it takes forever

22 to do it.
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1 CHAIR SOKAS: Okay. All right. If

2 they can redact it, then it might not be an

3 issue.

4 MEMBER GRIFFON: But, Rosie, also, on

5 the other Board, the Radiation Board, I chaired

6 the Dose Reconstruction Subcommittee for about 10

7 years and we discussed in public meetings those

8 individual dose reconstruction cases, the

9 findings, the specifics. I mean, you know, we

10 just had to be very cognizant of not discussing

11 any identifiers.

12 CHAIR SOKAS: Okay. Okay. So, you

13 could like just not use maybe even --

14 MEMBER GRIFFON: It could be and has

15 been done, is what I am saying I guess, yes.

16 CHAIR SOKAS: Okay. Okay. I mean, I

17 am sure DOL is going to pay attention to the

18 confidentiality stuff. So, if they can handle

19 that from their end, that would make life easier

20 for us.

21 Okay. Anything else that we didn't

22 cover? Anything else that we need to ask Carrie
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1 for?

2 MEMBER GRIFFON: Can I ask you a

3 question, Rosie? You mentioned this informal

4 audit report.

5 CHAIR SOKAS: Well, the informal audit

6 report, we have got it in our -- I think it was

7 one of the things you had to use like an ID code

8 for.

9 MEMBER GRIFFON: Oh, okay. I will

10 have to look back.

11 CHAIR SOKAS: And it was dated

12 February 17th. I can't remember if it was '15 or

13 '16. But it is definitely worth reading. You

14 definitely want to go through it.

15 The problem from my perspective,

16 again, it was process, what came forward, what

17 came back. That is where some of that criticism

18 about, oh, all we wanted was an answer to this

19 question and, instead, we got this blah, blah,

20 blah, blah, blah. You know, I mean, they don't

21 say it in that -- you can sort of sense the

22 frustration from the Claims Examiner because they
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1 didn't get what they wanted from the physician.

2 But that kind of made me think, well,

3 geez, if you had an in-house physician, that

4 would be an easy translation. I mean, you know,

5 some of the stuff, as Steve said earlier, you are

6 not going to send every Claims Examiner through

7 medical school, but if you had somebody in-house

8 to answer a couple of questions like that, that

9 might be the better way to go.

10 But, anyway, it did not address

11 content of any of it. So, it was interesting. 

12 It did give you percentages by regional office of

13 the times when the CMC resulted in an acceptance

14 or a denial of the claim. And those varied quite

15 a bit by region. I mean, that was very

16 interesting.

17 So, that, in and of itself, sets up a

18 question about some of the different regional

19 stuff, which is also interesting. Say that it is

20 the same contractor. So, it is the regional

21 culture that seems to be different or maybe it is

22 the type of cases that come through in the
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1 different regions. I don't know.

2 MEMBER GRIFFON: And that was what was

3 sent to us from DOL? I will have to look back. 

4 I don't think I looked at it.

5 CHAIR SOKAS: Yes, it is one of the

6 ones you had -- Carrie, correct me if I am wrong

7 -- but I think it was one of the ones you had to

8 put in that -- she sent you a separate email with

9 an ID, you know, with like a password. So, you

10 had to enter the password in order to open it.

11 And it was definitely worth reading. 

12 It is just not enough of -- you know, it didn't

13 really have quality in it.

14 MEMBER GRIFFON: Okay.

15 CHAIR SOKAS: I mean, it was really

16 procedural, procedural quality, but not content

17 quality.

18 I think we are at our mark now, I mean

19 at our four o'clock point. I don't want to hold

20 people up.

21 Is there any other comment, item that

22 we have forgotten?
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1 Carrie, anything you need clarified

2 from us? I know we kind of threw a lot of

3 questions at you?

4 MS. RHOADS: No, not right now. I am

5 going to write them down and, then, I will send

6 you a list.

7 CHAIR SOKAS: Okay, great. Thank you

8 so much.

9 MS. RHOADS: Okay.

10 CHAIR SOKAS: Well, thank you,

11 everybody. I hope everybody has a wonderful

12 summer, and we can be in communication as long as

13 we copy Carrie.

14 MEMBER VLIEGER: And are we planning

15 on another teleconference before we meet in

16 October?

17 CHAIR SOKAS: I think it depends on

18 how fast we can get these charts.

19 MEMBER VLIEGER: Okay.

20 CHAIR SOKAS: I don't think there is

21 a point to it unless we are each able to get our

22 five charts reviewed, and then, we want to
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1 discuss them. So, you know, if that can happen

2 soon, then we will try to set up another meeting. 

3 And if it can't happen soon, then -- I mean, it

4 has to happen at least six weeks before, so that

5 we know that we can do The Federal Register

6 notice anyway. So, we will see.

7 Okay. Any other questions? Any other

8 comments?

9 (No response.)

10 All right. Thank you, everybody.

11 (Whereupon at 4:02 p.m., the

12 teleconference was adjourned.)

