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U.S. DEPARTMENT OF LABOR

+ + + + +

ADVISORY BOARD ON TOXIC SUBSTANCES 

AND WORKER HEALTH

+ + + + +

MEETING

+ + + + +

WEDNESDAY

APRIL 15, 2020

+ + + + +

The Board met telephonically at 11:00 

a.m. Eastern Daylight Time, Steven Markowitz, 

Chair, presiding.

MEMBERS

SCIENTIFIC COMMUNITY

JOHN M. DEMENT

GEORGE FRIEDMAN-JIMENEZ

MAREK MIKULSKI

KENNETH Z. SILVER

MEDICAL COMMUNITY

MANIJEH BERENJI

ROSE GOLDMAN

STEVEN MARKOWITZ

CARRIE A. REDLICH
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CLAIMANT COMMUNITY 

KIRK D. DOMINA

RON MAHS

DURONDA M. POPE

CALIN TEBAY

DESIGNATED FEDERAL OFFICIAL

MICHAEL CHANCE
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CONTENTS

Welcome/Introductions ......................... 4

Review of Agenda ............................. 23

Status of Recommendations

Solicitation of Nominations .................. 24

DEEOIC Updates: Program Highlights

Changes in DEEOIC, Procedure Manual

New Bulletins........................... 27

DEEOIC Response to Issues, Jan. 28, 2020 meeting

SEM issues raised by Dr. Redlich

PM Exhibit 18-1 smoking language

Timeline and quality control 

 provisions of new CMC contract

Quality control language of existing 

 IH contract........................... 65

Proposed Recommendation: Parkinson's

and Related Diseases ........................ 101

Adding IARC 2A Carcinogens to SEM,

Evaluation of other IOM sources ............. 136

Status of DOL Requests to Board

B Reading, Provider Outreach........... 171

Public Comment Period ....................... 193

Occupational Health Questionnaire Revision .. 205

Wrap-Up ..................................... 268
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P-R-O-C-E-E-D-I-N-G-S

11:11 a.m.

MR. CHANCE: Good morning everyone. 

My name is Michael Chance and I would like to 

welcome you to today's teleconference virtual 

meeting of the Department of Labor Advisory Board 

on Toxic Substances and Worker Health. I am the 

Board Designated Federal Officer, or the DFO. I 

-- I think obvious to everyone today, as you are 

aware, this meeting will be completely virtual as 

a precaution against the COVID-19 pandemic.

I am joined virtually by Carrie Rhoads 

from DOL and Kevin Bird from SIDEM. He is our 

contractor. And I want to welcome everybody. I 

want to tell everyone that we appreciate the work 

that the Board members have put in preparing for 

today's meeting, and for the upcoming 

deliberations today and tomorrow. We are 

scheduled to meet today. We -- again, at 11:00. 

We are slated to 5:00 Eastern Time with the 

public comment period to commence at 3:30. As we 

began this morning, I think that you will see 
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that there have already been a few growing pains 

on protocol and how we proceed. So just bear 

with us and be patient as we try to get through 

the first of this type of meeting. And we will 

try to help anybody who has any kind of technical 

difficulty. You can reach out to Kevin or Carrie 

as we move forward. I want to make sure that 

everybody is heard, so just bear with us.

Regarding the operations of today's 

meeting, again, I believe that you have all seen 

the agenda. Today is a lengthy proceeding. So 

there are breaks that are set up already in the -

- in the meeting. But if -- you know, as -- as 

Dr. Markowitz proceeds forward, as he feels that 

there is a break in the flow and people need a 

break, we can certainly be liberal with that.

I wanted to let everyone know that 

copies of all meeting materials and the written 

public comments are -- are -- or will be 

available on the Board's website under the 

heading Meetings and the listing there for the 

committee meetings. So the documents will also 
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be up on the Webex screen, I believe. So 

everyone can follow along with the discussion. 

The Board's website can be found at 

DOL.gov/OWCP/Energy/regs/compliance/board.htm. 

If you haven't already visited the Board's 

website, I strongly encourage you to do so. 

After looking on today's meeting date, you'll see 

a page dedicated entirely to this meeting. The 

web page contains publically available materials 

submitted to us in advance of the meeting.

We did obtain a few things late --

late last evening. So bear with us. I believe 

that everything should be up on the site. We 

will publish any materials that are provided to 

the committee. There are -- there you should 

also find today's agenda, as well as instructions 

for participating remotely. If you're having a 

problem, as I said, you can email the Energy 

Advisory Board at dol.gov, or just reach out to 

Kevin or Carrie, or just -- if you're having --

having a problem, this is -- this is kind of 

uncharted territory.
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If you're joining by Webex, please 

note that the session is for viewing only and 

will not be interactive. The phones will be 

muted for all non-Advisory Board members. Please 

note that this is a new way of conducting these 

meetings and we ask you to be patient as we work 

out any old and new technological issues. As I 

said, you may contact Ms. Rhoads or Mr. Bird for 

technical assistance throughout this meeting if 

needed.

About meeting transcripts and minutes 

-- the transcript and minutes will be prepared 

from today's meeting. During Board discussions 

today, as we are on a teleconference line and all 

-- everyone is remote, please speak clearly 

enough for the transcriber to understand. When 

you begin speaking -- especially at the start of 

this meeting -- please state your name so we can 

get an accurate record of this discussion and 

attribute to the proper speaker. Also, I'd like 

to ask our transcriber to please let us know if 

you're having an issue with hearing anyone or 
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with the recording.

As the DFO, I see that the minutes are 

prepared and ensure that they're certified by the 

Chair. The minutes of today's meeting will be 

available on the Board's website no later than 90 

calendar days from today per FACA regulations. 

But if available sooner, they will be published. 

Also, although formal minutes will be prepared, 

we will also be publishing verbatim transcripts 

which are, obviously, more detailed in nature. 

Those transcripts should be available on the 

Board's website within 30 days.

I would like to remind the Advisory 

Board Members, there are some materials that have 

been provided to you in your capacity as special 

government employees and members of the Board 

which are not for public disclosure and cannot be 

shared or discussed publically, including in this 

meeting. Particularly, as you are aware, we will 

have the public on later on -- this afternoon. 

So please be circumspect. Please be aware of 

this as we are continuing with the meeting today. 
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These meetings can be discussed in a general way 

which does not include using any personal 

identifiable information such as names, 

addresses, specific facilities if a case is being 

discussed, or a doctor's name.

On top of my usual opening statement, 

I was asked to reiterate a discussion that I --

took place with on April the 2nd of this year 

with Dr. Markowitz and Douglas Pennington, who is 

the Deputy of the Energy Program. I'd like to 

spend a moment discussing an issue that was 

raised in the last meeting. This is my second 

one, and I remember it being raised in the last 

meeting, and that was on April 2nd. And that 

discussion was primarily regarding resource 

allocations and requests for resources. I 

believe that Dr. Markowitz wanted me to just kind 

of go over that quickly so that everybody 

understands what was said in that meeting and --

and where we are with regard to resources so that 

-- that at least that has been -- that loop has 

been closed and everybody is aware that we have 
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gone ahead and -- and done that.

We discussed at length the matter of 

resources and outlined some of the challenges 

that must be overcome. Just briefly, I outlined 

the conversation as thus. I mean, depending on 

the specifics of what the Board is envisioning --

and currently, I think as everyone knows with the 

COVID pandemic, there are a great deal of --

there's a great deal of competition -- probably 

more heated than ever for -- for vital government 

resources.

The Board -- and it would be incumbent 

upon the Board, as a full body -- would need to 

determine what the mission would be of -- of this 

-- of this -- of these resources that are -- that 

are desired. There would be a need to ascertain 

those -- the proper tasks. Obtain hourly rates 

of contractors from the general -- General

Services Administration Schedule, based on job 

titles. And the Board would need to estimate the 

workload needed for any -- any contractor that --

that you envision that would be needed.
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The Board must determine what 

resources it needed by a labor class category. 

It would need to design a comprehensive statement 

of work outlining all required duties and tasks. 

I -- I want to -- I cannot stress enough, the 

contracting process is extremely complex. I am 

not a contract law expert -- specifics in 

requirements are -- are necessary to be able to 

bring any contract vehicle online. All 

requirements would need to be -- would need to be 

met for each request.

Another issue that was raised by Mr. 

Pennington is a good point. If any -- any 

potential to create records that would devolve 

out of a contracting group -- a group of 

contractors evaluating data -- this might require 

some sort of federal system of record. So 

there's more to it than just the contract.

The budget for FY 2022 is being 

discussed within the next few months. Usually, 

those submissions are put forward in the fall. 

2021 formulations are already complete. I know 
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that Dr. Markowitz asked a bit about that. It 

would be very -- I mean, very, very difficult to 

get (telephonic interference) in for 2021. Even 

if it could be requested, as I said, it is not 

likely to be granted given the current situation 

-- budget under COVID-19 pandemic crisis. 

Everything that (telephonic interference) be. 

And there is a huge crunch on all government 

resources. So -- you know, just to outline that. 

It would be something that -- that would be, 

again, incumbent upon the Board to develop a 

working business case to demonstrate the need for 

funds. And be able to demonstrate a compelling 

reason to go forward when such funds are already 

in great demand for high priority matters 

throughout the entire government -- outside of 

the Department of Labor. So it -- it is a -- it 

is a big challenge.

And so I wanted to -- I hope that I --

I hit all of the high points of the discussion 

that Doug and I had with Dr. Markowitz. And --

so that everyone knows that that -- that was 
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done. And that those considerations have been 

evaluated and communicated back to Dr. Markowitz. 

So -- with that, I apologize for the long 

monologue, but I needed to get through all of 

that. And with nothing else on my list, I now 

convene the meeting of the Advisory Board on 

Toxic Substances and Worker Health and turn over 

the microphone to Dr. Markowitz. Thank you.

CHAIR MARKOWITZ: Thank you, Mr. 

Chance, for that welcome. I would like to 

welcome Board members back for -- to this board 

meeting. Welcome also to the leaders of the staff 

of the Department of Labor, members of the public 

who are on the Board or are attending the meeting 

today. I know that for the Board members -- for 

all of us actually work had been dislocated, and 

I realize there's some very important competing 

priorities with today's times and tomorrow's 

times. And so we're going to try to address the 

various issues as expeditiously as we can in 

order to get through the agenda.

It may be that the public comment 
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period -- if there aren't that many people who 

want to make public comments, we may continue the 

Board meeting during that time period, however, 

to concentrate the -- our -- the time that we 

spend on this. But we'll -- we'll see. We'll 

see as that goes along. Okay, so I -- next, I'd 

like to do introductions. I think maybe if -- if 

you need to do a roll call of all the Board 

members, maybe the easiest way to do this would 

be if someone were to call on the Board members 

and they could indicate that they're present, and 

also introduce themselves. Is that suitable?

Okay. I can't hear anybody.

MR. BIRD: Carrie -- Carrie or Mike, 

do you guys want to do a roll call?

MS. REDLICH: I can start. This is 

Carrie Redlich.

(Simultaneous speaking.)

MS. REDLICH: Can everyone hear me?

CHAIR MARKOWITZ: Yes, go ahead.

MS. REDLICH: Just for the record, I 

was the very first person on the call today.
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(Laughter.)

MS. REDLICH: Yes, this is Dr. Carrie 

Redlich. I am the director of the Occupational 

and Environmental Medicine Program at Yale. Also 

a pulmonary physician and it actually will be a 

pleasure to think about something other than 

COVID and personal protective equipment and ICU 

beds. So I am looking forward to this meeting.

CHAIR MARKOWITZ: Carrie Rhoads, do 

you want to call people out?

MS. RHOADS: Sure, I can do that. Dr. 

Berenji?

MEMBER BERENJI: Yes, good morning. 

This is Mani Berenji. I am an occupational and 

environmental medicine physician, assistant 

professor at Boston University School of 

Medicine.

MS. RHOADS: Okay, Dr. Dement?

MEMBER DEMENT: John Dement, Professor 

Emeritus in the Division of Occupational and 

Environmental Medicine at Duke University Medical 

Center. I am a -- an industrial hygienist and 
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epidemiologist.

MS. RHOADS: Thank you. Mr. Domina?

MEMBER DOMINA: My name is Kirk 

Domina. I am the Employee Health Advocate for the 

Hanford Atomic Metal Trades Council in Richland, 

Washington. We currently represent about 2800 

active members. I've been out here 37 years and 

I'm a member of the United Steel Workers Union.

MS. RHOADS: Thank you. Dr. FriedmanJimenez?

MEMBER FRIEDMAN-JIMENEZ: Hello, I am 

George Friedman-Jimenez. Occupational and 

Environmental Medicine physician and 

Epidemiologist at NYU School of Medicine and 

Bellevue Hospital in New York City.

MS. RHOADS: Thank you. Dr. Goldman?

MEMBER GOLDMAN: Hello, I am Dr. Rose 

Goldman, Founding Director of Occupational and 

Environmental Medicine Program at Cambridge 

Health Alliance and is currently Director of 

Faculty Affairs here and Associate Professor of 

Medicine at Harvard Medical School and Harvard 
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School of Public Health.

MS. RHOADS: Thank you. Mr. Mahs?

MEMBER MAHS: Mahs -- Ron Mahs. I am 

a construction worker. I retired from Oak Ridge, 

have been in the trade 45 years. Representing 

the claimants and the national building trades.

MS. RHOADS: Thank you. Dr. Mikulski?

MEMBER MIKULSKI: Hello, good morning. 

This is Marek Mikulski and I am an occupational 

epidemiologist with the University of Iowa. 

Former life training was an occupational 

physician. I currently direct a former nuclear 

weapons workers medical training program for Iowa 

sites.

MS. RHOADS: Thank you. Ms. Pope?

MEMBER POPE: Good morning, Duronda 

Pope. I am with the United Steelworkers and the 

emergency response team. I am a former worker of 

Rocky Flats. Worked there 25 years.

MS. RHOADS: Thank you. Dr. Silver?

MEMBER SILVER: Ken Silver, Associate 

Professor of Environmental Health in the College 
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of Public Health at East Tennessee State 

University. And I was finishing my doctorate, 

focusing on Los Alamos historical emissions, I 

worked very closely with the Los Alamos workers 

and their families. Followed through to work pro 

bono on actual EEOICPA claims for the people out 

there. And have written and published a little 

bit on uses of historical information around the 

DOE complex.

MS. RHOADS: Thank you.

(Pause.)

MS. RHOADS: Sorry?