13

14

15

16

17

18

19

20

21

22
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A

ability 50:5

able 9:20 21:1,14 27:7

29:10 41:22 54:4

55:16 60:14 62:17

63:16 70:14 85:1

91:15 100:15 101:17

104:17 105:16,19

107:1,9,15,16 114:21

absence 37:18

absolutely 47:7 84:4

accept 86:7

acceptance 112:13

acceptances 55:13

62:19

accepted 40:21 62:20

64:2,3,8,13,13

access 16:20 35:22

55:19 60:9 104:18

105:15 107:5,10,15

108:1,16 109:4

accident 26:21 32:14

33:15

accidentally 84:1

accuracy 22:2 30:14

accurate 8:7 18:14

accurately 19:12

achieve 11:18 101:11

101:13

actions 71:20 90:8

activity 36:1 93:10

actual 30:2 45:13 93:19

add 27:19 29:10 31:18

65:2

adding 91:13

addition 29:8 84:7

additional 10:19 11:3

11:16 12:6 69:1 75:22

address 76:18 112:10

addressed 77:13

addressing 41:22

adequate 71:21

adhere 84:17

adjourned 115:12

adjudication 90:8

adjustment 34:7

administers 47:20,21

administratively 28:3

28:22

advance 7:1

advice 13:3

Advisory 1:3,20 4:8

6:15 7:16,19 9:2,11

14:7 80:1 108:12

advocates 22:7 53:9

afternoon 4:4

agenda 7:4 99:20

aggregate 90:22

agree 31:19 58:15 59:1

60:19 67:13 73:2 74:9

agreed 23:2

ahead 50:10

air 53:11

allowed 14:20,22 24:9

amendment 96:17

amount 102:17 105:11

analysis 71:21

analyzes 15:7

annually 44:18

answer 4:22 14:21,22

16:5 18:11,12,13 19:7

24:9 55:1 74:6 79:8

85:19 86:17 91:6 99:3

111:18 112:8

answering 53:10

answers 102:18

anybody 11:8 27:17

49:9 106:11 107:19

anymore 41:11

anytime 34:3

anyway 48:2 112:10

115:6

apiece 55:17 104:15

apologize 56:22

apples 74:14

application 86:1

applied 61:14

applies 81:22

applying 29:19 39:6

appreciate 4:16

approach 29:21 66:21

approaches 41:14

appropriate 15:3

approved 44:22 45:1

56:13 69:14

April 7:19 12:21 14:11

18:18 21:3 26:7 33:2

100:9

arbitrarily 13:17

AREA 1:6

areas 3:7 10:18 24:9

68:5 69:14 98:12

argument 48:19

asbestos 65:10 91:19

aside 108:8

asked 14:2 17:15 21:4

22:9 26:9 57:16 73:1

asking 26:12 36:11

37:14 40:14 45:13

63:6 64:19 72:4 74:8

74:10 76:12 85:11,22

86:2 95:9 106:7,7

aspect 20:21 25:9

aspects 20:20

assess 10:15 48:7 74:4

assessed 70:14

assessment 21:11

37:17 69:22 70:9 91:7

assign 11:3 12:5 68:20

assigned 13:17

Assignments 3:16

assistance 13:4

association 83:7

assuming 43:21 81:4

92:11 93:20 104:6

107:8

assumption 52:21

109:19

assumptions 49:10

assurance 54:18 105:8

asthma 65:11,13,21

68:1

attempt 71:19

attention 110:17

attorney 18:10

attorneys 84:13

attribute 71:19

audit 57:17 71:2 74:15

83:21 84:2,7,8,9,10

111:4,5

audits 109:9

augmented 46:12

August 95:1 100:3

107:22 108:2

automatically 17:6,7

18:22

available 6:6 8:15,22

25:11,14 106:15

awarded 22:6

aware 9:8 82:11

awesome 93:3

B

back 15:15 23:1 24:13

24:18 34:2 36:20

45:22 46:9 50:1 63:4

70:2 80:13 95:19

99:13 103:15 111:10

111:17 113:3

backed 29:7

background 12:18

bad 74:1

baffles 49:9

ball 37:1

bar 66:21

base 99:16

based 26:13 36:2 38:20

64:10,20 69:2 76:9

83:9,20

basically 12:5 16:11

28:9 29:19 30:11

32:12 33:4 36:5 53:21

74:21 95:12

basics 75:4

basing 84:14

basis 29:20 30:6

bat 41:9

behalf 59:22

belongs 77:18

best 102:15

better 16:11 35:20

42:10 54:13 58:19,19

73:5 96:21 112:9

beyond 19:20 43:1

bias 87:1

big 69:2

bigger 89:19

biggest 24:2 67:9

binder 33:1

bioassay 34:15,16

bit 13:18,19 36:13

39:17 40:14 47:11

61:19 63:13 65:10

104:4 108:9 112:15

blackboard 71:12

blah 111:19,19,20,20

111:20

board 1:3,20 4:9,16,20

5:20 6:15 7:19 8:2 9:3

9:6,11 10:8 11:6,8

13:11 14:4,7 37:14

38:1 44:5 50:14 52:2

57:12 58:2 73:4 80:1

96:7,10,18,20 97:6,8

103:8 108:12 110:5,5

Board's 4:13 6:7,13,19

7:16 8:15 9:1

boilerplate 21:7

bold 13:4

bonus 30:9

books 30:12

bottom 13:5 32:7

bouncing 47:11

bound 35:16

box 24:10

boxes 70:14

break 6:4

breathing 53:11

bring 25:6 31:3 48:16

88:15 96:17 103:14

brings 25:1

broad 14:16 37:21

54:11 63:7

building 23:6

bullet 64:22 79:14

bullets 37:7,8 61:11

bunch 37:7

bureaucratic 72:9

business 101:16

C

C-O-N-T-E-N-T-S 3:1
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calculations 58:6

calendar 8:16

call 3:3,3,3 4:7,21 11:16

11:20 18:5 23:18

101:12 107:18 108:3

call-in 7:15

called 16:14,16 23:4,6

calls 42:16

capabilities 98:20

capability 43:2

capacity 9:4

carefully 66:1

Carrie 2:5 3:4 4:6 9:15

12:7 28:8,12 29:9

31:21 32:17 35:19

43:8 44:2 55:14 61:1

61:7 62:14 68:22

75:15 76:17 79:20

81:7,8 85:3 89:11

93:17 94:10 97:19

104:3,11 108:11

110:22 113:6 114:1

114:13

case 3:7 34:19 86:18

88:10 106:8,13

cases 16:14 40:21 44:4

57:11,17 59:10,18

60:9 89:5,12,14 91:3

106:10,22 110:8

112:22

categories 64:21

causation 61:17

cause 15:12

caused 23:2

CCOP 81:15

CE 15:15,15,19 19:15

19:19,21 20:11 21:21

22:22 23:20 24:12,12

24:16 38:17 39:10

44:20,21 46:3,10,14

46:15 47:4,19 52:17

75:18 80:19 81:22

82:9 85:8,12 86:3,6

87:21 89:16 106:14

CE's 17:8

Center 47:20

central 29:21 30:18

certain 18:11 23:2 34:8

35:1 103:16 106:8

certainly 11:1 12:9

22:15 42:4 53:22

79:14 99:1 108:3

certified 8:13

CEs 22:18 38:14 39:15

42:22 48:6 49:4 84:13

Chair 1:14,20,20 3:6,14

3:17 5:2,4,19 8:14

9:14,15 12:2 13:1,8

17:2 18:20 19:4 21:10

22:14 24:6 25:5,10,18

26:2,15 27:2 29:8

31:17,20 32:22 35:6

35:18 36:12 37:8 40:2

40:13,17 42:12,19

43:4,7 44:12 45:9,12

46:7,18 47:6 50:1

53:19 55:4 57:13 58:9

58:22 59:12 60:6,20

65:3,12,20 66:9,18

67:4,16,21 69:10,18

73:19 74:9,13 76:16

77:16,19 78:3,9 79:3

79:21 80:5,14 81:3,8

82:5,16 84:20 85:15

86:20 87:12 88:3,20

90:15 91:5,10 92:4,21

93:2,6,14 94:2,18,21

95:6,9 96:2,9,14 97:1

97:4,8,11 100:1,8,14

100:21 101:15 102:13

103:10,13,18 104:2

104:10 106:9 108:17

109:7 110:1,12,16

111:5,11 113:5,15

114:7,10,17,20

chaired 110:5

chalk 71:12

challenge 63:17 70:13

108:5

challenges 10:10

challenging 55:20

105:22 106:2 107:22

chance 60:2

change 29:21 31:11,12

89:16

changed 39:17 53:2

changing 95:15

channeled 24:8

characteristics 56:1

charge 3:5 98:22

chart 56:16 109:9

charter 52:1

charts 55:16,16,19 56:3

59:4 75:10 84:22

105:13,14,20 107:6

107:10 114:18,22

checking 56:16

chemical 20:4 23:2,4,5

23:7,14 35:10 39:1

48:10 99:11

chemical-radiologic

78:18

chemicals 15:8,12

48:11 102:4

chime-in 73:18

choose 34:20

CIH 51:6

circle 70:4

Circular 26:14 27:5

32:19 91:18 95:14

Circulars 93:13 94:11

95:11,20

cite 95:17

claim 15:20 16:6 17:13

17:16 32:13 38:17

64:10 82:13 88:2,7

112:14

claimant 2:1 16:17,19

17:4,8,9,10 18:4 19:1

20:8 21:20 22:11

49:14

claimant-friendly 65:16

66:22

claimants 10:20 17:8

65:19 67:19

claimed 15:4 16:7 92:2

claims 14:14,22 15:4

17:19 24:4 25:3 39:7

39:11 40:22 42:21

43:11,13,13 44:19

46:5,13 47:2,3 48:7

54:11,20 59:20 60:2

67:15 69:7,7,17,19

75:18 98:11 103:17

103:22 109:18 111:22

112:6

clarification 24:14,19

70:8 77:1 95:4 98:14

clarification/recomm...