CHAIR MARKOWITZ: Did you call Calin 

Tebay?

MS. RHOADS: I did --

(Simultaneous speaking.)

MEMBER TEBAY: I can barely hear you.

MS. RHOADS: Oh, sorry. Okay, go 

ahead.

MEMBER TEBAY: Good morning, Calin 

Tebay, Buildings Rights and Sheet Metal Worker. 

I am the current site-wide beryllium health 
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advocate at Hanford and I am also the Hanford 

Workforce Engagement Center representative.

MS. RHOADS: Okay, thank you. All 

right, I think back to you, Dr. Markowitz.

CHAIR MARKOWITZ: Okay. Steven 

Markowitz, the -- the Director of the Barry 

Commoner Center at City University, New York,

Occupational Health physician and epidemiologist. 

I run the biggest former-worker medical 

screening program, which is suspended, now, for 

the time being. Could we have the introduction 

for the Department of Labor folks on the line? 

That would be great.

MS. RHOADS: Rachel, are you on?

MS. POND: Yes. This is Rachel Pond. 

I am the director of the program. It's formerly 

Leiton, and you'll see that the agenda says 

Leiton, but it currently is Rachel Pond. And I 

will be talking with all of you shortly.

MS. RHOADS: Is anyone else on yet? 

John or Doug?

MR. VANCE: John is here. Can 
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everyone hear me?

MS. RHOADS: Great. Yes.

MR. VANCE: Good morning, everyone. 

This is John Vance. I am the Policy Branch Chief 

for the Energy Compensation Program. I am 

looking forward to chatting with you all today.

(Simultaneous speaking.)

MR. PENNINGTON: Yes, this is Doug 

Pennington, the Deputy Director of the Energy 

Program.

MS. RHOADS: Thank you, Doug. Okay, 

that's the Department of Labor folks.

CHAIR MARKOWITZ: Okay, and any 

members of the public, if you want to volunteer 

your name, that would be great.

MR. BIRD: Dr. Markowitz -- sorry, can 

you say that again?

CHAIR MARKOWITZ: Sure. If there are 

members of the public on the phone, if they want 

to just introduce themselves by name, that would 

be great.

MR. LEWIS: Dr. Markowitz, before you 
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get the Public, this is Greg Lewis from the 

Department of Energy.

CHAIR MARKOWITZ: Oh, okay. Yes. 

Thank you Greg.

MR. BIRD: Hold on one second, Dr. 

Markowitz, I’ll just un-mute everybody.

(Pause.)

MR. BIRD: Hello, if there are any 

members of the public on the line who would like 

to introduce themselves, feel free to do that 

now.

MS. MEDINA: This is Sandie Medina 

from the Worker Health Protection Program in Las 

Vegas, Nevada.

(Simultaneous speaking.)

MS. VLIEGER: Good morning, this is 

Faye Vlieger.

(Simultaneous speaking.)

MS. BARRIE: Good morning, this is 

Terrie Barrie.

CHAIR MARKOWITZ: Okay, we heard --

this is Steven. We heard Sandie Medina, Faye 
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Vlieger, Terrie Barrie. Is there anybody else we 

didn't catch?

(Simultaneous speaking.)

MS. NELSON: This is Malcolm Nelson, 

the Ombudsman for the Energy Program.

MS. CISCO: Jeanne Cisco from the 

Portsmouth Workers Health Protection Program.

MS. QUINN: Trish Quinn with CPWR and 

the PTMed Former Worker Program.

CHAIR MARKOWITZ: Okay, that's great. 

Thank you. Thank you for attending. And I --

Kevin, I don't know. Maybe you'd want to un-mute 

the public at this point so they can say whatever 

they want while they listen in. Let me --

MR. BIRD: Dr. Markowitz -- can you 

say that again? You broke up a little bit.

CHAIR MARKOWITZ: Yes, sorry. If you 

want to un-mute -- I mean, sorry, do you want to 

mute the public?

MR. BIRD: Yes, absolutely.

CHAIR MARKOWITZ: Okay, so I want to 

review the agenda. And then we'll get back to 
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whatever Mr. Chance wants to say under the Status 

of Recommendations, Solicitation of Nominations. 

So that occurs in conjunction with the report of 

the Department of Labor Staff.

So we start off with reports, 

information, updates from Department of Labor --

both on the program overall as well as on the 

interaction with the Board. And those are listed 

in the Agenda. I will review those now. And 

then later in the morning -- or early afternoon, 

I guess, we're going to be discussing 

Parkinson's-related disorders. And after a short 

break, we will be discussing the Department's 

request to us to address -- actually, on the 

Webex you just keep going up the -- to 1:30, 

that's where I am at. Discuss the requests 

around the Board considering the status of 

certain cancer-causing agents and how they might 

be viewed in the SEM. After which we'll discuss 

-- have a discussion about the part of the 

Board's tasks that -- which is to evaluate the 

CMC, industrial hygienist performance.
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We'll discuss additional DOL requests 

to the Board around B reading, around provider 

outreach, and then have a discussion about the 

current occupational questionnaire. At 3:30 

we'll have a public comment period. We welcome 

the public to make comments. Right now on the 

website -- on our website, today's meeting, we 

have one -- a one-page comment from Ms. Vina 

Colley. And if -- if the public comment in --

before 5:00 p.m., then we're probably just going 

to continue the meeting.

Day two -- tomorrow, right now we have 

listed for 11:00 a.m. a discussion of the 

recommendation, the DOL's response -- of that 

response around site-wide job titles. We have a 

discussion about changes in the Procedure Manual 

and bulletins that are going to come out since 

the last meeting. A brief update on expanding 

asbestos job titles. We can review public 

comments. And then, we need to get into any new 

issues that arise.

So then we need to discuss -- this 
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board's term is up mid-July. Then we have, I 

think, three months to -- to finish or to 

continue our work. And what I think we ought to 

do as we go through today's meeting is -- have in 

the back of our minds what we're going to be able 

to complete within the next three months. I 

think we should have a telephone meeting the 

second two weeks of June -- the latter part of 

June -- just so we can close out any 

recommendations, and official communications we 

want to make to the Department.

And so -- so -- I hope to get as far 

as we can get on discussions today. Any items we 

can't quite close out today, we have another 

opportunity during this fourth term. Any 

questions about any of this? Or any other items 

anybody wants to add to the Agenda?

Okay, so let me turn it back to Mr. 

Chance to discuss the status of recommendations 

and solicitation accommodations.

MR. CHANCE: Thank you, Dr. Markowitz. 

The -- I am trying to pull up the document here. 
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The -- regarding the nominations -- everybody on 

the call is certainly eligible to go ahead and 

participate. I believe that I want to make sure 

that I have the date right. The open nomination 

period, everyone is eligible to re-nominate for 

the next term on May 1. So that is an ongoing 

issue that is -- is coming with regard to the --

but we -- but we are prepared to take any 

nominations that nominations that we receive and 

evaluate those and pass them forward by May 1.

The status of the latest 

recommendation on asthma, I believe, is with the 

Secretary's office for clearance and is due out 

on May the 5th. Carrie Rhoads, are you on?

Carrie, can you hear me?

MS. RHOADS: Yes, that's right. May -

- the next recommendation response is due out in 

early May. That's the one on asthma from the 

January meeting.

MR. CHANCE: Right. Are there -- is 

any outstanding issues other than that that I'm 

missing?
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MS. RHOADS: No, that was the one. 

And the rest of the recommendation responses have 

been posted on the web.

MR. CHANCE: Okay, all right. So I 

just wanted to make sure that I didn't miss 

anything. I -- you know, bear with me, Dr. 

Markowitz, I am still kind of new at this. So I 

wanted to make sure that I didn't leave anything 

out. But I believe that that's all that we would 

need to cover with -- with recommend --

outstanding recommendations and the nominations. 

Is there anything else you would like for me to 

discuss?

CHAIR MARKOWITZ: No, no. We can just 

continue -- continue on the Agenda. That's fine.

(Simultaneous speaking.)

MR. CHANCE: Okay.

CHAIR MARKOWITZ: Let's into some of 

the --

(Simultaneous speaking.)

MR. CHANCE: Thank you.

CHAIR MARKOWITZ: -- the funds -- the 
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updates? The program highlights?

MS. POND: Yes, hello everyone. I do 

want to start off by saying thank you to the 

Board members for taking time out of your 

schedules, particularly during this period of 

emergency, to be here with us and to go through 

this agenda and all the work that the Board has 

been doing for us.

Today I am going to walk through just 

some overview items. Just kind of generalities 

of what we're currently doing, our recent 

accomplishments, some items that cover COVID and 

the types of things we doing for that. A few 

other things that will just kind of give you a 

broad overview. And then after that, I am going 

to turn it over to John Vance who is going to 

cover some of the more details that are on the 

Agenda, as well as to Doug Pennington. So we 

should be able to cover all the topics this 

morning that are on the Agenda through the -- up 

until the 12:45 discussion. That -- we'll turn it 

back over to -- to Dr. Markowitz and they can 
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move on to the next topic.

Dr. Markowitz, I am going to go

through this -- the overview, and then John is 

going to talk a little bit. When you -- and then 

we'll switch it over to the 12:15, we'll try not 

to run past the 12:45. But if you need -- you 

know, if there are questions in between, you'll 

probably want to work out a mechanism for how 

people want to ask those questions. I will try 

to pause in between subjects a little bit and see 

if there are questions as I move through what I 

am talking about. And I am sure John and Doug can 

do the same.

So I am going to start out with just 

some statistics, you know, this is about our 

recents, but we've paid almost $18 billion in 

over 300,000 claims since inception of the 

program. Interestingly, now almost $6 billion of 

that is medical benefits. That's where we're 

seeing a steady increase in the last five years -

- in the amount of money that we're spending. 

Large part is due to the fact that we've -- our -
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- our population is becoming a little bit more 

elderly. There are more consequential 

conditions. There's more need for services, like 

home healthcare. So that is becoming more of 

what we're doing is optimizing medical benefits 

and ensuring people are getting the equipment 

they need, the services they need and that sort 

of thing. And that's part of the reason that 

we've -- we've talked briefly about -- we've 

centralized some of our medical bill 

authorization processes into the national office.

But I want to talk a little bit about 

recent accomplishments. We -- effective, like I 

think April 1st, we started a new case assignment 

process. It's just something that we did in the 

final adjudication branch in 2018. Basically we 

used to assign cases by jurisdiction. Meaning 

this is the last place that the employee worked 

was in a particular location, where that location 

was, they were assigned to a particular district 

office. That process was beneficial and worked 

really pretty well at the beginning of the 
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program. However, as we have evolved, we get 

more cases from one particular area, like 

Hanford, and less from some other areas like the 

AWEs and -- and the -- the Cleveland 

jurisdiction. So in light of that and in order 

to kind of even out the workload across our 

district offices, we have now moved to an 

assignment process that is a round robin across 

the country. It works pretty well for our Final 

Adjudication Branch. And so far, in the first 

couple of weeks of this, it has been working 

pretty well for our district offices.

When we made this transition, we did

do some training -- cross training across 

district offices regarding particular facility 

issues. We have place of contact in each of our 

district offices for facility issues so that if 

somebody in Jacksonville has a question about a 

Hanford facility, they can go to that POC. We 

also have reference materials. There's a lot of 

materials that have been collected over the years 

that we -- our claims staff utilizes to 
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familiarize themselves with facility issues.

So we're going to continue to monitor 

that, but I think overall it's going to assist us 

in balancing workload, in hiring across the 

country, and those sorts of things. Another 

thing that we started last year -- well we've 

always done pretty robust sampling, but we've got 

to -- more of a -- let's say consistent process 

for sampling work in that throughout the country, 

both in our final adjudication branch and our 

medical benefits examiner branches and in our --

our district offices, we have instituted each to 

provide their reviews of a certain percentage of 

the work that's randomly selected on a monthly 

basis, on the workload of the claims examiners. 

We talk about that work, make sure that they're 

aware of -- of where they're doing well, where 

they're not doing well, where there are issues 

with the cases -- things that we can fix on the 

spot.

And in conjunction with that, we also 
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started this year -- we hired some quality review 

analysts in each of our -- that work for our 

national office. And what they're doing is they 

are evaluating cases -- in addition to our -- our 

annual accountability reviews, they -- they 

produce a spreadsheet that contains a series of 

questions in each and every area of the work that 

we do. That would be development letters and 

recommended decisions and final decisions and 

ancillary medical benefits. And each one of 

those categories are being evaluated on a weekly 

basis by these accountability review analysts. 

They are looking at work -- not that was done six 

months ago, but work that was done recently. And 

this will give us a feedback that will provide 

our supervisors and our claims staff with 

immediate feedback. It will give us an idea of 

where we need to do additional training. What --

you know, if there are particular pockets of --

of subjects that we need to change our policy on. 

Those sorts of things will be a lot more 

acceptable for us to make changes to the program 
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overall where we need to as we move through the 

year.

We still are going to do our 

accountability review, which are the annual 

assessments that are conducted by a team of 

employees throughout the country. Those will 

still happen this year. They may not happen in

person, as they usually do, because of the COVID 

pandemic. But we will be doing those. So we're 

going to have a pretty robust quality review 

process in addition to what we used to do. We 

also continue to evaluate 10 percent of our 

claims after they've gone out -- or, before 

they've gone out as a result of recommendations 

that were made several years ago by the 

Government Accountability Office.

And so those all together will be put 

into spread sheets at -- by -- in 2020. For some 

of them, 2021. But the rest of them that we can

compare and contrast, we'll be able to look at 

what we -- what areas we need improvement based 

on all four of these categories. The sampling, 
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the accountability reviews, the quality review 

analysts, and the GAO audit. And we continue to 

conduct some, still hoping that this is going to 

enhance our current quality review process.

As I indicated earlier, we centralized 

our medical benefits. That is going well. It's 

probably going to have to be consistent in the 

way we respond to all of the additional home 

healthcare and ancillary medical benefits that we 

see.

I wanted to talk a little bit about 

the impact of the current pandemic and the kinds 

of things that we've been looking at. We've been 

pretty busy trying to make sure that we are able 

to maintain the safety of our claimant population 

as well as provide the benefits that they 

(telephonic interference) need. So there is 

information, FAQs, on our website that provide 

some of these details about what we have done and 

what we're moving forward in terms of flexibility 

for people that cannot leave their homes. And 

particularly considering the fact that our 
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claimant population are susceptible to this 

particular virus.

One of the things is that we're being 

a little bit more flexible on deadlines. For 

example, we have physicians that can't see 

patients -- or don't feel that the patient should 

come into the office right away, or they have to 

delay providing us information. So we are very 

flexible on those deadlines. We -- one of the 

areas that we have set up a bulletin, it's 

Bulletin 20-03, is about home healthcare. We 

have certain changes that we've made during this 

period of pandemic emergency for home healthcare.

Normally we require face-to-face 

examinations for any expiring home healthcare 

authorizations, any new requests, any requests 

for new care. During this time we are allowing 

for home healthcare extensions can be done 

through a letter of medical necessity by a 

physician if the physician feels that it would be 

unsafe for the claimant to go into the office for 

a face-to-face examination, and that's on 
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existing levels of care.

For levels of care that are greater 

than what they've already got, for the new 

requests, we are allowing for telemedicine under 

certain circumstances. Those circumstances are 

outlined in our bulletin.

One thing that we do need to account 

for in our -- in how we respond and what -- what 

information we can obtain is that the Department 

of Energy is not fully staffed right now. Not 

everybody can telework. They can't get access to 

some of the verification records that we would 

need to verify employment. Therefore, we are 

looking at -- we have to take that into 

consideration when we're developing a case until 

such time that they can provide us with that 

information, we will likely have to hold some of 

those cases.

We also are no longer doing in-person 

hearings at this time. We do have the ability to 

conduct hearings through phone calls and Webex. 

And that is where we are -- where we stand with 
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that at this time.

Resource centers are not open to the 

public at this time, but they are continuing to 

work. They are able to telework. They have 

started to answer -- you know, a couple of years 

ago or last year they started answering initial 

phone calls. They can still do that from home --

transfer calls.

We do have them coming into the office 

-- or going into a resource center once a week to 

collect and scan mail. And so we are still able 

to intake claims. We're getting weekly reports 

from them regarding how many claims we're 

getting. So it's still pretty robust in terms of 

the number of contacts we're getting and the 

number of claims that we're taking in.

The other thing is that we have -- you 

know, some doctors -- claimants need their 

medications. There are pharmacies that will 

allow mail order. Doctors are able to extend 

their prescriptions beyond sometimes 30 days --

now, you know, is up to 90 days. And that is not 
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a problem for us.

We are continuing to reach out to the 

public where we can in terms of -- calls with 

providers, email blasts. But we are not doing 

outreach right now. We had to cancel our 

outreach events for March, April, and May as a 

result of this. We hope, obviously, when this is 

all over we will go back to that and continue our 

authorized (telephonic interference) workshop 

from the town hall meetings and other outreach 

events that we believe are important to continue 

to do when we can.

We did -- we are still updating our 

training. Our basic -- our basic claims examiner 

training is being updated by a contractor with 

oversight by a federal employee. And so those 

are -- those are the big things that -- that 

we're -- well, there is one other thing I wanted 

to mention with regards to ongoing activities is 

the new medical bill -- contractor.

We have a new contractor that will be 

handling those issues effective April 27th of 
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this year. We have in -- this is an OWCP 

workers-compensation-program-wide contract, and 

so mailers are going out to all of the claimants 

for all of the divisions and to the providers to 

let them know of this change. Again, our 

conference call was provided -- will provide this 

information to them, and we have email blasts 

that people prescribe to that will have this 

information as well as other types of information 

we'll put on the website.

So before I move on to some of the 

updates on board issues, are there any questions 

about any of that?

CHAIR MARKOWITZ: This is Steven

Markowitz. I have a question. You talked about 

the various activities relating to quality 

review. -Did any of those new activities or 

renewed activities pertain to the CMC or the 

industrial hygiene evaluations?

MS. POND: No these are -- well, they 

touch on them. In terms of what they'll be 

reviewing, is the types of information that's 
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submitted to CMCs, types of information submitted 

to IHs, whether we're asking the right questions. 

We will be reviewing the responses that come 

back, but not as an audit for the CMCs or the 

IHs. These are really a review of the claims 

examiner's work.

CHAIR MARKOWITZ: Okay, thank you. 

Another question I have is the -- there's a 

transmittal document that was issued by the 

program April 3rd that summarized changes to the 

Procedure Manual. Were there any -- or maybe 

you're going to get to this. Maybe I am jumping 

the gun. But I'm just wondering if either now or 

if you -- and if you could just briefly review 

any changes that are pertinent to the kinds of 

issues that the Board gets involved in. to here

MS. POND: Yeah, I will -- and John is 

going to go through the Procedure Manual changes 

and the bulletins that have come out. So when we 

get to him, I'll have him go through those.

CHAIR MARKOWITZ: Okay, great thank 

you. Other questions?
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(Simultaneous speaking.)

MEMBER DOMINA: This is Kirk Domina. I 

have a question on -- for Rachel on Bulletin 20-

03.

MS. POND: Yeah?

MEMBER DOMINA: I guess what my 

question is -- and I understand and appreciate 

that on the letter of medical necessity that --

like on a new claimant who is trying to get 

coverage out here, specifically, in Hanford, you 

know, we have some people that are really, really 

vulnerable. And then you also have nurses that 

work in other facilities, not maybe just for a 

home health to be able to come and help with that 

evaluation.

And it's -- you know, the families are 

-- you know, people are scared. And I understand 

you guys are doing the best you can, but trying 

to, you know, let somebody into their home or 

stand six feet, or ten feet, or 20 feet away to 

do a video to try and get something approved, I 

was just wondering if there's a little more 
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leeway or something that we can do to try and 

help people.

Because, you know, it's kind of -- it 

went through the nursing homes and stuff out here 

in the Tri-Cities pretty quickly and bad. And it 

still continues. And, you know, people are just 

trying to protect their loved ones. And I am 

just trying to figure out if there's a way that 

we can do this on -- I am talking specifically on 

brand new coverage for home health.

MR. PENNINGTON: Rachel, can I speak 

to that real quick?

MS. POND: Sure.

MR. PENNINGTON: This is Doug.

MS. POND: Introduce yourself --

(Simultaneous speaking.)

Mr. PENNINGTON: This is Doug 

Pennington, the Deputy Director of the program. 

Kirk, specifically to your issue, that is kind of 

why we developed the process that we did was on a 

new request where, in essence, the doctor will be 

asking to introduce people into the claimant's 
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home on a -- up to a daily basis, all the way up 

to 24 hours a day, where you could have as many 

as 10 people coming into the home and as few as 

one on a regular basis, we felt it was necessary 

to ensure that the physician had all the tools 

necessary to adequately assess the risks of 

bringing those people into the home.

And part of that was making sure that 

the physician could conduct an examination that 

provided them all the information necessary to be 

able to truly assess the claimant's medical need 

and weigh those risks versus bringing people into 

the home on a regular basis. So by bringing in a 

trained RN, physician's assistant, or advanced 

practice nurse who have expertise in being able 

to essentially protect themselves and their 

claimant from exposure to COVID through 

appropriate protective equipment and gear, as 

well as standard medical knowledge and expertise, 

we felt that was the best way to mitigate the 

exposure risks by bringing an individual into the 

home while also assuring that we had the 
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opportunity to provide the physician with eyes, 

hands, and ears at the claimant in order to 

conduct that face-to-face examination so it's not 

just a two-dimensional person on a video screen.

That they're able to assess the vital 

signs. They're able to essentially make sure the 

claimant's physical needs are going to be 

appropriately met by the home healthcare. And 

like I said before, balance the risk of them 

bringing in home healthcare aides into the 

claimant's home during this pandemic. Does that 

answer your question?

MEMBER DOMINA: Yeah, kind of. But 

I'll think of rephrasing a few things. Thank 

you.

MS. POND: So just to follow up on 

that, I -- I -- we are constantly and 

continually, throughout this, looking at ways 

that we can be as flexible as possible. So this 

is what we have come up with and been able to 

publish bulletin on currently. And as we 

continue to look at these things, if there are 
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additional flexibilities we can make, we will 

publish additional information on it.

Okay, I am going to move on -- oh, go 

ahead. Sorry.

CHAIR MARKOWITZ: I am sorry. It's 

Steven. I just want to ask a question. Has the 

program received any claims for -- specifically 

for COVID infection or disease?

MS. POND: No, I don't believe so. 

They -- you know, it would have to be tied -- I 

think that if COVID were to come in, it would 

obviously be some sort of a consequential 

condition because of their preexisting. I am not 

aware of any. Doug or John, have you heard of 

any that we've received?

MR. VANCE: Not that I am aware of. 

This is John Vance. But, you know, with this 

program, I am sure we'll see them at some point.

MR. PENNINGTON: Yeah, this is Doug 

Pennington. We have not yet identified any 

consequential claims requests. But since they're 

not, as Rachel pointed out, not occupational, 
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somebody would have to actually tie the receipt 

of the disease specifically to the existing 

accepted condition as a consequence of it in 

order to -- for us to cover it.

CHAIR MARKOWITZ: Thank you.

MS. POND: Other questions before I 

move on? I just have a couple more things, and 

then I will turn it over to John.

Okay. So one of the -- just a couple 

updates on Board issues that I am going to 

address. Some of the other items will be 

addressed by either John or Doug. But with 

regard to the ability for IHs to speak with 

claimants, we do have a process for that already. 

It is -- we do require that the claims examiner 

be on the phone. But if an IH believes that it's 

appropriate to speak to a -- a claimant, they can 

do so. We've only had that happen once so far, 

but that ability to do that is out there.

There was a question about cases --

being available through the public portal. We --

you know, I think that the Board's original 
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request was that certain people have access to 

the case files. And we talked about the fact 

that, long term, we plan to have an ability for 

our claimants to be able to look at their case 

files directly. That is something that we still 

plan to do.

However, we needed to ask for, you 

know, resources from OMB and a budget to make 

that happen. There are some contractual -- things 

that contractors have to do with regards to our 

technology to make that happen. We're going to 

be piggybacking on some technology that's 

currently being developed for our sister program, 

the Federal Employees' Compensation program that 

we are hoping to move into place in 2021, in the 

Fiscal Year 2021.

So once we get our new budget, we do 

hope that that capability will happen in 2021. 

There are some caveats, as I said, depending on 

what resources we get, but that is our plan.

OHQ revisions, we've got -- had some 

feedback back and forth in conversations about 
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the OHQ. We are moving this into a -- a database 

format that the resource centers can complete 

easily, taking into consideration a lot of the 

recommendations that the Board has made to how we 

can change this.

I think there was a follow-up question 

from one of the Board members just last week or 

the week before that was responded to. And at 

this juncture, I think we've responded to 

everything, and we're in the midst of finalizing 

it. It's -- I noticed this was on the agenda for 

the Board to discuss during this -- the course of 

this meeting. And of course, if there are more 

recommendations for it, we will be -- we will 

take those into consideration. But we are in the 

midst of trying to move forward with a revision 

to that now.

There was also a question about data 

requests. I think there was a lung cancer claims 

data request, post-1995 data request for claims -

- post-1995 claims with industrial hygienist 

report. That requirement was clarified, also, in 
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a discussion with, I believe, Dr. Markowitz 

within the last several weeks. So we are working 

on that and hope to have that to you, 

particularly now that we have a little bit more 

of a clear plan for those two requests for data.

And then there was also a very recent 

request for development letters. We have those. 

I just looked at about ten of them. I want to 

make sure that we have what we need to -- that 

will give you a pretty good sampling. So those 

should be coming to you in a week or so. That is 

what I have before I turn it over to John. Are 

there questions about those last two items before 

I do so?

CHAIR MARKOWITZ: This is Steven. I 

have a question about the -- the interview by the 

industrial hygienist. So could you just -- I 

know it's in the Procedure Manual, which I 

haven't yet committed to memory -- could you just 

refresh our memories about how that interview is 

initiated? How it is that the program decides to 

conduct an interview?
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MS. POND: Well, it's -- there are --

there are two ways that actually it can happen. 

I think that we've had requests from a claimant 

to speak to an IH. And that is, I think, what 

we've facilitated with the claims examiner on the 

call. Please correct me if I am wrong, John or 

Doug. But -- and the alternative is an 

industrial hygienist has a case file, they 

believe that they need to have more information, 

or their discussion with the -- with the actual 

claimant would be beneficial, they -- they can 

request that. But the claims examiner will 

facilitate it. John, I don't know if you want to 

go into a little more detail about how that 

works?

MR. VANCE: Yes, I mean it -- hold on. 

Yeah, this is John Vance. Rachel is correct. So 

it's basically, you know, the initiation of this 

can be under any real circumstance where an 

industrial hygienist, either one of our 

contractors or an internal, you know, federal 

industrial hygienist has looked at a case and 
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just has determined that it really is something 

that -- that we need to talk to the claimant to 

get a better understanding of what the 

circumstances are with regard to a particular 

work activities or exposure.

And that was sort of the issue that 

came up in one case where there was some 

contention over the way that the industrial 

hygienists were characterizing as an exposure, 

and a claimant was offering a contradictory 

viewpoint on that so that we ended up having to, 

you know, talk to the claimant.

It was something that is coordinated 

and administered by the claims examiner that's 

overseeing the case, and then an industrial 

hygienist has an opportunity to ask questions 

about the circumstances where the employees work 

and their exposure. And then that information is 

recorded and incorporated into the case file. 

And then it's also reevaluated by the industrial 

hygienist to determine whether or not it in some 

way is going to modify their exposure analysis 
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output.

CHAIR MARKOWITZ: This is Steven 

again. Thank you. So how long has this been 

that these interviews have been able to be 

conducted -- when -- when -- more or less, what 

was the start date? Trying to figure out what --

what the dynamic is.

MR. VANCE: I am looking now. It was 

in our -- one of our releases for our Procedure 

Manual. So it was -- I don't have the exact 

date, but it was not in our most recent one.

MS. POND: Yes, maybe about three to 

six months. Maybe three months.

CHAIR MARKOWITZ: The -- okay, thank 

you. So has the -- the claimant community, 

whatever that consists of, has there been any 

notification that the claimants can request to 

have such an interview?

MS. POND: There isn't a formal 

notification that we sent off to all of our 

claimants. But we've got the information on the 

website. It's included in the -- I believe it 
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would be included in the changes that was -- are 

defined in the transmittal. If a -- you know, we 

do have -- claims examiners do talk to the 

claimants pretty regularly, and, you know, if --

if an issue like that comes up, then the claims 

examiner would definitely allow the -- tell them, 

you know, there is this option. But we haven't 

sent out a specific mailing or anything like 

that.