69:21 73:21

clarified 114:1

classically 15:8 17:12

clause 83:6

clean 31:14

clear 10:1 27:14,21

30:2 70:18 75:6,7,17

80:16,20

clearly 8:4 30:5 91:15

clicking 6:20

clinician 78:5

closed 60:11

closer 38:8

clue 59:18

CMC 1:5 4:10,11 9:12

13:2 14:13,17 16:3,12

16:15 17:5,11,20

18:15 24:12,13,15,17

24:18 45:16 52:16,17

52:18 54:9 74:2 77:3

81:15 82:3,21 83:1,5

83:10,20,22 86:5,5,8

87:4,20 88:6,8,9 90:8

90:22 106:11 107:2

112:13

CMC's 87:22 88:8

CMCs 10:21 24:21

53:16 81:17 86:11

90:19

code 111:7

coffee 101:4

cognizant 110:10

collect 44:17,18

collecting 41:15

come 38:19 49:19 54:4

62:1 64:11 68:10,11

79:14 91:15 112:22

comes 48:9,15 64:6

coming 44:19

comment 7:14 11:13

25:20 85:7 113:21

comments 6:6 11:9

36:14 115:8

Committee 25:6 28:16

30:21 41:19 52:2

68:19 77:14,15 78:13

81:2,17 88:15 104:7

108:20

Committees 78:20

common 76:4,9

communicate 93:20,21

communication 71:8,9

72:22 73:5 75:1

114:12

communications 70:10

72:10

COMMUNITY 1:17,19

2:1

complaints 71:3 74:15

complete 54:1 97:21

completely 48:18 102:8

complicated 51:13,14

106:22

comprehensive 38:2

44:15

compromising 105:15

computer 56:22

computerized 70:19

computers 102:6

concern 30:13 46:15

55:12 62:9 66:1,3

68:11 98:12

concerned 63:2,14

concerns 46:2 61:18

64:15 92:7

conclusion 70:3

condition 15:4

conducting 109:10

conference 4:7

confidentiality 109:13

110:18

conflict 50:17

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conflicting 80:10,18

81:20 82:2 85:9 86:12

conflicts 51:1

connection 75:7

consecutive 66:13

consequential 64:1,9

68:8,12 69:8 98:10

consider 96:8

considered 73:14

consistency 10:3 39:5

52:4 54:8 55:2 57:9,9

consistent 51:22 52:5

constraints 41:18

construct 53:22

construction 34:13,16

Consultant 4:12 15:22

87:10,13

consultants 50:15

consulting 10:5

contains 6:22

contaminants 19:20

content 13:16 21:12

84:5 112:11 113:16

continually 33:9

continue 9:9

contract 4:11 13:2

15:22 22:4,5 30:9

34:5 87:9,10,12,14

contracted 76:8 77:22

contractor 58:3 87:2

112:20

contractors 29:5

contracts 30:5,6

contradicts 86:5

contribution 67:20

convene 9:10

conversation 60:11

89:3 104:20 105:22

106:1 109:9

convert 52:8

cook 30:12

COPD 23:2,9,12,13

26:11 65:11

copies 6:5 107:12

copy 17:5 21:20 114:13

correct 86:9 106:11

113:6

correctly 19:11 34:12

correlating 31:7

count 43:10

countering 33:7

country 55:10

couple 22:20 59:4 63:8

90:2 106:16 112:8

course 39:18 50:12

56:1 62:9

court 37:2

cover 23:21 90:20

110:22

covered 24:1 27:22

28:2

CPWR 41:14

credible 71:20

criteria 35:8,14 61:13

65:18 66:8 74:2,3

criticism 111:17

culture 112:21

curious 50:9

current 54:18 77:7 88:1

97:20

currently 26:11 62:10

72:17 77:9

cut 61:3

CV 88:9

D

D 2:2

D.C 14:10

d.htm 6:15

dad 76:15

data 33:15 37:19 43:5

44:17 49:11,12,15,17

49:21 51:19 52:13,18

52:20,22 53:12,20,21

76:22 104:1

database 20:6 38:19

102:7

date 6:20 102:9

dated 111:11

day 8:18 28:1 78:11

days 8:16 9:1 23:17

deal 89:22

dealing 78:2

decades 39:20

December 22:9

decide 54:2 82:10

decided 28:21 31:9

deciding 30:18

decision 16:16,16

17:18 18:2 32:11

52:14 84:14 85:9

86:14

decisional 16:21

decisions 53:16 74:4,6

91:1

dedicated 6:21 102:17

deficiencies 84:4

definitely 48:19 92:18

111:13,14 113:11

definition 37:15 84:18

definitions 71:17 84:16

degree 49:2

delete 77:20

denial 56:15 112:14

denials 43:20 55:9,12

62:19 73:9,14

denied 40:22 56:14

59:11 62:20 64:8

69:13 88:2

Denver 53:9

deny 17:18 18:2 88:7

Department 1:1 4:8

15:6 16:15,18 17:21

22:7 28:2,6,9,21 29:1

29:3 32:4,8,10,16,18

33:8 35:21 49:13,18

53:7 76:4,7,12 79:18

96:13 104:12

Department's 98:19

depending 4:4 20:1

depends 66:7,20 104:5

114:17

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illness 30:7,14 64:3

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instructions 3:3 7:4

instrument 23:19,21

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majority 14:7

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36:17,22 43:10 44:14

46:21 56:6,22 57:20

61:11 80:11 90:11

92:12 93:2 96:15

97:13 104:21 113:18

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21:8 25:8,15,21 46:1

46:11 51:12,16 53:14

54:5 65:1,4,5,15 66:5

66:10,19 67:13,17

69:4,16 73:17,20

74:12 77:11,17,21

78:8 79:1,19 80:3,12

80:22 81:6,10 82:15

85:5,6,16 86:2,10,21

87:3,11 90:16 91:9

92:1 95:4,7 96:1,16

97:2 99:21 100:6,13

100:17,18 101:6

103:3,4,11,14,19

104:9 108:11,22

109:3,6,17

material 6:22

materials 6:5 7:2 9:3

102:4

matrix 20:1,4 25:3 64:1

68:8 98:9

matter 75:1,5

mean 21:10 25:11 29:5

29:10 30:16 34:1,18

37:20 39:21 42:2,5

43:18 44:1,12,14

47:11 52:14 53:3

55:15,21 56:10,19

57:5,7,10,14 58:10

60:7,10 61:19 62:22

65:8,17,22 67:4,18

68:1,9 69:4,17,19

71:22 72:15 74:12

75:2,6 78:9 79:5 82:5

83:9 88:21 91:5 100:2

105:16 106:4,18

107:8,12,22 110:9,16

111:20 112:4,15

113:15,18 115:3

meaning 73:22

means 53:4 71:15

90:10

meant 75:12

measures 97:17

mechanisms 55:6 77:5

mechanize 89:21

medical 1:19 3:13 4:12

10:15 12:10,17 15:22

24:3 40:9 47:7 49:4

60:16 61:8,14 69:22

70:9,10 72:9 77:14

80:9,9,17,17 81:1,18

82:11,14 85:13 87:10

87:12 88:2,18 98:14

103:22 112:7

medicine 98:19

meet 6:1 108:4,13

114:15

meeting 1:8 4:8,14,17

6:3,5,9,20,21 7:1,20

8:1,6,14 9:8,9,10 11:6

11:6,15,16,21,21 12:4

12:6,22 14:10 18:18

22:7 26:7 28:16 33:2

41:13 53:8 71:6 89:2

94:14 97:7,8 99:14,17

99:18,20 100:7,9,16

100:20 101:5,8,19

103:2,20 108:14,20

115:2

meetings 6:8 7:21 28:9

108:7,19 110:7

meets 35:1 108:12

Melissa 5:21

MEMBER 5:7,9,11,13

5:18 11:11 14:6 17:12

19:2,5,18 20:16 21:2

21:8 22:3,16 24:7

25:8,15,19,21 26:4,16

27:20 28:19 31:4,6,19

32:3 33:6,20,22 34:1

35:7 37:3,9 40:12,16

42:2,13,20 43:6 45:3

45:11 46:1,11,20

47:10 49:8,22 50:8,9

50:11 51:12,15,16

52:11 53:14 54:5 57:4

57:14,20 58:1,15 59:6

59:7,13 60:19 65:1,4

65:15 66:5,10,19

67:13,17 69:4,16

73:17,20 74:12 76:2

77:11,17,21 78:8 79:1

79:16 80:2,12,22 81:6

81:10 82:8,15 84:11

85:5,16,22 86:2,9,10

86:21,22 87:3,4,11,14

88:5 90:12,16 91:9

92:1,15,16,22 93:4,11

95:4,7 96:1,4,10,16

97:2,5,10 99:21 100:6

100:13,17 101:6,21

103:3,11,14,19 104:9

108:11,22 109:3,6,17

110:4,14 111:2,9

113:2,14 114:14,19

members 1:16 4:17,20

5:5 7:12 9:3,5,19 10:8

13:11 96:19 104:7

memo 28:10,14 29:4,6

29:7,11 31:1,7,15,16

31:22 32:5,9,12,17,18

33:2,3,5,7 70:21,22

memory 81:10

memos 28:8 29:2 33:9

mention 61:15

mentioned 63:13 92:20

111:3

mentions 47:18,19

met 1:13

metal 20:14 22:22 23:3

23:5,6 31:12 38:21

methodologies 76:21

mid-October 11:15

middle 23:22 34:4

miles 60:1

mind 27:14 61:7

minute 30:9 70:1

104:22

minutes 7:22 8:12,14

8:19 28:18 101:4

missed 56:11 77:7

105:1

missing 26:17

mode 70:6

model 58:2

moment 81:13

MONDAY 1:10

money 34:7

monitor 53:1

monitoring 33:15 37:19

49:11,12,15 52:13,18

52:22 53:12

month 55:10

monthly 44:17

months 44:14 59:10

morning 4:3

mother 76:14

motion 96:7,17 97:6

motives 71:20,22

move 13:15 60:21 68:3

68:18 85:3

moved 65:9

moving 36:16 52:7 67:1

muted 7:12

N

nail 63:8

name 4:6 5:1 8:6

narratives 37:17

narrow 40:14 93:18

national 87:13

nature 8:22 51:20

necessarily 34:11 66:7

68:17

necessary 60:17 101:2

need 10:17 11:3 12:3,6

20:17 31:6 38:5,10

39:8 41:21 45:16

49:14 54:13,15 55:1,8

55:9,18 56:8,20 58:17

60:11 61:14 67:8

70:13,17 75:18,21

91:7 94:4,13 98:5

101:18 102:19 103:1

103:6 104:4 105:11

107:5,14 109:10,12

110:22 114:1

needed 11:17 23:8

82:21 91:13 105:7

Needs 3:15

never 15:15 16:12

20:15 24:14 34:17

new 22:4,5 34:3 61:13

nice 89:12 93:16

nicely 84:3

nineties 29:12 36:3

NIOSH 35:16 50:21

58:2

non-Advisory-Board

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normal 32:15

normally 15:22 16:17
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note 4:15 7:10,13