CHAIR MARKOWITZ: And how about the --

this is Steven again, just the -- I think the 

last question. So the industrial hygienists, 

whether the contractor or the in-house people, 

they're all aware that if there is some 

uncertainty they think they can resolve, they're 

able to communicate with the claims examiner or 

request an interview. Is that right?

MS. POND: Yes, yes.

CHAIR MARKOWITZ: Thank you.

MS. POND: Okay, so that's all --

(Simultaneous speaking.)

CHAIR MARKOWITZ: Any other questions 
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-- I am sorry, any other questions from Board 

members?

Okay, thanks.

MS. POND: Okay, I am going to be -- I 

will be on the phone the rest of the day today if 

there are additional questions. I will be here 

this morning, as will John. I am going to turn 

this over to John to cover some of the other 

issues with regards to changes in the Procedure 

Manual, new bulletins, SEM issues, and a couple 

of other things. So thank you all for your 

attention, and I will send this over to John for 

now.

CHAIR MARKOWITZ: Thank you.

MR. VANCE: All right, well good 

afternoon, everyone. This is John Vance again. 

It's a pleasure to get an opportunity to speak 

with everyone again. So on the agenda, I am 

going to speaking to the Procedure Manual and 

some bulletin updates. And then I think we move 

into some responses directly to the Board issues. 

So let me try to stick to the agenda. I've got 
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five minutes, apparently, to talk a little bit 

about the Procedure Manual. But if we go over, I 

think we'll just sort of play it by ear here. So 

--

(Simultaneous speaking.)

CHAIR MARKOWITZ: Well, you can have a 

little bit more time. Don't worry, John.

(Laughter.)

MR. VANCE: That's what I figured. So 

let me start by just saying, for everyone that's 

on the Board or on the call, the Department of 

Labor does maintain a huge volume of information 

about our policies and procedures online. We 

have a tremendous amount of resources available 

to allow people to understand how claims 

examiners and our appeal board goes about doing 

their day-to-day work. And our Procedure Manual 

is basically the epicenter of that policy and 

procedural guidance. So it is available online.

And I also want to encourage folks to 

sign up for our program or policy updates. There 

is a link on our main page that talks to email 
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notifications on updates because we do update our 

procedure manual fairly frequently. And that 

email will just alert you to when changes have 

occurred. We also update our website with 

notifications on our program highlights when we 

have updates or changes to the policy. So I just 

wanted to make a plug for those two things.

With regard to the process of 

Procedure Manual editing, again, this is a claims 

examiner and -- you, know process guide. It's 

for staff. It's directed to staff, but it helps 

the public understand sort of how staff go about 

doing their work in conjunction with the 

evaluation of claims. So it's a very important 

document. And we take input from staff, from, 

you know, stakeholders, from the Advisory Board, 

in how we modify our -- our procedural guidance.

And I also want to say our procedural 

guidance is framed within the context of the law 

and our regulation. So this is just merely 

guidance as to how we best can administer, you 

know, our legal requirements for adjudicating 
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cases.

So we do issue publications that --

that encompass the entire Procedure Manual. If 

we have interim updates that we want to make 

based on either a very specific change, or a 

expedited issue, we will issue interim bulletins. 

And so what I am going to do is talk a little 

bit about some of the more recent things that 

have been going on and cover our most recent 

release that went out on March 31st.

So let me just start by going to our -

- our March 31st release. So we had a major 

update to our Procedure Manual. It went from 

Version 4.0 to 4.1. For the most part, I think 

it -- it represented a lot of administrative and 

technical updates. But we did have some 

important changes.

We incorporated a bulletin -- there 

had been an interim bulletin that had updated 

some guidance from Version 4.0. We have replaced 

an instruction about who was responsible to 

process and adjudicate medical benefit claims. 
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That has now been centralized into a medical 

benefit adjudication unit. So we had put out a 

bulletin explaining that change. That bulletin 

was subsequently incorporated into the official 

Procedure Manual as part of this 4.1 release.

The update also included changes in 

guidance that we had to incorporate into the 

Procedure Manual about reporting to the National 

Instant Criminal Background Check System 

instances or evidence, or we have information 

that relates to people that could be potentially 

prohibited from purchasing or obtaining firearms. 

This would be like us receiving information 

regarding someone who has recently been -- you 

know, imprisoned as part of a, you know, a 

felony. So that -- that was a requirement that 

we had to update. And that has gone into our 

Procedure Manual.

We had updated guidance relating to 

the centralization of our customer service 

interactions with the resource centers. So we 

had provided some guidance with regard to how 
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phone calls are handled by the resource centers. 

We had -- this is something specific that the --

to the Board, we have updated our Exhibit 15-4, 

which speaks primarily to the presumptive 

standards that -- that the program applies in 

adjudicating Part E cases. We had the addition 

of two new presumptive standards relating to nonHodgkin's lymphoma. That has actually been 

released as part of a bulletin, Bulletin 02-02. 

So that was an interim update to Version 4.0, and 

we merely formalized it into the -- into the 

Procedure Manual as part of this 4.1 release.

The -- the big change that did occur 

for 4.1 was the elimination of recommended 

decision cover letters. This again is sort of 

like something that originates from staff where 

we look at comments and feedback that we receive

from staff and stakeholders with regard to 

changes to our process.

We received a lot of feedback saying 

that our cover letters were redundant and not 

very helpful, and that it was something that a 
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lot of folks deemed as unnecessary because the 

decision itself provides a lot of relevant 

information about the nature of the decision and 

what's -- what's going on. It also already 

identifies the people that are involved in the 

decision.

So we made a determination that the 

cover letter was really unnecessary for 

recommended decisions. So we've removed that 

from our process, and now we won't be going -- or 

have gone to a process where we will be sending 

all the parties to a decision just a copy of the 

decision itself, along with any relevant 

attachments.

We also simplified our waiver process. 

We have gone to a single waiver, versus the two 

different types that existed prior to the release 

of Version 4.1. So hopefully that will simply 

the process, will get rid of some of the 

confusion that people were having with regard to 

our waiver that was a bifurcated waiver between 

people that wanted to agree to part or all of a -
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- a particular recommended decision. And that 

again was feedback that we'd received from the 

District Office and also from a claimant about 

the confusion about our waiver process.

We also had updated guidance regarding 

reimbursement for costs for eyewear. We have 

also memorialized guidance regarding medical 

marijuana. We have basically stipulated that it 

is still a federally controlled substance and we 

as a federal agency cannot accept it as having 

any kind of medical value. So it's not a 

reimbursable medical benefit.

So those are the big changes that went 

into the last edition of our Procedure Manual. 

We are currently working on the next version, 

which is going to encapsulate the changes that 

Rachel mentioned with regard to our transition to 

a new medical bill processing contractor. So 

we're hoping to get that out as close to April 

27th as we possibly can.

So, as I mentioned, we have 

incorporated two bulletins into this last release 
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of the Procedure Manual. Our other bulletin that 

was issued recently was our telemedicine bulletin 

that just talks about the increased flexibilities 

that the program has released with regard to how 

we will allow certain telemedicine interactions 

to occur. And, you know, as Rachel mentioned, 

we're continuing to look at that. That's 

something that we will be continuing to revise 

based on input from stakeholders and our own 

internal experience in trying to administer, you 

know, that policy.

So that is the -- that is the -- the 

update I have for policies and procedures. And 

again, for folks that are -- that are online or 

on the call, just remember, all of our policies 

and procedures are available through our website. 

We actually also archive prior editions. So if 

you do want to do any kind of review of prior 

versions of our Procedure Manual, it's all 

available through our public reading room link. 

So please avail yourself of those -- those 

options and links.
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CHAIR MARKOWITZ: Thank you. Were 

there any questions for Mr. Vance?

Okay. Anything else, Mr. Vance, you 

want to discuss?

MR. VANCE: Not on the policies and 

procedures. We can move on with the agenda.

MS. POND: I think that -- okay, 

sorry. I think that we're going to -- John can 

continue but -- so, yes, there's another section, 

so I'll let you move forward with that.

CHAIR MARKOWITZ: Okay, I think we're 

going to come back to Mr. Chance's notification 

about our request for resources, but we can do 

that at the end of the next session, so I guess 

you all can continue.

MR. VANCE: All right, well, that's 

what I was waiting for. I was waiting for Dr. 

Markowitz to give me permission to continue.

So, I'm going to move on into the 

agenda for the next item which is talking about 

some of the responses to issues that have been 

raised since the last meeting. 
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So, we do get lots of input from the 

Board that’s not really encompassing into formal 

recommendations, so we do want to try to be 

responsive to, you know, all of the concerns that 

are raised. 

And we have received some input with 

regard to the Site Exposure Matrix and some other 

issues with regard to the application of policy 

by Dr. Redlich, and so I just had some quick 

comments that I wanted to make in response to 

those concerns. 

And I think it can be something that 

maybe the Board would want to continue to discuss 

if there are continuing concerns, but it has to 

do primarily with the way that we present 

information in the Site Exposure Matrices with 

regard to pulmonary disease, and so let me just 

sort of walk through my notes.

So, I think the concern had been about 

how COPD is listed in the Site Exposure Matrices 

and, you know, for those of us that are very 

familiar with the Site Exposure Matrices, it 
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provides information about known medical 

conditions that have a connection to toxic 

substance exposure.

And so our Site Exposure Matrices 

lists out conditions that are basically known to 

science to be somehow associated with exposure to 

particular toxins, and so we do have chronic 

obstructive pulmonary disease listed in the Site 

Exposure Matrices. It's listed under pulmonary 

disease, chronic obstructive. 

It has multiple aliases, so that means 

that we would look for COPD or any of the 

conditions that are known to be an alias in our 

research of those toxins that an employee may 

have encountered during their work because that's 

critical in evaluating the causative relationship 

between an exposure and development of that 

disease.

So, we do have COPD listed in the Site 

Exposure Matrices to avoid any confusion about 

that, and there are multiple aliases for it, 

chronic bronchitis, emphysema, and just the 
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acronym COPD.

Then what I think has raised some 

concern and I just wanted to speak to it, is that 

the Site Exposure Matrices doesn't apply separate 

determinations that the program makes with regard 

to the application of procedural guidance with 

regard to how to do certain things with some of 

the conditions.

So, the Site Exposure Matrices doesn't 

speak to this, but we do have instruction to our 

staff that talks about the use of how to go about 

evaluating clients for interstitial lung disease 

and pulmonary fibrosis. 

So, we have specific procedural 

guidance that instructs our staff that when 

they're looking at a claim for interstitial lung 

disease or pulmonary fibrosis, they're then to go 

to the Site Exposure Matrices and use 

pneumoconiosis, other as the health effect for 

those two conditions.

So, this is not something that you 

would see or communicate -- it wouldn't be 
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communicated in the Site Exposure Matrices. This 

is merely procedural instruction that staff are 

to adhere to when they're evaluating cases for 

interstitial lung disease or pulmonary fibrosis.

And a similar situation exists for 

individuals that are identified as having an 

idiopathic pulmonary fibrosis. This was an issue 

that had come up some time ago where physicians 

would identify a condition like pulmonary 

fibrosis or lung fibrosis as idiopathic, which 

just means of unknown origin. 

We clarified in our procedure that a 

claims examiner is not to treat an idiopathic 

pulmonary fibrosis or lung fibrosis as being, you 

know, unrelated to work, but they would still 

have to look at that as potentially work-related, 

as the underlying condition, and not just 

necessarily as idiopathic.

So, in other words, if I'm a claims 

examiner and I have a physician diagnosis of 

idiopathic pulmonary fibrosis, I'm going to treat 

that condition as pulmonary fibrosis in my 
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evaluation of that client without any -- you 

know, without discrediting it as a potentially 

work-related medical condition.

And then finally, there were some 

concerns about how we report sarcoidosis in the 

Site Exposure Matrices, and again, that is not 

something that we have any known health effect 

for. 

That's certainly something that the 

Board can continue to look at is, you know, is 

there known, you know, exposures linked directly 

to a diagnosis of sarcoid or sarcoidosis?

What we do have is guidance in our 

procedural manual speaking to the fact that 

sarcoidosis can represent a misdiagnosis of 

chronic beryllium disease under our evaluation 

criteria for chronic beryllium disease. 

And again, that is a procedural 

instruction that we have an allowance for when 

claims examiners are evaluating claims, but 

that's not something that is captured or 

communicated in the Site Exposure Matrices.
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Finally, with regard to Dr. Redlich, 

there had been a request, and I think that this 

was something that the Advisory Board had 

identified or mentioned as to why asbestos has 

not been added to the pneumoconiosis health 

effect profile in the Site Exposure Matrices.

I'm happy to report that that is 

actually there now, so that is a toxin that is 

listed under pneumoconiosis, and we did make that 

update based on the input that we received.

Any other questions with regard to 

some of that information that I've just provided?

CHAIR MARKOWITZ: This is Steven. So, 

Kevin, could you put up from our meeting briefing 

book, the SEM fixable file just so we can be 

looking at that? 

And then -- because I think maybe Mr. 

Vance addressed these, but I just want to make 

sure that the issues that were raised in that 

file are the same ones that we're discussing now 

or to make sure there are no residual issues as 

well.
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Okay, so if you go down to the next 

page? Go down to the next page, Kevin.

MR. BIRD: Yeah, which page? Here, 

let me.

CHAIR MARKOWITZ: It's page -- you can 

go to page two and then page -- page two briefly 

and then page three.

MR. BIRD: It doesn't seem to be 

showing correctly in the -- I'm just going to try 

--

CHAIR MARKOWITZ: Dr. Redlich, I don't 

know if you want to address this. Oh there, 

okay, fine. So, yeah, so this is entering 

through the Paducah site in the SEM. And so Dr. 

Redlich, given what Mr. Vance just said, does 

that address some of the issues that you were

looking at here?

MEMBER REDLICH: Well, you know, I 

want us to retest it to see if -- and I was just 

doing that now. I did miss a few of his comments 

because of a problem with the phone line.

As far as sarcoidosis, it just seems 
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like it would be much simpler, since we know that 

clinically, sarcoidosis and beryllium disease are 

indistinguishable, that one would link beryllium 

to sarcoid in the SEM, but that link doesn't mean 

that that's what the final adjudication is, but 

I'm still confused why one wouldn't link those 

two. 

You know, if A equals B and, you know, 

can be caused by, if both of those -- you know, 

if those are indistinguishable and beryllium can 

cause them, we know that most clinicians have 

very little experience recognizing or diagnosing 

chronic beryllium disease. It seems that the 

obvious thing to do would be to provide that link 

in the SEM.