notes 81:9

notice 9:17 11:17 12:3

115:6

number 15:3 20:20 30:7

30:11 33:13 36:1

43:10 46:5,13 54:20

55:11 58:4 59:8 61:10

66:15 69:3 89:5,7,14

101:22 103:17,21

numbered 37:6

numbers 44:5 54:4

56:17 60:22 89:13

numbers-crunching

62:22

nutshell 17:1

O

o'clock 113:19

Oak 29:14 59:22 60:4

108:4

oath 55:21

objectivity 10:2 52:3

54:8 55:2

obscure 15:6

obviously 8:21 21:22

55:19 94:5 106:3

108:15

occupational 20:9

37:19 41:7,8 91:18

92:9 98:19,20

occupations 66:15

occurrence 32:15

October 11:22 103:2

105:20 114:16

of-interest 51:1

off- 32:14

offer 96:17

office 19:10 30:18 36:8

82:13 93:1 112:12

office's 29:21

Officer 3:4 4:14

OFFICIAL 2:4

oh 20:12 40:9 47:20

76:16 89:22 92:21

93:2 95:12 99:4

104:20,22 111:9,18

okay 13:7 14:6 19:4

21:8 22:14 25:18 26:2

31:20 37:3 44:12 61:9

67:4,21 70:5 77:16,19

79:4 80:4 81:3,9 83:3

91:10 92:4,21 93:14

94:2 97:1,4,11 102:13

103:10,13 105:14

110:1,12,12,16,16,21

111:9 113:14 114:7,9

114:19 115:7

old 70:6

OMG 72:6

onboard 97:9

once 64:2 75:10

one's 71:19

one-page 12:11

ones 29:16 37:5 44:21

44:22 51:7 63:1 82:10

89:9,9,10 98:7 100:22

106:17,20 113:6,7

open 7:21 21:13 113:10

opening 67:3

operations 51:4

opine 15:10 71:9,10,10

opining 88:10

opinion 16:1,1 18:7

35:4 48:16 69:22 70:9

86:20 87:21 88:19

98:14 107:3

opinions 72:4 74:4 91:2

opportunity 99:16

opposed 89:21

optimistic 100:14

option 57:19

oranges 74:14

order 3:3 27:22 29:4

91:6 107:14 113:10

organization 30:16,17

30:20

original 33:1,2,5 105:6

originally 58:13

OSHA 29:12 35:22 36:8

92:19

ought 20:21 21:1 36:8

78:1 81:1

outcome 74:18 75:8

outside 24:10 103:8

overall 52:2 70:12

overlap 38:4

overstating 106:12

overturned 89:8,9

owned 87:15

P

P-R-O-C-E-E-D-I-N-G-S

4:1

p.m 1:14 4:2 6:2 115:11

page 3:2 6:21,22 13:2,5

13:6,6 32:20 85:4,4

pages 12:12

painters 31:10

parameters 44:9

Pardon 96:4

part 5:15 19:2 27:21

28:2 38:9 40:7 48:8

51:19 53:21 57:5

59:21 68:21 78:7,11

103:15 108:13

participate 7:17 9:20

participating 7:5,6

participation 108:6

particular 30:22 40:17

50:7 63:1 79:10 87:19

107:10 109:14

parties 22:8

partly 51:18

parts 31:14 55:5

passing 39:2

passionate 92:8

password 113:9,10

patterns 41:1

pay 110:17

peer 15:18 39:9

peer-reviewed 102:21

pending 90:8

people 10:12 12:17

14:3,7 23:18 35:12,15

41:12 48:13 49:3

50:19 51:3 57:15 64:9

67:14 68:14 69:7 70:2

71:3 82:22 83:18

87:16 94:9 105:10

113:20

percent 16:11 44:5

percentage 42:21 43:3

57:17

percentages 112:12

perfect 81:11

perfectly 68:19

performance 30:10

performed 19:9,11

performing 30:19

permission 107:10

permit 108:13

person 66:12 85:20

person's 55:22 86:6

personal 74:3 86:4

103:5 106:5,5

personnel 33:16

perspective 10:22

67:22 98:8 111:15

perspectives 11:1

phone 11:16,20 12:4,6

100:20 101:1,12

107:18 108:3

phones 7:11

phoning 9:21

physician 20:10 52:4

72:17 74:3,16 76:22

77:3 82:12 83:22

86:18 98:20 112:1,3

physicians 10:5 71:16

72:13,15,16 80:19

physicians' 54:9

pick 47:1

piece 10:14,15 47:12

61:15 63:22 84:12

98:1

pieces 18:21 96:22

106:8

pile 43:16

place 17:4 30:1 33:14

34:4 36:4 42:17 72:3

75:13 77:8 82:17,20

places 38:15

plan 11:4 84:7 94:4,6

planning 114:14

plants 60:4

plausible 83:7

play 45:7 48:9,15

please 4:22 7:7,9,13 8:3

8:6,9 9:8

plenty 13:15

plus 26:16 61:16,16

point 18:3 21:17 29:22

37:13 42:3 45:13 47:9

49:5 64:19 82:17

87:15 96:15 98:22

113:19 114:21

police 18:9

policy 50:22 95:10

ponder 99:2

pop 69:15 98:11

portray 96:21

posed 19:15

position 32:5 40:3

positions 10:4

positive 67:5 68:2

possibilities 63:6 64:5

104:13

possible 10:6 62:6 96:7

possibly 51:10

post- 31:14

post-'95 28:22 29:6

31:16 32:11,13,19

93:8 94:11

post-1995 27:5 31:8

32:5 92:9

post-exposure 28:14

posted 7:15

posting 9:17

posture 88:7

potential 10:18 22:2

39:19 83:12

practices 48:20

practitioners 49:4

precise 73:2

precisely 74:17

preferably 102:21

prepared 7:22 8:13,20

preparing 4:17

presentation 12:13,21

13:18 14:10 27:11
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presented 14:16 18:1

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presiding 1:14

presumably 85:12 91:3

presumption 52:19

53:2 65:7,8 66:21

67:2

presumptions 52:9

65:16 66:6,16

presumptive 61:13

63:10 98:3

pretty 10:1 14:9 37:20

58:5 72:22 75:20 82:7

prevent 18:21

previous 76:18

primary 64:2

printed 23:15

prior 66:13 90:7

priorities 69:2

priority 64:20 68:5

private 25:16

probably 13:8,10 44:1

48:14 56:21 62:21

68:9 70:11 74:11 83:4

86:8 88:21 91:14 94:4

99:15 100:3 101:20

102:14 108:15

problem 3:7 7:7 24:2

30:8 59:21 69:14 71:8

72:22 104:21 111:15

problematic 40:18

problems 14:12 43:21

82:3 83:21 95:14

procedural 84:3 113:16

113:16

procedurals 18:10

procedure 14:11 19:3,7

21:18 42:17 48:1

84:18

procedures 38:11,12

39:9 42:8,15 47:14

77:8 97:20

process 14:8,17 19:16

21:19 37:14 38:15

39:4,15 40:1 43:22

48:9 50:16 52:9 54:21

58:20 72:18 111:16

produced 54:19

professionals 18:4

profound 72:22

program 10:12,16

12:14 14:2 16:10 22:8

27:4,22 34:4,16 44:7

49:17 61:13 63:19

71:14 76:10 88:18

106:7

programs 102:11

promise 64:16

proper 37:17

proportion 43:11

propose 94:5,22 95:18

104:11

protocols 48:20

provide 22:1 32:6 34:15

41:22 49:14 62:17

64:17 109:3

provided 7:3 9:4 20:22

26:7 53:3,4

provider 86:4,6

provides 19:21

providing 71:3 88:18

public 6:6 7:14,16,21

9:6 25:4,14,17 38:11

106:2 108:16 109:11

110:7

publications 83:14

publicly 9:7

publicly-available 6:22

publish 7:2 108:20

109:1

published 8:18

publishing 8:20

PubMed 79:8

pull 12:11 13:11 20:2

23:22 67:10 70:2 89:2

103:1

pure 15:7,9,12

purview 78:7 103:8

put 12:12 26:11 33:14

34:3 63:4 113:8

puts 15:1

putting 36:7 53:8 96:6

Q

QA/QC 39:9

QTC 87:15,17

qualified 85:21 88:9

qualifies 35:2

quality 10:2 21:11,11

49:15 52:3 54:8,18

55:2 57:9 62:10 80:8

80:16 81:19 84:5 91:7

97:17,20,22 105:8

113:13,16,17

quantity 15:11 21:5

49:15

queries 32:4

question 17:2,3,9 18:11

19:6 21:11 22:15

25:12,17 26:9 27:17

40:4 41:4,6,16 50:2

51:21 52:7 53:10,15

54:6 55:1,6,15,20

56:7 57:8,10 61:9

62:2,8 63:14 73:1,10

73:13 74:7 75:11,14

77:2,2 80:6,21 82:7

83:8 89:20 90:1,4,13

90:21 91:6 93:15,17

98:16 99:1,4 101:6,10

101:15 102:18 103:1

103:19 105:12 109:8

111:3,19 112:18

questioned 88:8

questioning 15:20

questionnaire 20:9

41:7,9 47:19,21

questions 10:16 11:9

12:13,15 14:1,14,22

15:15 16:5 19:15,19

22:6 27:3,19 36:19,20

39:13 42:4 59:16,17

61:6 63:5 64:20 72:11

76:19 78:10 82:14

83:17 97:12,13,15

98:11 112:8 114:3

115:7

quick 4:21 22:20

quite 25:2 27:21 28:20

30:8 39:17 57:16

112:14

quote 19:8,12 34:3 70:1

71:18

quote/unquote 71:2

72:1

quotes 71:13

R

radiation 50:14,14

99:11 102:4 110:5

radioactive 102:4

raise 22:15 57:2

raised 10:16 25:13 46:3

66:1 109:8

raising 57:7

ran 22:20 50:13

random 44:13

randomly 47:2

ratchets 56:1

rating 30:10

ratings 87:17

rational 71:15,20

rationale 93:12

rationalization 70:1

71:18 98:15

rationalize 71:12 72:1

rationalized 88:1

rationalizing 71:14

read 17:4 55:16 70:2

reading 19:8 111:13

113:11

ready 8:17

real 21:18 22:20 27:7

59:16 62:1 67:20 77:6

realistic 41:21 73:6

100:15

realistically 100:2

realize 71:14

really 10:11 12:13

16:19 20:17 24:2 30:4

43:4,7 53:19 59:15

60:5,18 62:15 63:5,20

64:19 66:1 67:22 68:2

74:6 81:14,16 82:16

90:4 91:7,12 96:15

101:1 105:7,12

113:13,15

reason 21:18 32:13

71:11 107:18

reasoning 74:5

reasons 56:15 62:20

95:16

recall 30:4

receive 45:21

recommend 95:15

recommendation 16:13

37:9

recommendations

37:16 41:2 42:9 75:17

96:11,12

recommended 17:18

18:2

reconstruction 110:6,8

record 8:7 34:21

recorded 35:1

recording 8:11

records 24:21 33:16

54:1,2 104:14,15

redact 56:3 110:2

redacted 44:4 45:14,19

109:19

redacting 107:11

reduced 49:1

refer 83:1,1,2,4,10

referee 16:14,15,17

85:20 86:1,18 87:1,5

87:7,8 89:6,15,15

106:20 107:3

referencing 13:9

referral 82:21

referrals 18:14

referred 106:10

referring 43:2 82:6

refers 52:17

refine 45:6

reflection 44:1

refuted 88:8

regard 67:2

regarding 37:16 38:14

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region 112:15
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regions 113:1