There are different ways. You know, 

COPD, emphysema, chronic bronchitis, I think as 

you recognized, that those are interchangeable 

terms for basically the same chronic obstructive 

lung disease, you know, granuloma and lung 

disease. 

You know, sarcoid and beryllium really 
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being indistinguishable, it would make sense to 

have them linked.

MS. POND: This is Rachel. You know, 

usually we do. The doctors oftentimes can tell 

us that this is sarcoidosis based on what they 

see, at least in our experience on the exams, on 

the tests that they take, and those sorts of 

things.

If we automatically assume that 

sarcoidosis is beryllium disease and put a link 

to beryllium in the SEM, then we're really not 

making that distinction that can be made in 

certain circumstances in certain cases. 

We don't want our claims staff to go 

in the SEM and say, oh, okay, this person has 

sarcoidosis. We're going to go ahead and assume 

that that's really related to beryllium and it's 

really beryllium disease and not sarcoidosis.

 It's not an assumption we want to make 

without a doctor's input until we really ask 

those questions on a case by case basis to a 

doctor.
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MEMBER REDLICH: Yeah, I guess it's 

just that I've now reviewed, you know, a number 

of claims where, because the SEM did not link, 

you know, recognize that there was beryllium 

exposure, an obvious case of chronic beryllium 

disease was, you know, that diagnosis was missed.

So, the linkage in the SEM, that --

one still takes into account the duration or the 

timing of exposure, you know, the onset of 

disease, and all of those factors.

So, I haven't seen any situation where 

the SEM acknowledging a disease exposure 

association immediately led to that diagnosis 

because it appeared to me that there was still 

input from the, you know, claims examiner or from 

the contract physician to then take that 

information and use that information as part of 

their decision making. 

I mean, there were other -- you know, 

I've often reviewed cases that I thought were 

sarcoid and were sarcoid, so to me, that's just -

- you're using that information, but by not 
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providing it, I just don't think that that 

improves the accuracy.

MS. POND: Well, our procedure manual 

and our training to our staff explains to them 

that when they see sarcoidosis, they should be 

looking for beryllium, so beryllium tests, 

beryllium, you know, a possible diagnosis for 

beryllium, to do (telephonic interference) 

beryllium in certain circumstances, and that's 

where that comes in.

Putting it in the SEM, I think for our 

purposes, would just be making an assumption. 

Since beryllium doesn't cause sarcoidosis and 

they are two different conditions, we don't want 

to put beryllium in the SEM for that purpose. 

We have training materials and our 

procedure manuals that captures what the CE needs 

to look for when looking at a particular case, 

particularly for sarcoidosis and the possibility 

that that's beryllium disease. 

MEMBER REDLICH: No, that all makes 

sense and I agree, but in cases I reviewed, the 
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question was sometimes that maybe the SEM was 

queried in the wrong way, but there was a query, 

were there any exposures at this workplace that 

could cause sarcoid? So, that is always going to 

come up with, no, there are no exposures, because 

-- so that, and then that information is given to 

the, let's say the contract medical physician and 

saying, look, there is no exposures at this 

workplace that could cause sarcoid, and the 

clinician recognizes that this is likely 

beryllium disease. 

And, I mean, I reviewed a case such as 

that and then the claim examiner said that, you 

know, the physician didn't know what he was 

talking about because he didn't answer the 

question. 

You know, it's partly the question 

that the -- maybe another way to solve this would 

be that the question that is posed because it 

creates these scenarios where the question is, 

you know, were there any exposures at this 

workplace that caused the patient's sarcoid, and 
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that's always going to be a no.

MS. POND: Yeah, there are case by 

case situations and we have to look at it on a 

case by case basis at this point. Yeah, there 

are cases where you're going to see maybe they 

put it wrong and maybe they didn't ask the right 

questions, but a lot of times they do. 

So, I don't want to get into a 

discussion about what all could go wrong in the 

case on sarcoidosis right now, but, you know, we 

believe at this point, putting beryllium in 

sarcoidosis is not the best route for our, you 

know, for the direction we're going in this.

 Again, if the Board comes up with a 

recommendation on this, we're happy to evaluate 

it.

MEMBER REDLICH: Okay, I mean, sarcoid 

is a relatively rare disease. It's not like COPD 

or asthma.

MEMBER GOLDMAN: This is Rose Goldman. 

Could I just ask a question here about the SEM 

then? Because if you have interstitial fibrosis, 
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you would have a link there, for example, to 

potential asbestos so that the examining 

physician could see or somebody could ask the 

question, is this interstitial fibrosis, could 

this be asbestos? 

So, you're not making it 100 percent 

that it is asbestos, but you're putting that 

link, potential link out there so that one could 

then pursue that further. 

So I thought that was sort of the 

model that's out there in terms of using the SEM, 

and if that's the model, then why wouldn't that 

apply to something like sarcoid which is very 

similar to beryllium, and you're just saying 

there could be a linkage because it's not really 

sarcoid; it's really beryllium lung disease?

Just like interstitial lung disease, 

UIP or something, if somebody isn't looking 

closely or see that there's been an asbestos, 

heavy asbestos exposure, could be missing that. 

So, it seems like that is the pattern for other 

conditions, so I'm not quite sure why that 
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doesn't apply here.

MR. CHANCE: Everyone, this is Mike. I 

think that Rachel, you know, she made it clear. 

If you guys have, if the Board has a 

recommendation, please deliberate and bring that 

forward. I don't think that this is the forum to 

debate these specific case-specific issues.

CHAIR MARKOWITZ: Okay, that's fine. 

This is Steven, just a quick question relating to 

this slide. Where does the claims examiner find 

interstitial lung disease, or interstitial 

pulmonary fibrosis, or pulmonary fibrosis in this 

26 health effects from Paducah?

MR. VANCE: Well, I don't have 

specific -- I'm not looking at that right now, 

but I do know that our procedure manual has 

specific instructions, and I can find that and 

send it to Ms. Rhoads talking to the fact that, 

if a claims examiner does identify a diagnosis of 

interstitial lung disease or pulmonary fibrosis 

for any claim, whether it's at Portsmouth, 

Paducah, or elsewhere, they're to search in the 
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Site Exposure Matrices under that pneumoconiosis, 

other health effect that's listed in the Site 

Exposure Matrices, and as I mentioned, that has 

been updated to include exposure to asbestos now.

MEMBER REDLICH: Yes, and I will 

confirm that. As long as it's clear that if you 

get pulmonary fibrosis, that you look under 

pneumoconiosis, other, that is correct that 

asbestos is now listed, which it hadn't been, so 

I appreciate that.

CHAIR MARKOWITZ: Okay, I think the 

other slides that you have, Dr. Redlich, on this 

same issue pertain to other pneumoconiosis and 

asbestos, so I think that's the example.

MEMBER REDLICH: Yeah, I don't --

CHAIR MARKOWITZ: Yeah.

MEMBER REDLICH: Okay, we might go 

through -- we could address that as maybe a 

recommendation as far as what would be 

appropriate exposures to have under that other 

pneumoconiosis.

CHAIR MARKOWITZ: Okay, so we'll take 
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note of that and the Board can come back to that. 

If it wants to formulate a recommendation, then 

we can. Thanks. Any other final comments on the 

matter or can we move on?

MEMBER REDLICH: No, I think that 

that's reasonable to do. I just think that 

another easy solution would be to use the 

clinical terms that are, you know, clinicians are 

familiar with, but if there's a way to translate 

that into a term, you know, as long as that's 

happening reliably, then that should work.

MEMBER DOMINA: This is Kirk. I got a 

question for Mr. Vance. I believe at one of our 

meetings, the one in the spring, I think we 

talked about, and I just want to clarify this, 

that the claims examiners have access to a 

different SEM than we do that has some other 

drop-down boxes in it. Is that correct?

MR. VANCE: Yeah, I mean, the 

filtering functionality is a little bit 

different, but the data that is in the Site 

Exposure Matrices is the same except for that 
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exception that we talk about with regard to the 

functionality where we have to freeze it. 

The version that the claims examiners 

receive is frozen, and then it has to go through 

a security review by the Department of Energy, 

and then that's updated, but the search criteria 

is a little bit more advanced for the claims 

examiners, but the same data is available to both 

the public and claims examiners. 

It's just that the public variant is a 

little bit behind in the data because what we're 

building is, you know, our contractors, 

subcontractors continually updating the Site 

Exposure Matrices, but the same basic filtering 

functionality is there that is used by the claims 

examiners.

MEMBER DOMINA: Thank you.

MEMBER REDLICH: You know, it would, 

just would be helpful, not for now, but if you 

could just -- this is Dr. Redlich again. If you 

could just let us know which clinical diagnoses 

are now linked to the other pneumoconiosis, that 
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would be helpful.

MR. VANCE: Okay, and as I'm sitting 

here, which is nice about working from home, is I 

can look things up very quickly. 

So, our guidance with regard to 

pneumoconiosis and how we treat that with regard 

to the diagnosis of pulmonary fibrosis or 

interstitial lung disease is actually on page 187 

of our version 4.1 of our procedure manual. 

So, that's the specific procedural 

reference to how we do that in evaluating claims 

for pulmonary fibrosis and interstitial lung 

disease.

MEMBER REDLICH: Okay, I can review 

that. Thank you.

MR. VANCE: Yes. Okay?

MEMBER REDLICH: Okay.

MR. VANCE: Any other questions on 

that particular topic? And then I'll move onto 

the next one, which hopefully won't be as 

controversial.

Okay, hearing none, the next one that 
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I had on the agenda was Exhibit 18-1. There'd 

been a question raised about the importance or 

the relevance of asking individuals when 

evaluating pulmonary conditions about smoking, 

and the question just is that, you know, we 

generally don't consider smoking as part of an 

occupational evaluation for pulmonary disease. 

So, we took a look at the exhibit in 

its entirety and decided that, yes, there was a 

problem with that exhibit, but we also had other 

concerns with that exhibit that has raised 

questions about whether or not we should even be 

trying to offer diagnostic criteria that are 

generally characteristic of particular types of 

diseases.

So, after looking at it very carefully 

and considering it, the Department of Labor has 

decided to go ahead and review that entire 

exhibit just because we really need to rely on 

the expertise of a qualified physician in 

evaluating whatever clinical or diagnostic 

evidence exists that they interpret as supporting 
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a diagnosis. 

And so any kind of framework that the 

Department of Labor could utilize in sort of 

identifying general characteristics or 

considerations of what should go into a 

diagnosis, we've determined that that's just not 

something that we need our team to be adding into 

the procedure manual and potentially causing 

confusion with our claims staff. 

So, we really want to make sure that 

our claims staff are evaluating cases based 

solely on the input of qualified physicians in 

interpreting whatever available clinical or 

diagnostic evidence exists in a case.

So, the decision has been made that 

we're going to go ahead and remove that exhibit. 

That will be added into our agenda for one of our 

next reviews of the procedure manual update.

CHAIR MARKOWITZ: This is Steven. I 

just have a short comment. All I can say is, I'm 

sorry, hallelujah.

MEMBER REDLICH: Thank you.
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MR. VANCE: All right, well, that was 

the final comment that I had, and thank gosh it 

was a noncontroversial one, and it made everybody 

happy, so I'm done unless there are any other 

questions.

MS. POND: Thanks, John. I'm glad 

that we did -- we've gotten a lot of input on 

this 18-1, so I'm glad that the Board is a lot 

happier about this, so I think it is probably the 

best decision.

So, with that said, I'm going to turn 

it over to Doug Pennington to talk about some of 

the issues, the rest that's on the agenda here.

MR. PENNINGTON: All right, hello, 

this is Doug Pennington again. So, I'm going to 

start with the question regarding our contract 

medical consultant contract. The contract ends 

in August of 2021. 

So, typically after August of 2020, we 

would begin working with, usually at the 

beginning of the next fiscal year, our 

contracting office to develop a statement of 
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work. 

It would usually be based similarly on 

the existing statement of work unless there are 

specific needs or changes that we identify as 

beneficial to the government, and that is always 

how we characterize contract changes, is they 

should be beneficial to the government.

And so the expectation would be that 

we would have that statement of work in place and 

enough time based on what the contracting office 

sets as the time table for recompetition of the 

contract, and so it's very much driven by our 

contracting office and we work at their time 

tables that they set for us.

So, that's pretty much what I can 

share on that. Are there questions regarding 

that?

CHAIR MARKOWITZ: This is Steven. So, 

you start working in August of this year on 

various aspects of the contract, including 

statement of work, and how long does that process 

take roughly?
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MR. PENNINGTON: Anywhere between 

three to nine months depending on a number of 

factors from our needs, to the contracting 

office's reviews, to the Solicitor's Office's 

reviews, and so it can range based on a variety 

of factors.

CHAIR MARKOWITZ: Thank you.

MR. PENNINGTON: Again, government 

contracting, you know, this is how I'll say it 

and I think Mr. Chance said it at the beginning 

of the meeting. Government contracting is 

difficult. 

Most of our contracts, due to a 

variety of factors, get delayed in their issuance 

even, and so we end up often having to extend 

existing contracts beyond the traditional 

contract ending period. 

It just depends on what factors the 

contracting office puts in front of us. So, we 

always do our best with the variables that are 

provided to us. Additional questions?

MEMBER BERENJI: Yes, this is Dr. 
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Berenji. Can you guys hear me?

MR. PENNINGTON: Yes.

MEMBER BERENJI: Okay, perfect. I 

actually had a question about this process. Do 

you folks actually do some sort of audit of all 

of the CMC reports just to make sure that you can 

look at quality, if they're meeting standard 

medical metrics?

MR. PENNINGTON: The contract 

currently has a provision where our medical 

director, our staff medical director performs 

regular audits of a sampling of the work, and 

those are published on our website when 

completed, and so we make them publicly available 

in non-case specific redacted iterations, but we 

still provide the results of the CMC audits on 

our website.

MEMBER BERENJI: Thank you.

MR. PENNINGTON: Does that answer your 

question? Okay, any other questions? Okay, 

hearing none, I will move on to the contract 

industrial hygienists' quality control language.
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So, the contract industrial hygiene 

contract is -- that's a mouthful. It is a 100 

percent reviewed contract. So, what that means 

is every IH referral that is sent to them, the 

contractor, is quality controlled by their staff 

on a variety of bases. 

They do not do a 100 percent quality 

control themselves because of the variety of 

certifications and credentialing that their staff 

have, but when it comes to us, we have certified 

industrial hygienists on our federal staff who 

review 100 percent of the reports that we receive 

for compliance, for accuracy, for consistency, 

and we actually sign them.

So, if you noticed in the industrial 

hygiene reports that you've reviewed, every one 

of them has been signed by a federal employee. 

So, we have a 100 percent review of all of the 

reports already for our quality control. Any 

questions?

CHAIR MARKOWITZ: Yeah, this is 

Steven. I've got a question. So, on the medical 
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side, you have your medical director who, every 

quarter, takes a sample of claims and then 

performs kind of a fresh-eye look, an independent 

look at the CMC work on particular claims, and 

you have nothing quite comparable to that on the 

industrial hygiene side, is that right?

MR. PENNINGTON: No, because we have 

100 percent reviews, so why would we need to then 

do a second percentage review? If 100 percent of 

all reports done by our contractors are reviewed 

by certified industrial hygienists on staff, why 

would we then do an additional percentage review 

on top of that?

CHAIR MARKOWITZ: Sure, the Board is 

going to talk about that later. That's fine. 

Thanks.

MR. PENNINGTON: Any other questions?

CHAIR MARKOWITZ: So, if there are no 

questions on the IH side, I just want to come 

back while we still have the DOL on the agenda 

here. 

I just want to come back to the 
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information about the resource request because I 

just want to give the Board the opportunity to 

ask any questions or get any clarifications on 

that side.

And if you could just briefly 

summarize kind of the time table for any requests 

and how that time table plays out? Because it 

takes a long time to turn things around and to 

get things approved, and so I want to make sure

that the Board is clear about that.

MR. PENNINGTON: Mike, do you want me 

to do that or would you like to do that again?

MR. CHANCE: I can, well, maybe we 

could both do that. Let me start off and, you 

know, again, as I indicated in my opening 

monologue, I am not a contract law expert, but I 

do have my own, you know, my own experience with 

this, you know, and as Doug pointed out, you 

know, contracting is not easy. 

It's always a lengthy process, and 

it's painful, and it requires a great deal of 

precision to lay out exactly what it is you want 
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to do and who it is you want to do it.

You know, building basically your 

business case, writing out the narrative for your 

statement of work, you know, what --

CHAIR MARKOWITZ: I'm sorry, Mr. 

Chance?

MR. CHANCE: Yes?

CHAIR MARKOWITZ: I'm sorry, I don't 

mean to interrupt. So, we got that.

MR. CHANCE: Okay.

CHAIR MARKOWITZ: My question is much 

more targeted.

MR. CHANCE: Is this about timing?

CHAIR MARKOWITZ: Yeah, the time 

table, and that's all.

MR. CHANCE: Okay, right, and let me 

try to get into that, and if I miss anything, 

Doug can help me out, but, you know, basically as 

I said, 2021, you know, is a done deal. We've 

already formulated the budgets for that. 

You know, there are instances where 

you can request, I mean, you know, pretty much at 
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any time, you know, which would be kind of, let's 

call it a budget anomaly, which is --

Generally speaking, you know, it has 

to be a pretty compelling emergency, and that 

would have to be done like right now, I think, 

and Doug might be in a better position to be able 

to talk about 2021 for the Energy budget. 

And then formulations for the FY 2022, 

as you can see, we do these things far out into 

the distance, will be discussed over the next few 

months, you know, into the summer, and finalized 

early fall.

And, you know, again, bear in mind 

these dates that I'm saying are perfect scenario 

dates, you know, where, you know, you're in an 

uncharted territory here where I don't know what 

these dates really are. 

And so, Doug, I don't know if you can 

maybe help get some more precision into that?

MR. PENNINGTON: Sure, so typically in 

August -- we'll use this year. In August of this 

year, each program begins working on their -- so 
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this is 2020. It's the fiscal year 2020. We 

begin working on the fiscal 2022 budget in August 

of 2020. 

We begin getting it ready. We make 

our narratives and supporting documentation. We 

have to get it through layers of vetting before 

we submit it to the budget office within the 

Department of Labor. 

We do that in the first quarter of 

FY21, which would be typically the November, 

December time frame, sometimes October depending 

on the year and the issues that are occurring.

 Again, those timelines are actually 

set by the budget office, and so we respond to 

their timelines. It gets reviewed, vetted, put 

together, and eventually submitted to OMB. 

OMB reviews it, and then in February 

or March typically, we end up getting what's 

called a pass-back which basically OMB, the 

Office of Management and Budget, passes it back 

to us for review based on their comments, their 

questions, their edits. 
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We then have to respond to those. 

That is then done throughout the summer so that 

it can be presented back to OMB and eventually to 

Congress, so that way the President's budget can 

be presented to Congress for 2022 in the 2021, 

but the end of the 2021 calendar year, sorry, 

fiscal year, so that way in theory, it can be 

voted on at the beginning of the 2022 fiscal 

year, which again would be in October of 2021.

So, as you can tell, we're basically 

trying to build budgets more or less two years 

ahead of time, and so if you're trying to do 

anything off cycle, which would be any budget 

request that doesn't match that, it has to be an 

emergency request. 

And again, as Michael pointed out 

several times, it requires a substantial amount 

of justification because in essence, most monies 

have to be appropriated, which is again, a 

congressional authority. 

For those budgetary things that don't 

need to be appropriated, they still have to go 
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through OMB for apportionment, and OMB looks at 

everything off-cycle as an issue where the first 

question is why wasn't it planned for? What's 

the emergent need? Why can't it wait? What is 

the essential need that requires us to reallocate 

funds from potentially one project to this 

project in order to accomplish something? All of 

those things have to be taken into account.

And that's not even including the fact 

that all of this has to be approved through the 

budget office and the Secretary's office for 

their sign-off as well before it ever gets to 

OMB. Does that answer your question, Dr. 

Markowitz?

CHAIR MARKOWITZ: Yes, thank you. 

That was very clear. Any questions from the 

Board?

MEMBER FRIEDMAN-JIMENEZ: Yes, this is 

George Friedman-Jimenez. How does the budget 

process take account of the possible impact of 

COVID-19 on the worker's comp budget? 

An example would be someone is on 
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chemotherapy for a cancer that's related to work 

that's funded under the program, and then they 

get COVID-19 and wind up in the ICU. 

They come up with a big hospital bill 

that then would be a consequential damage because 

they had an underlying condition that was due to 

their work that caused them to incur this, to 

develop this medical problem most likely due to 

COVID-19. So, there may be some overlap cases 

like that. 

My question is are you planning for 

that in any way by modeling how often you think 

that will happen, adding that to the budget so it 

doesn't completely obliterate other parts of the 

program, the quality controls, CMC auditing, IH 

parts that then would get hit hard by these 

additional unexpected expenses?

MR. PENNINGTON: So, let me address 

that in two parts. First of all, I'll address 

the budgetary aspect, and then I'll address the 

consequential condition aspect.

The budgetary aspect is all of the 
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budget discussion we've had so far is about what 

we call administrative budgets. They're the 

budgets related to the funding and operation of 

people and systems and contracts. 

They're essentially everything but our 

benefits. Our benefit fund is a permanent, 

unlimited appropriation. We have whatever money 

is necessary to pay the bills when it comes to 

paying benefits. We do not have to go back to 

Congress. We do not go through the budget process 

per se. 

We still go through the process of 

telling Congress what we believe our budgetary 

needs are, but it's informative. It is not 

decisional, and so we have whatever money is 

necessary to pay the bills when it comes to the 

benefits side.

On the consequential conditions side, 

if, again, somebody files a claim saying that 

they received COVID-19 as a direct consequence of 

their accepted condition or conditions, and they 

can outline it and we accept that, then yes, we 
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would begin to pay for the medical benefits 

associated with COVID-19.

But again, that would be something 

that has to be accepted as a consequential 

condition before we would be able to pay for it, 

which means there has to be a filing for it, for 

the condition. 

There has to be the medical evidence 

submitted, including physician statements and 

such, and so it's part of our claims process. 

John, would you have anything to add?

MEMBER FRIEDMAN-JIMENEZ: That answers 

my question, in particular the first part of what 

you said. Thank you.

MR. PENNINGTON: Okay.

MR. VANCE: Yes, and Doug, this is 

John. I did not have anything else to add.

MR. PENNINGTON: Okay, thank you. Any 

other questions?

CHAIR MARKOWITZ: Okay, thank you. 

So, now let's move onto the next agenda item, 

which is going to be a discussion of a 
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recommendation on Parkinson's-related disorders.

 And Marek, I'm not sure that Kevin can 

have this, but I just sent him your -- okay, 

good. Okay, so I don't know, Marek, whether you 

wanted to show this or not, but if you do, here 

it is, and if not, we can take it down. Let me 

turn it over to you.

MEMBER MIKULSKI: Yes, thank you, Dr. 

Markowitz, and thank you for the opportunity to 

work on this subject.

Last year, our group shared the 

presentation and the chart write-up with the 

Board that provided with the overview of the most 

recent clinical and research information on 

Parkinsonisms in general, and Parkinson's disease 

specifically.

This presentation included updates on 

the nosology of these disorders, as well as some 

details of clinical diagnosis and most recent 

information on the risk factors associated with 

Parkinsonian disorders.

What we intended for this presentation 
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and the short write-up was to provide resources 

for the Department of Labor on Parkinsonism in 

general and the process of delegating the claims, 

but it also answers some of the questions that 

the Department of Labor has asked the Board at 

the beginning of this term. 

With this information that was 

included in the presentation, we put together a 

set of proposed recommendations that were circled 

around last week, and I wanted to briefly go over 

these and hopefully submit them for the Board's 

vote.

So, the first question we heard to 

aliases used for Parkinson's disease. We have 

identified several different aliases that have 

been used both clinically and in research over 

the years, and these are all listed in the 

recommendation.

It needs to be remembered that 

Parkinson's disease is the most common of all 

Parkinsonian disorders. However, despite having 

common clinical characteristics, these disorders 
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may differ in the clinical onset, symptomatology, 

the rate of progression, as well as risk factors. 

Can we go to the next slide, please?

MR. BIRD: Marek, do you want the 

document that Dr. Markowitz just sent me or the 

PowerPoint that you sent?

MEMBER MIKULSKI: The PowerPoint 

slides. I have four slides for each of the 

questions with the recommendations, so if we can 

move onto the next slide?

MR. BIRD: Great, we'll do that.

MEMBER MIKULSKI: Thank you. The next 

question, or actually a set of questions referred 

to specifically diagnosis of Parkinsonisms and 

Parkinson's disease, and the criteria to evaluate 

the medical evidence and records for 

appropriateness of the diagnosis.

The diagnosis of any type of 

Parkinson's disease is a fairly complex one, and 

despite all of the recent advances in brain 

imaging techniques, as well as research into 

biomarkers, it is still pretty much based on the 
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clinical presentation that involves 

neurobehavioral evaluation, as well as review of 

the family history, risk factors, and most 

importantly, a therapeutic response or lack 

thereof to dopamine replacement therapy.

We have provided, both in the 

presentation and in the write-up, the most recent 

diagnostic criteria formulated by the 

International Movement Disorders Society, but we 

feel that it is warranted that it is only the 

clinical diagnosis of Parkinson's disease that is 

made preferentially but not exclusively by a 

neurologist. 

With the ICD, respective ICD codes 

that we have included in the rationale for the 

recommendation, that is used in the adjudication 

of relevant claims. Can we go to the next slide, 

please?

Questions two and three relate to 

exposures, toxins associated with Parkinsonisms 

diagnosis and any presumptions that could be 

offered, for example, including job titles and 
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work processes that put workers at higher risk 

for those exposures.

In addition to carbon monoxide and 

manganese exposures that are already included in 

the procedure manual and the Site Exposure 

Matrix, our group has identified several case 

reports describing Parkinsonisms’ symptomatology 

following exposures to solvents, including carbon 

disulfide, methanol, and toluene.

These solvents have been commonly used 

throughout the Department of Energy weapons 

operations, and we have provided in the enclosed 

rationale with examples of job categories and 

work processes that would put workers at the 

highest risk of exposure.

Exposures to solvents, specifically 

TCE, trichloroethylene, has also been found to be 

associated with the increase in risk for 

Parkinson's disease in the epidemiological 

studies. We've included a brief review of those 

studies in the rationale. 

It should be highlighted however that 
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TCE was one of the most commonly used solvents 

industrially throughout the mid-1970s and traces 

of it have been found in nearly all of the 

samples from the DOE side that were surveyed by 

the DOE site science program in the early 1990s.

As you see, our recommendation also 

includes exposures to polychlorinated biphenyls. 

Exposures to PCBs have been shown in the 

epidemiological studies, but we associate it with 

increased mortality rates from Parkinson's 

disease in highly exposed female workers, a 

finding that was eventually confirmed in the 

pathology studies. However, it has not been 

further studied epidemiologically. 

Again, as was the case with the 

solvents, PCBs were commonly used throughout DOE 

weapons operations, and we have provided with 

examples of a listing of 10 congeners, PCB 

congeners in the rationale for the 

recommendation. Can we move to the next slide, 

please?

Finally, question number four, 
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referring to causality presumptions for any of 

these exposures. As we previously discussed and 

described in our presentation, the causality 

relationships for these toxicants are yet to be 

established.

Epidemiological studies are still 

trying to answer these questions regarding 

characteristics of exposures, primarily dose 

response relationships, as well as latency and 

potential susceptibility to the exposures.

We do see though, however, that taking 

into account the number of positive studies, as 

well as the strength of the association in these 

exposures to TCE and PCBs, these are to be 

considered as likely as not being contributing or 

aggravating to the risk of Parkinson's disease 

throughout the claim adjudication process. 

We did not make any specific 

recommendations regarding latency as this 

information is very limited in the studies that 

we have reviewed. 

However, based on the epidemiological 
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data, we do feel strongly to recommend that the 

duration of exposure to either substance be taken 

into account when adjudicating the claim.

With that, I'd like to turn it over 

back again to Steve.

CHAIR MARKOWITZ: Okay, thank you. 

That was a terrific presentation. The floor is 

open for comments by Board members.

MEMBER DEMENT: This is John Dement. I 

have just one question. We, in the past, have 

been given, I think, a document that really goes 

through the review of the studies that support 

the Board's recommendation. Are we going to vote 

on this at this meeting or are we going to have 

that document to take a look at again?

CHAIR MARKOWITZ: So, typically what 

we've done is constructed recommendation language 

and voted on it, and then afterwards, I write a 

rationale for the recommendation. 