Register 108:21 115:5

regulation 35:17

regulations 8:16

relate 81:14

related 12:14 64:3

relates 52:1

Relating 91:19

relationships 83:13

relatively 44:3 62:16

relevant 81:16

reluctant 73:8

rely 49:20

remember 16:9 19:22

29:15 34:11 35:7,16

61:21 82:18 111:12

remind 9:2

remote 108:16

remotely 7:5,6

renal 61:21

renewing 30:6

repeat 80:11 82:7

repeated 78:12 80:21

report 15:14,16,17,21

17:10,11 21:5 24:15

24:17 27:1 35:22

45:20 46:6 53:8 73:22

74:1,2 76:3,6,7 79:19

86:8 87:5,22 88:6

99:13 104:1 111:4,6

reporting 30:7,14,15

35:8

reports 1:6 4:10 9:13

10:3,6 21:6,12 36:2

52:16 54:11,18 76:18

82:2 87:5,7 90:19,20

91:1 93:1

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34:6 35:20 36:7 43:5

44:9 47:15 53:6,21

54:14 58:14 60:22

61:12,19 62:15 68:22

69:5 73:6 89:5,11

103:7,7,21 104:3

requested 21:20 52:16

109:18

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requests 17:4 21:14

69:3,11,13,16 77:1

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require 56:3 89:15

required 27:15

requirement 35:2

requirements 33:13

35:8 109:13

research 79:9 83:14

resort 101:14

Resource 47:20

resources 80:8,15

81:16 86:15

respect 14:1

respond 91:17

responding 98:13

response 22:13 28:7,13

31:22 32:2,7 36:15

40:8 70:19 88:6 91:16

115:9

responses 24:11 93:16

responsibilities 73:3

responsible 104:16

responsive 78:1

responsiveness 76:22

rest 12:16 62:13

restrict 67:8 68:4

restrictive 66:17

resulted 112:13

resulting 78:19

return 46:10

revamping 41:7

review 3:3,5,11,13 12:8

12:10 15:18 21:12

22:1 36:18 38:6 57:11

57:15,22 58:4 61:15

76:9 89:6,8 95:10,19

95:20 107:1

reviewed 73:10 114:22

reviewing 39:10 58:5

73:14 104:17

reviews 13:2 19:9 37:10

39:10 40:21 80:9,17

81:18 92:19

rhetorical 85:19

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5:5,8,10,12,14,19

12:20 13:7 28:15

32:21 36:9 44:7 45:5

79:22 80:4 94:1,15,19

106:6 108:18 109:2,5

109:15 114:4,9

rid 41:10

Ridge 29:14 60:1,4

108:4

right 12:2,2,9 13:14

19:4 21:8 23:8,22

25:18 26:15 27:18

33:22 36:16 40:6 41:8

41:9 42:11,12 43:6

44:14 45:20 46:11,21

47:7,8 49:22,22,22

50:8 51:12,15 55:8

56:4,11 57:2,13 59:6

59:6 61:11 63:4 65:9

66:5,18 67:16 68:1

69:10,18,18 70:7,20

71:11 74:21 78:3,8,9

82:15,22 83:11 84:20

84:20,20,21 85:15

86:8,13,21 87:3,11

90:17 94:1 96:9,9

97:5,9,15 98:16,20

99:12 100:13,13

101:18 103:18,20

104:2,4,8,9,9 105:2,3

105:9 106:4 108:17

108:22 109:2,5,5,15

110:1 114:4 115:10

Rob 109:12

role 72:14

roll 3:3 4:21 102:9

room 5:22

Rosemary 1:14,20 3:6

3:13,16 5:2

Rosie 11:11 17:3 37:4

39:22 55:4 58:22 65:1

77:11 92:2 95:5 96:4

110:4 111:3

routine 63:3

routinely 17:22 18:2

rule 28:22

rules 108:12

run 50:18 80:7

running 34:5

S

Sadler 109:12

safer 34:10

safety 29:22 37:19

48:19

sample 54:11 55:8

samples 34:15 45:18

sampling 43:12 57:11

saw 37:5 41:4 88:12,13

saying 16:6 38:20 46:7

46:12,19 53:17 86:12

86:16 110:15

says 13:2,5 14:18 19:8

20:12 34:17 48:10,11

49:13,19 84:19 86:4,6

SC&A 57:21

scanned 107:7

scenarios 40:18

scenes 58:21

schedule 100:15

scheduled 6:1 7:14

100:3

scheduling 6:3

school 85:14,17 112:7

Schroeder 5:21

science 29:7 88:2

scientific 1:17 83:7

scientists 74:20

scope 11:9

screen 6:11 28:17 70:3

80:13

Screening 76:10

script 47:22 48:1,3,4

search 19:16 20:20

79:9,9,15

searched 83:14

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SEC 34:13

second 33:3 63:22 89:6

107:3

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security 56:2

see 6:20 8:12 12:17

16:22 17:17 18:18

21:6 23:9 24:10 26:8

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47:4,22 49:6 56:8

59:3,14,19 64:12

75:16 76:15 81:14

85:1 87:7 89:5,17

99:8,9 102:1,12

103:22 106:14 115:6

seen 18:1,17 20:15

22:12 24:14 38:12

52:15 60:3 61:20 65:6

76:1 87:6 105:2

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23:8 25:6,12,17 38:19

48:9 83:12

send 23:10,12 28:6

36:10 45:6 112:6

114:5

sending 22:18 85:13

107:12

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100:4 111:21

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20:5 23:1 26:12 79:17

79:22 80:2 86:5 91:4

106:15 113:3,8

separate 25:2 113:8

September 100:5 108:3

series 29:13 44:4 78:10

session 7:10,14

set 20:6 65:17 66:10,16

66:21 94:22 108:8

115:2

sets 20:11 112:17

settle 85:21

seven 26:17 36:21
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shape 58:14