In this case, we would, with the 

recommendation, there are several parts of the 

recommendation. We would just hit those, put 
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those together, and then use the rest of the text 

as the rationale for the recommendation. I think 

that -- does that address your concern?

MEMBER DEMENT: Yeah, I just, I want 

to make sure that we've taken -- it's been a 

while since I've taken a look at these studies. 

I just wanted to have the background to look at 

before we vote.

CHAIR MARKOWITZ: Okay.

MEMBER MIKULSKI: And the rationale 

actually includes the list of all of the recent 

references of other studies that were reviewed 

for this review.

MEMBER DEMENT: Yes, thanks a lot --

(Simultaneous speaking.)

MEMBER DEMENT: -- a lot of good work.

CHAIR MARKOWITZ: I have a quick 

comment. I wonder whether it's worth putting in 

there that the VA recognizes exposures from Camp 

Lejeune contaminated water. 

I think it was TCE was the implicated 

solvent. They recognized that exposure during a 
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certain time period at Camp Lejeune is associated 

with Parkinson's disorder as a matter of 

presumption. 

You know, that's not the science, but 

that is a different federal agency at least 

recognizing the connection on a presumptive 

basis. Are there other comments?

(Simultaneous speaking.)

CHAIR MARKOWITZ: Go ahead. I'm 

sorry.

MEMBER GOLDMAN: This is Rose Goldman. 

I think this is a really good summary, and I 

think that one of the important points here is 

that there are certain agents such as a very bad 

overdose of carbon monoxide or manganese, which

in and of themselves as a toxic effect, cause a 

Parkinsonian type syndrome. 

That is different than these other 

possibilities, and exposures to these other 

solvents increase the risk of what we would 

normally call Parkinson's disease in the 

population, and so that's an increased risk for 
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developing the (telephonic interference)

CHAIR MARKOWITZ: Hello?

MEMBER GOLDMAN: I mean, and I think 

that's part of the basis of the VA and Lejeune. 

You know, more on an epidemiological basis, the 

people who have these exposures to that water or 

the solvents had an increased risk of what we 

would call Parkinson's disease.

MEMBER MIKULSKI: That's correct, and 

it has been added just most recently, TCE 

specifically.

MEMBER GOLDMAN: So for example, the 

reason I bring that up, and there are cases of 

major overdoses to TCE where people have fully 

collapsed and become unconscious and rescued, and 

they developed a particular change in their 

trigeminal, their fifth nerve palsy and recovered 

from that. 

So, that was like an acute exposure to 

TCE as a direct toxic effect, which is really 

different than this which is chronic long-term 

exposure leading to an increased risk for 
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development of what would otherwise be an 

indistinguishable disease from other people who 

have Parkinson's disease, but then it's 

increasing the risk for that, which is what I 

think you're trying to put forth in this 

document.

MEMBER MIKULSKI: Yes, this is 

specifically regarding the chronic exposures, and 

the epidemiological studies have taken into 

account a lifetime exposure to TCE.

CHAIR MARKOWITZ: Other comments or 

questions? So, this is Steven. I have a 

question actually. I'm just looking at the 

language of the recommendation parts of this to 

look for, you know, clarity.

So, the first part of the 

recommendation, actually, Kevin, if you go up, 

which is the -- I think if you go to the second 

slide, yeah.

Okay, so the -- when we talk about 

differentiation between Parkinsonian disorders, 

is the recommendation about exposures as follows: 
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do they apply to all or does this say that they 

apply to all Parkinson's-related ICD codes? Is 

that what this says?

MEMBER MIKULSKI: Yes, all this is 

specifically to all Parkinsonism cases and 

including Parkinson's disease, yes.

CHAIR MARKOWITZ: Okay, so somewhere 

you discussed Parkinson-Plus disorders, which are 

--

MEMBER MIKULSKI: Yes.

CHAIR MARKOWITZ: -- which are 

distinctive clinically. So, is the intent that 

the causal links also could be applied to these 

Parkinson-Plus disorders?

MEMBER MIKULSKI: No, it's not. The 

Parkinson-Plus disorders are a separate group of 

disorders and these are hypothesized, but thought 

to have a genetic etiology for the most part.

 So, while we talk about the clinical 

diagnosis of Parkinsonisms in general, we talk 

about ICD-9 and ICD codes that that would not 

apply to, our recommendation would probably not 
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apply to Parkinson-Plus syndromes.

CHAIR MARKOWITZ: Okay. Okay, thanks. 

Other comments at this point? So, let me 

suggest that we just, it's 1:15, that we take our 

very leisurely 15-minute break and come back at 

1:30 where we will resume this discussion on the 

Parkinson's issue and see if we --

MR. BIRD: Dr. Markowitz?

CHAIR MARKOWITZ: Yes?

MR. BIRD: I'm sorry to interrupt, but 

just a very important note. I just sent an email 

to the Board members. We are going to, in an 

effort to try to free up some call-in lines for 

members of the public, we are going to undertake 

a little change on our end. 

So, this line for members of the 

public will continue to operate as it has, but 

for Board members, please check your inboxes. I 

just sent some instructions for everyone to 

follow. 

I just wanted to make sure everyone 

saw that and realized what to do. But again, 
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members of the public, nothing is changing for 

you. Feel free to stick around.

MS. POND: And Kevin, this is Rachel. 

So, I'm going to stay on just in case there are 

questions, and you're going to send me -- yes, I 

got it. Thank you.

MR. BIRD: Absolutely.

MS. POND: Thanks.

CHAIR MARKOWITZ: Okay, thank you.

MR. BIRD: With that, Dr. Markowitz, I 

apologize for interrupting, but should we go 

ahead and start our break now?

CHAIR MARKOWITZ: Yes.

MR. BIRD: Okay, thank you.

(Whereupon, the above-entitled matter 

went off the record at 1:18 p.m. and resumed at 

1:39 p.m.)

CHAIR MARKOWITZ: Okay. So Kevin, if 

you could bring back up -- yeah.

We were discussing -- we were 

discussing this -- hold on one second. Okay. We 

have -- sorry about that. 
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We have a recommendation, a draft 

recommendation, and we were discussing the 

elements of the recommendation. Actually, there 

are four parts to it, which is separated into the 

four questions I think that the Department of 

Labor gave to us.

This recommendation differs from many 

of our other previous ones because this is 

specifically in response to a request from the 

Department for assistance looking at Parkinson's 

related disorders.

So if you can go to the next slide.

MR. BIRD: Dr. Markowitz, sorry. Can 

you speak a little more clearly into the phone?

CHAIR MARKOWITZ: Yeah. Okay. Is 

that better?

MR. BIRD: Much better. Thank you.

CHAIR MARKOWITZ: Okay. I'm sorry 

about that.

Anyway, we're -- I was just saying 

that this recommendation is not something that we 

developed on our own as much as a response to a -
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- this is a request from the Department for 

assistance on Parkinson's related disorders. So 

we have language for our recommendation divided 

into four parts that correlate to the four 

questions asked of us.

Do you want to just go to the next 

slide? And so the floor is open for additional 

general comments about this issue.

MR. BIRD: Dr. Markowitz, are you 

going to want to edit this text? Should I be 

pulling up a Word version? Are we going to make 

changes?

CHAIR MARKOWITZ: We may, and so what 

you can do is you could pull up the version, the 

Word document that I sent you a couple hours ago.

MR. BIRD: Exactly.

CHAIR MARKOWITZ: And, Marek, I -- it 

-- from the last version you sent me, which I 

sent around to the Board last week.

Okay. So are there additional general 

comments about this document?

So why don't we walk through the 
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language of the recommendation and see if there 

are any amendments before we decide whether we're 

ready to vote on them or not?

So this first recommendation we're 

looking at, any comments, suggestions? Okay. So 

let's go to the next -- if you scroll down some 

you'll get to the next part of the 

recommendation.

So I wonder whether we should 

potentially put the ICD codes that we think 

should be included in the body of the 

recommendation, in other words to repeat them 

somewhere there in the rationale to the -- to 

this recommendation. We don't have to do that --

PARTICIPANT: Can someone turn off 

their speakerphone? Getting some echo.

CHAIR MARKOWITZ: Sorry about that. 

Yeah, so I was just saying that I think if we 

could, and we needn't do it right at the moment, 

but I think we should include the ICD codes in 

the actual body of the recommendation itself, not 

just in the rationale. That's something pretty 
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simple.

Any comments on the language of this 

part of the recommendation?

MEMBER FRIEDMAN-JIMENEZ: This is 

George Friedman-Jimenez. Just a very minor 

point. Change the word between to among. In 

other words, differentiation among Parkinsonian 

disorders, because there are more than two of 

them.

MR. BIRD: That's a change you want to 

correct, Dr. Friedman-Jimenez?

MEMBER FRIEDMAN-JIMENEZ: Yes.

MR. BIRD: Okay. Great.

MEMBER FRIEDMAN-JIMENEZ: Thank you.

(Simultaneous speaking.)

MEMBER MIKULSKI: I agree with 

expanding the recommendation to add the ICD-9 and 

ICD codes. Can be easily done within the next 

few days.

CHAIR MARKOWITZ: Okay. So then we 

can just add a sentence to the end of this that 

says that the following ICD codes should be 
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included, colon, and then we'll fill in the 

blanks.

Any other comments or --

MEMBER POPE: This is Duronda Pope. I 

was wondering, Dr. Markowitz, if we needed to 

include any language about that Parkinson-plus. 

I didn't see any of that language within the body 

of the summary.

CHAIR MARKOWITZ: Right. So the -- I 

think -- so at the end of the rationale after 

this is when Dr. Mikulski and the group discuss 

Parkinson-plus. And they have specific ICD 

codes.

Go down a little bit more. Yeah. So 

right there, you see the paragraph Parkinsonplus. So that paragraph has specific ICD codes. 

So I'm thinking if those are not included in the 

recommendation, then it'll appear that the 

Parkinson-plus syndromes aren't included in what 

we're talking about.

Does that address your point?

MEMBER POPE: Yes. Thank you.
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CHAIR MARKOWITZ: Okay. So we can 

move on to the next part of the recommendation, 

which is back down where you were, Kevin. Okay.

So this is the response to a 

particular question from the Department, which 

documents are associated, and then secondarily, 

what presumptions did the board offer regarding 

exposure?

Are there any comments on this, on the 

language? I think the second part about 

presumptions actually is not addressed in the 

language we're looking at. It's -- the first 

part is addressed, and then there's a later part 

of the recommendation that addresses 

presumptions.

So the question is when we bring this 

to a vote, is whether board members feel 

comfortable with this recommendation and the 

rationale.

Okay, so for those --

(Simultaneous speaking.)

MEMBER DEMENT: This is John Dement. I 
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wonder if we could have a little discussion of 

the methanol issue. Now, the others I'm a little 

more comfortable with. I just don't know the 

literature on Parkinsonism and methanol.

CHAIR MARKOWITZ: Dr. Mikulski, do you 

want to address that, or --

MEMBER GOLDMAN: This is Rose. I 

don't hear him, but I discussed it with him, and 

I guess this was based on one case -- one or two 

case reports.

MEMBER DEMENT: Then I guess do we 

want to base a presumption on just case reports?

CHAIR MARKOWITZ: The rationale, 

actually, bottom of page 5 into page 6, discusses 

methanol and cites the case reports. It depends 

on how convincing those case reports are, I 

think.

Marek, are you back on the line?

Kevin, has Marek reached out to you at 

all?

MR. BIRD: No. I haven't heard from 

him yet, or since he dropped off.
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MS. RHOADS: I just sent him an email 

asking if he's dropped off.

MEMBER GOLDMAN: This is Rose. I had 

discussed it a bit with him. I thought this was 

one of the weaker points on the review. Maybe we 

all -- we have to look at those case reports more 

deeply.

MEMBER FRIEDMAN-JIMENEZ: This is 

George Friedman-Jimenez. It seems that some of 

these, or maybe all of them, are ingestion rather 

than inhalation of methanol. So I do think we 

need to look at the case reports because we're 

probably talking about inhalation in the nuclear 

facilities.

There is one case report called 

Progressive Parkinsonism in a young experimental 

physicist following long-term exposure to 

methanol. That could be inhalation.

So I think we need to study this 

further with regard to methanol. I agree with 

Dr. Dement.

MEMBER DEMENT: I agree. I just don't 
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feel comfortable with it right now without taking 

a look at that more closely.

MR. BIRD: Dr. Markowitz, do you want 

to move on? We're about 20 minutes over.

(Simultaneous speaking.)

CHAIR MARKOWITZ: Yeah. Sure. Yeah.

Are there other exposures that are 

listed in this part of the recommendation that 

deserve additional scrutiny?

Okay. So let's move on just to the 

last part of the recommendation. Although if 

Marek is not on -- I think what we need to do, 

actually, is to suspend this discussion until Dr. 

Mikulski is able to get back on because he's 

really been the central person in this effort for 

quite a while now.

MEMBER MIKULSKI: I'm here, Steven.

(Simultaneous speaking.)

CHAIR MARKOWITZ: Oh, you are? Okay. 

Great.

MEMBER MIKULSKI: Yes.

CHAIR MARKOWITZ: Okay. So okay. So 
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the last part of the recommendation --

MEMBER MIKULSKI: I agree with the 

previous comment. Both methanol and toluene are 

probably the weakest exposures in this rationale.

The methanol case report said the 

leading -- well, exposures by ingestion except 

for that one report of the physicist. This is 

something we need to review more closely, 

absolutely. I agree with that.

CHAIR MARKOWITZ: Okay. So the next 

part of the recommendation.

MEMBER GOLDMAN: This is Rose.

CHAIR MARKOWITZ: Go ahead.

MEMBER GOLDMAN: This is a way to move 

with this. Make the recommendation for the ones 

that we feel the most comfortable about, and then 

say as part of the recommendation that we are 

further looking into methanol and toluene or 

whichever ones are the ones that seem less 

likely.

Because some of them, with long-term 

exposure, it increases the risk versus these 
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ones, which was overdose on ingestion. And we're 

not that familiar with this one, because methanol 

has been around for a long time, and its path has 

been very typical and neurologic outcome has been 

attributed to it.

So we could do that, and that way keep 

moving with the ones that we feel more 

comfortable about.

CHAIR MARKOWITZ: Well, we could 

remove methanol from that text and stick with the 

others, and then later come back with a 

supplemental recommendation around methanol.