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share 71:1 94:7,11 95:2

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38:21

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showing 24:19

side 38:9 40:1 50:14

58:2 65:18,19 69:8,8

87:21

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significant 39:1

similar 90:21 93:8

simpler 52:10

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105:17

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situation 33:11

six 11:17 36:21 104:7

115:4

six-week 12:3

size 55:8

skew 106:18

skip 78:6 91:11

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102:17

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3:16 5:2,4 9:13,15

12:2 13:1,8 17:2

18:20 19:4 21:10

22:14 24:6 25:5,10,18

26:2,15 27:2 29:8

31:17,20 32:22 35:6

35:18 36:12 37:8 40:2

40:13,17 42:12,19

43:4,7 44:12 45:9,12

46:7,18 47:6 50:1

53:19 55:4 57:13 58:9

58:22 59:12 60:6,20

65:3,12,20 66:9,18

67:4,16,21 69:10,18

73:19 74:9,13 76:16

77:16,19 78:3,9 79:3

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81:3,8 82:5,16 84:20

85:15 86:20 87:12

88:3,20 90:15 91:5,10

92:4,21 93:2,6,14

94:2,18,21 95:6,9

96:2,9,14 97:1,4,8,11

100:1,8,14,21 101:15

102:13 103:10,13,18

104:2,10 106:9

108:17 109:7 110:1

110:12,16 111:5,11

113:5,15 114:7,10,17

114:20

sole 20:7

solo 97:15

solvent- 66:11

solvents 31:12 66:14

somebody 41:5 57:21

72:19,20 98:21 105:8

107:11 109:12 112:7

someone's 30:9

someplace 33:4 106:22

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50:11 80:11,12

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43:16 45:3,16 50:18

57:17 58:20 61:10

72:8 75:4 97:14

111:21

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sources 78:16 79:7

99:10 102:20,21

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special 9:5

specific 20:18 35:8

36:19 43:22 44:9,10

54:12 59:17 60:22

61:22 63:15,19 66:4

84:15 89:12

specifically 12:14

17:14 22:10 56:10

66:20

specificity 62:3

specifics 110:9

spectrum 14:16

speed 21:22

spend 99:8 108:13

spirit 68:16

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72:13,15,16,17

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stakeholders 10:11,19

standard 16:10

standardization 37:10

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73:7

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start 8:5 41:22 45:5

starting 61:6

state 8:6 15:9,12 17:19

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states 1:1 27:21

stating 32:12

status 29:19 98:18

statute 27:21

step 21:19 58:11

steps 3:16 11:19

Steve 11:12 25:5 41:4

43:8 46:1,8,20 56:6

57:6 63:12 65:4 80:11

81:4 85:6 89:19 90:15

91:20 93:21 94:12

99:19 103:3 104:5

107:18 108:5 112:5

Steven 1:20 5:17 19:5

54:5 69:5 73:17 77:12

95:5 100:17

stinted 20:2

stop 29:5

stopped 26:13 48:18

straight 93:18

straightforward 44:3

62:17 75:12

stray 87:6

strayed 76:6

strengthen 29:2

strictly 19:14 84:17

studies 101:22 102:8

study 102:3

stuff 29:20 31:11 40:9

42:18 57:22 60:16

62:5 75:1,16 84:2

89:21 105:17 106:4

110:18 112:5,19

sub-bullets 69:1

sub-subdivide 93:19

Subcommittee 1:5,13

4:10,21 5:3,15 6:9 7:3

7:20 9:12,14 27:13

28:9 73:4 88:22 94:16

96:6,11 108:19 110:6

Subcommittee's 7:18

Subcommittees 38:4

65:7 100:20 108:13

108:14 109:18

subcontract 105:9

subject 72:1

submit 103:21

submitted 7:1

subset 106:19

substance 37:18

Substances 1:3 4:9

6:16 9:11

subtle 96:5

succeed 101:9,9

such-and-such 17:20

suddenly 48:21

sufficient 15:11 81:19

82:11

suggest 19:13 63:2

92:8 99:8

suggested 41:12 91:13

summarily 31:9

summer 114:12

supervisor 82:9 85:10

85:11,12

supporting 70:3

supports 33:4

supposed 34:15 53:7

53:10 71:1 84:16

86:13

sure 10:5 25:11,22

27:11 29:15 32:3

36:12 37:4 39:5 41:19

45:10 51:2 60:17 65:3

65:21 73:19 81:18

82:7 86:16 88:22 89:1

90:13 92:15,16 93:5

95:6 96:1 100:5 107:6

110:17

suspicions 72:4,5

sword 50:13

synergistic 78:17 99:7

99:11 101:18 102:3

T

table 54:17

take 44:8 60:7 61:5 73:3

76:19 78:14 79:13

91:16 102:20 104:12

104:22

taken 41:14 55:21

takes 21:4 109:21

talk 12:1,8 31:7 33:8

36:18 37:1 73:7 87:18

87:20 88:17 99:5

talked 34:2 103:16

104:3

talking 12:18 26:5

47:12 61:4 72:12

74:13 78:4 91:8 100:6

100:8

talks 82:20

targeting 97:16

task 9:22 27:7 52:2

72:12 94:3 109:14

tasked 54:7

tasks 3:16 11:2,4 12:5

93:19 94:5

taught 74:20
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team 91:21

teasing 68:21

technical 43:1 58:5

109:4

technically-trained

70:15

technician 23:19

technicians 23:21 24:1

31:13

teleconference 8:3

114:15 115:12

telephone 100:7,9,16

101:8

telephonically 1:13

tell 28:10 53:11,13

73:22 109:13

telling 23:20 28:20

37:13 82:22

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ten 45:18 55:16 62:4

Tennessee 60:4

term 71:22

terms 39:22 40:19

41:15 93:17 97:15

99:20

terrific 92:4 93:6

thank 9:15,19 21:9 37:3

79:21 80:4,5 96:14,15

114:7,10 115:10

thanks 9:16

thing 13:9 34:2 43:17

44:2,15 45:4 50:4

51:17 59:2 73:12

85:19 88:21 96:5 98:9

102:15 105:2,4

things 11:14 13:10

20:14 21:13,22 27:19

31:14 34:8,10 35:1

39:22 41:3 46:15

48:16 49:8 51:13

54:14 57:5 58:6 67:14

67:17 68:18 70:13

75:3 91:3 96:3 105:21

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21:2 22:3,17,18 24:2

27:6,9,11 29:12 30:21

31:6,17 32:21,22 33:5

34:12 35:18 36:7,20

37:12,21 38:3,3,22

39:8,11 40:3,5 41:9

41:11,12,17,20 42:4

42:17 44:13,15 45:14

45:16 46:20,21 47:1,6

47:19 48:8,13,17

50:21 51:5,7 54:16

56:11,19 57:4,14

58:11,13,16 59:1,4,8

59:14,15,20 60:8,13

60:21 61:4,8,20 62:6

62:15,16 63:9,15 64:3

64:15 65:10,12 67:1,6

67:6,8,22 68:7,9,13

68:17 69:5,12 70:9,12

70:21 71:5,7,10 72:6

72:19 73:6 74:7,9,10

74:13 75:3,20 79:8,13

80:10 82:4 83:11,17

84:8 88:21 89:19 90:5

91:5,10,12,14 92:6,17

92:22 94:15 95:18,21

96:5,18,21 97:14 98:1

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101:2,4,13 102:13,14

103:7 104:20 105:18

105:21,22 106:11

107:17,19 108:5

109:7 111:6 112:2

113:4,7,18 114:17,20

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third 85:20 93:7 105:4

thought 41:3 42:5

65:13,20 75:12,15

78:3 80:20 90:17

102:2,11 105:7

threads 70:11

three 12:15 15:5 35:12

44:14 59:10 64:6,12

67:9 68:9 95:11

100:19 104:21

threw 114:2

throw 84:11

tie 30:9

time 1:14 4:4,16 6:2

16:22 17:17 26:18

31:5 38:18 39:17 40:6

41:17 51:11 57:16

60:10 61:16 68:10

90:9 101:8 102:17

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timeframe 35:11

timeline 94:22

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112:13

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to-face 108:10

today 4:18 5:16 6:2

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23:17 34:22 35:4

60:22 68:21 100:10

today's 4:7,14 6:20,21

7:4 8:1,14 11:9

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top 13:1 61:6 62:18

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topic 28:20 29:11

topics 96:19

total 89:13 104:15,18

touch 99:16

toxic 1:3 4:9 6:15 9:11

29:2 31:16 32:13

37:18 48:20,21 74:17

92:10

toxin 31:8 61:16 83:8

toxins 15:3,6

track 36:13

trained 105:13

training 50:3 80:8,15

81:16,17 84:15 85:12

86:15,17

transcriber 8:4,9

transcript 5:1 7:22

transcripts 8:21,22

translation 75:2 112:4

transparency 21:17

transparent 51:2

treating 77:3 78:4 83:22

trichloroethylene 61:22

65:22

trigger 73:15

triggers 70:5 73:8

trouble 14:4 75:13

90:12

true 18:19 30:20 47:7

53:18 54:12 65:20

68:7 71:21

try 36:3,6 63:20 64:4

79:3 100:4,22 101:7

101:13 103:1 115:2

trying 10:1 29:15 80:13

81:22 89:21 90:14

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turn 9:13 13:20 36:8,17

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turned 63:9 100:11

turns 21:21 49:13,18

two 6:3 12:11 15:5 18:4

23:17,18 48:16 55:5

62:4 68:18 72:1 90:3

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109:18

type 16:22 48:11 69:17

112:22

typo 72:14

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U.S 53:6 79:17

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37:8 59:12 66:9

ultimately 55:1 58:3

unclear 82:6

unconscious 71:22

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understand 8:4 17:21

38:7,10 42:10 51:6

54:20 60:5 105:12

UNITED 1:1

universe 63:6 64:17

68:17

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up-to-date 102:2

update 102:10

upstream 74:11

use 14:13 20:6 31:13

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verbatim 8:20 78:12

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versus 62:3,4,4

vets 87:17

vetted 87:15

view 21:17 103:5

viewing 7:10

visited 6:18

visits 29:13 36:2

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10:8 14:6,8 17:12

19:2,18 21:2 22:3

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82:8 84:11 85:22 86:9

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Neal R. Gross and Co., Inc.

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98:7 101:11 103:14

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107:15 108:18 111:14

113:19 114:22

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39:6 40:4 52:22 53:22

60:5,8 68:3 70:18

72:7 73:1 78:1 112:9

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we're 103:11

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week 22:21

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willing 93:9 100:22

winnows 15:5

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wonder 73:9

wonderful 102:14

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35:9 38:21 52:14

76:10 88:18

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workers' 33:11

working 89:1 94:9,11

106:1 108:9

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113:11

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write 88:5 90:19 114:5

writing 45:5 109:15

written 6:6 10:3 29:1

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wrong 20:13 113:6

wrote 22:4 29:4 33:9

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X

X 39:1 44:5 48:10,10

89:14 103:21 105:10

Y

Y 105:10

year 44:10 62:21 67:11

89:14

years 26:17,18 49:1

50:20 62:4,4 66:13

110:7

Z

Z 105:10

zone 4:5

0

1

10 12:15 26:18 40:22

66:13 68:12 110:6

11 26:18

11th 68:13

12th 68:13

13 3:7

15 111:12

1505 91:18

1506 92:9

16 111:13

17th 111:12

18 1:10

1990 34:14 66:13

1995 26:13 28:4,13 33:8

2

2:00 1:14 6:1

2:02 4:2

20 59:9

2005 26:19

2012 26:11

2016 1:10

217 70:22

217-15 70:21

217-16 70:22

26th 7:20

28th 7:20 12:21

3

30 9:1 101:4 104:15,18

105:6,13

37 3:11

4

4 1:6 3:3

4:00 6:2

4:02 115:11

5

50 16:11

50-percent 16:8

50/50 63:16

500 60:1

58 3:13

6

6 13:5,6

7

7 13:5,6 85:4,4

77 26:10

8

84 34:13

88 3:15

9

9 3:5

90 8:15

90th 8:18

91 3:16

95 31:15 48:16,22

98 36:5

98-99 29:12

99 36:5
NEAL R. GROSS

COURT REPORTERS AND TRANSCRIBERS 

1323 RHODE ISLAND AVE., N.W. 

(202) 234-4433 WASHINGTON, D.C. 20005-3701 www.nealrgross.com 

C E R T I F I C A T E

This is to certify that the foregoing transcript 

In the matter of: 

Before: 

Date: 

Place: 

was duly recorded and accurately transcribed under 

my direction; further, that said transcript is a 

true and accurate record of the proceedings. 

 

 ----------------------- Court Reporter 

129

Subcommittee on IH and CMC

and Their Reports (Area # 4)

Toxic Substances and Worker Health Adv. Bd.

07-18-16

teleconference