But here's my question. Do people 

feel comfortable enough with the other exposures 

and the write-up to vote today on those 

exposures? And I'm talking about toluene, 

trichloroethylene, and polychlorinated biphenyls, 

PCBS. Oh, also carbon disulfide.

MEMBER SILVER: This is Ken Silver. 

Marek, quick question. For toluene, is it mostly 

chronic toluene abuse cases, like glue sniffing?

MR. BIRD: Dr. Mikulski, I don't think 
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we can hear you. Are you on mute?

MEMBER MIKULSKI: I'm sorry. I was 

talking and didn't realize that I was on mute.

Yes. This recommendation is based on 

that one case report of a colleague over ten 

years in experience.

CHAIR MARKOWITZ: Well, by the same 

logic, if it's primarily or only based on case 

reports, then maybe we want to take another look 

at toluene.

MEMBER SILVER: A moment ago Dr. 

Goldman spoke from her long experience about 

methanol not being associated with this outcome 

and industrial exposures. Among the collective 

occupational medicine expertise here today, what 

about toluene? I know it's mostly chronic 

solvent encephalopathy, but -- Parkinsonism in 

your collective experience?

MEMBER GOLDMAN: For me --

MEMBER FRIEDMAN-JIMENEZ: I've seen 

cerebellar ataxia, but I haven't seen 

Parkinsonism from toluene.
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MEMBER GOLDMAN: That's just what I 

was going to say. I think with the huffers, it 

was mostly cerebellar ataxia and that type of a 

thing. So when Marek and I talked about it, I 

thought toluene, that's interesting because I 

haven't in my experience, which is not allencompassing of everything, but it wasn't -- a 

Parkinson's kind of syndrome wasn't something 

that I usually associated with toluene.

And again, I think that if we were 

going to make the case, I guess one is a sort of 

process issue. With some of the things, like 

again, manganese and carbon monoxide, are acute 

overexposure we know that people can come out 

with that.

With these others, my understanding is 

we are looking at long-term exposures where there 

was an increased risk among workers like that who 

had these exposures in an epidemiological -- from 

an epidemiological study.

So the issue here that we're facing, I 

think, with something like this toluene case and 
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also the methanol case is it's a couple of case 

reports that might look pretty convincing in a 

way, but it's only a case report. So how much 

faith can we put in that?

And there have been many studies of 

solvent-exposed workers with, you know, 

peripheral neuropathies and more encephalopathy, 

and just less familiar with long-term 

epidemiological studies that have come up with a 

Parkinson's type syndrome associated with, let's 

say, toluene or methanol.

But I'm open to looking at something 

or rethinking this.

MEMBER FRIEDMAN-JIMENEZ: This is 

George Friedman-Jimenez. I agree with that. I 

think case reports can be very strong evidence in 

something like occupational asthma where there's 

an acute response that you can observe 

repeatedly.

But in something that's chronic with a 

long latency or even a shorter latency like 

Parkinsonism, a case report is not as strong. So 
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I think we should revisit the whole 

recommendation after we review the studies 

because it's not clear to me.

I'm not familiar with the deep 

research literature on this enough to say that 

we'll make this recommendation for a pretty 

common disease without really understanding how 

strong the evidence is. And I, for one, don't 

really understand it well enough to make that 

commitment right now.

CHAIR MARKOWITZ: So -- this is 

Steven. So what process, then, would we go 

through to assure ourselves that there is or is 

not a relationship? Is it a question of 

circulating the key studies, giving time to 

people to review them, and then revisiting the 

recommendation?

MEMBER FRIEDMAN-JIMENEZ: This is 

George again. Maybe have a -- read the studies 

and do sort of a journal club discussion on the 

phone with Dr. Mikulski, and see if we can get a 

consensus on which of these are strong enough to 
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make the recommendations. And then make a full 

recommendation later rather than pulling out one 

or two now and then adding more later.

CHAIR MARKOWITZ: So we could expand 

the working group to include the -- well, anybody 

who wants. Not the full committee because then 

we couldn't meet, but expand the working group to 

include a subset of the board in which the 

specific task would be to go through some of the 

scientific studies and look at the quality of the 

evidence. Is that sort of what the proposal is?

MEMBER FRIEDMAN-JIMENEZ: Yes. And 

I'll volunteer to be on a subcommittee, and we'll 

just review the literature and come up with an 

assessment of how strong the evidence is so that 

our recommendation will be more evidence-based 

because this is not part of my real area of 

expertise, Parkinsonism. And I'd like to see the 

literature in more depth, and maybe others would 

feel similarly.

MEMBER GOLDMAN: This is Rose Goldman. 

I'm happy to be on that committee, too.
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What I think would be also useful is 

perhaps, and maybe Marek can help find this, get 

a couple of these really good long-term studies, 

let's say of workers who have had toluene 

exposure. And see if among the conditions 

reported is Parkinson's, because maybe I'm not 

remembering well, but that is not one of my 

recollections as a condition because then what we 

could do, we would then be faced with weighing, 

okay, here is a case report which might be one 

example of an acute overexposure of whatever it 

is.

But then there are these three or four 

really large-term major studies of toluene or 

methanol exposure, and we don't see that. And 

the problem with the overdose from ingestion with 

methanol is it's so lethal that if you ingest it, 

most people die before -- many people die before 

you even have a chance to see how they're going 

to be afterwards because it's so lethal. So, 

anyway, that would be my suggestion for how you 

go -- afterwards.
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MEMBER FRIEDMAN-JIMENEZ: Dr. 

Mikulski, do you have a -- complete literature 

review of the chemicals, the studies that we 

would need to review for these five chemicals?

MEMBER MIKULSKI: Yes. Yes, and I can 

send these around. Yes.

MEMBER FRIEDMAN-JIMENEZ: That would 

be great. And if anyone knows any other studies 

that are important, Rose, if you know good longterm cohort studies, so we can look at all the 

literature, read the abstracts, and then look at 

the specifics of the studies and see if we 

believe the evidence because we're here making a 

presumption on a common disease with a fairly 

rare exposure saying that we're presuming that 

it's related to the exposure. And I think we 

should be careful about making that presumption. 

Make sure that we understand the level of 

evidence.

CHAIR MARKOWITZ: Okay. So who wants 

to participate in that working group, which will 

consist of receiving -- well, the studies will be 
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sent to all board members, but people who want in 

four weeks or so, four, six weeks, whatever, to 

get together on the phone and talk through the 

literature?

I hear Rose. I hear George. Anybody 

else?

MEMBER DEMENT: This is John Dement. 

I would --

(Simultaneous speaking.)

MEMBER DEMENT: -- to be on that.

CHAIR MARKOWITZ: Okay. John Dement. 

And I also will be -- I will volunteer.

So, Carrie Rhoads, you're getting the 

list here, right?

MS. RHOADS: Yes.

CHAIR MARKOWITZ: Okay. So I have --

okay. So --

MEMBER DEMENT: What would be the 

timeline?

CHAIR MARKOWITZ: We're going to have 

a full-board telephone meeting during the second 

two weeks of June, which is two to three weeks 
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prior to the term expiring. And -- I think. I 

think it's mid-July.

Actually, maybe, does anybody know, 

Mr. Chance, Ms. Rhoads, what the date of the 

expiration of the board is?

MS. RHOADS: It's July 15th for the 

current term.

CHAIR MARKOWITZ: Okay. Fine. Okay. 

So full-board meeting, then, that last week or 

two of June, which means that this discussion 

should happen roughly four to five weeks from now 

towards the end of May, no later than that, I 

would think. Does that work?

Okay. Then let me say, in the 

interest of time, let's not go through the final 

part of the recommendation, which has to do with 

presumption of -- about exposures and 

recommendation around duration or latency. The 

working group can look at those issues, as well, 

when they review the studies. Is that fair 

enough?

Okay, any final comments on this 
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issue?

Let's move on, then, to the Group 2A 

and other IOM source working group. Dr. Berenji?

MEMBER BERENJI: Yes. Can you guys 

hear me?

MEMBER FRIEDMAN-JIMENEZ: Yes.

MEMBER BERENJI: Excellent. Okay. So 

this is the SEM Work Group. We were specifically 

tasked for looking at the IARC 2A list of 

chemicals. Do we have our slides?

MR. BIRD: Yeah. I'm pulling them up 

really fast.

MEMBER BERENJI: -- post up our 

slides.

Okay. Great. So next slide. 

Excellent.

So just to my fellow colleagues Rose, 

George, Duronda, if you have any further input or 

want to comment anytime, feel free to do so. 

Okay? Excellent.

So, really, our task was to review the 

IARC 2A data looking at the chemicals. And at 
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least from my previous understanding from our 

last board meeting, I understood that the DOL was 

in progress in incorporating this information 

into the SEM. But I'm not sure if we actually 

got official confirmation on that.

If Rachel or John or whomever wants to 

comment on that.

MS. POND: This is Rachel. We've 

incorporated some -- we've incorporated IARC ---

the first list. But the one that we asked you 

guys to look into is the one that we need to look 

at incorporating. So we're looking for your 

recommendations on this.

MEMBER BERENJI: Excellent. Okay. 

Just wanted to make sure that we clarified that 

for the record. Okay.

So we're really going to focus today 

on the IARC 2A chemicals for the sake of time. 

There are also other sources of information, most 

notably the National Toxicology Program, or NTP. 

I did do a brief review, but there was over 100 

chemicals, and given the situation with COVID and 
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my work commitments, I wasn't able to do a full 

review of that.

And also, I did do a preliminary 

review of the Haz-Map website, and we can take a 

look at that in a little detail. And then I know 

Carrie Redlich has also done a lot of work on the 

SEM and looking at the exposure links. We will 

look at that as well.

Next slide.

So our work group met virtually on 

February 18th and on April 7th.

Next slide.

And I'm sure we're very well familiar 

with this website, but just for the folks out 

there, this is the website. And at least from my 

last check yesterday, the SEM was updated on 

November 15th, 2019.

Is this correct, Rachel, John?

MS. POND: Yeah, that's correct. As 

you know, we have a process where we go through 

DOE for security reasons. And so that was the 

last official publish date.
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MEMBER BERENJI: Okay. Just wanted to 

make sure.

Really, the SEM is used to identify 

the relationship between toxic substances and 

illness. And we know that the claims examiners 

and the folks at DOL do primarily use Haz-Map, 

the Haz-Map database. And I believe that's the 

website for folks who want to check that.

So everything in SEM must be preapproved by DOE, as Rachel just mentioned.

Next slide.

So this is just a brief overview of 

what the IARC has updated since 2016. Group 1 --

which is listed there -- there are 11 chemicals; 

Group 2A, 22; and Group 2B, 47. So for interest 

of time, we're going to focus primarily on the 

Group 2A chemicals, and we'll go from there.

Next slide.

So if you actually go to the IARC's 

website, you can download the Excel spreadsheet 

looking at all these chemicals, which I found to 

be very illuminating. And I actually was able to 
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pick out the 2A chemicals from 2016, and I 

created my own Excel spreadsheet.

Can you still see those chemicals?

CHAIR MARKOWITZ: Yes.

MEMBER BERENJI: Okay. So if you can 

see there, there are 22 chemicals from 2016 

through 2019. And I last visited on the 17th of 

March, so this is a fairly recent update.

And you can see that there's 22 

chemicals total, and the ones that I bolded are 

the ones that, based on my review of the IARC 

monograph, have the most connection to the 

workers that we are focusing on. So those are 

the ones that I'm going to briefly review.

And George, Rose, did you have any 

comments about this Excel spreadsheet?

MEMBER GOLDMAN: First of all, 

congrats on really doing a fantastic job on doing 

this.

The only other question we had 

discussed in our group is how much some of the 

people that work for DOE taking care of the 
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grounds -- which we normally haven't talked about 

that much, because it would be the 

groundskeepers, whether or not they would be 

spraying things like weed killers, glyphosates, 

or some of these other things that are 

pesticides.

And I think in our group discussion, 

we weren't very sure if those kinds of workers 

would be part of what our group is dealing with. 

You know --

MEMBER BERENJI: Duronda, do you want 

to -- Duronda, I think you had mentioned during 

our call that you had some experience when you 

were at Rocky Flats.

MEMBER POPE: Yes, I did. So during 

our discussion, I talked about how we had 

laborers that kept the grounds during my career 

at Rocky Flats. And they oftentimes used 

pesticides and different chemicals to keep the 

grounds maintained -- to maintain the grounds, 

rather.

So I think that that labor group 
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should be included in -- as far as the exposure 

in this -- as it relates to this case.

MEMBER BERENJI: Very well said, 

Duronda.

MEMBER SILVER: This is Ken Silver.

MEMBER BERENJI: Go ahead.

MEMBER SILVER: I'll second that with 

a case from Oak Ridge. Some of you know Dr. Rick 

Bird, who had a hand evaluating a large number of 

Oak Ridge workers. And I assisted him on a case 

of a groundskeeper with liver/gallbladder cancer 

from spraying phenoxy herbicides. So it does 

exist in the DOE complex.

MEMBER BERENJI: Rachel --

MEMBER DOMINA: Hey, this is Kirk.

MEMBER BERENJI: Oh, go ahead, Kirk.

MEMBER DOMINA: Hey, out -- for us out 

here at Hanford, it would be under the 

jurisdiction of the teamsters. And they continue 

to do it today.

MEMBER BERENJI: Go ahead.

MS. POND: This is Rachel. I think 
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you were going to ask me to weigh in on this. I 

know it's one of our job categories. So, I mean, 

it's definitely something we'd want to be 

considering.

MEMBER GOLDMAN: So is that to say --

(Simultaneous speaking.)

MEMBER GOLDMAN: --- then would we be 

putting in these things that are pesticides that 

would be used for the ground?

MS. POND: Yeah. I mean, that would 

be considered one of our exposures, I believe, 

from these workers because they'll still be 

considered daily workers. Really, sometimes it's 

going to depend on the contract if they were, you 

know, not on a particular contract. But we do 

have that as a job category. That is one of the 

things that we need to consider.

CHAIR MARKOWITZ: This is Steven. I 

have a question for the Department of Labor.

When using the SEM, I think the entry 

point is by DOE's site. If one were to take one 

of these agents like glyphosate and just ask the 
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question from a publicly available SEM, is 

glyphosate listed anywhere in the SEM at any of 

the sites? Is that normal for the public, or 

does that require some special search from your 

end?

MS. POND: Well, I know it's doable. I 

am not as familiar with the differences between 

the public site and the internal site. I know 

that you can search by chemical if that's what 

you're asking. I would think you'd be able to do 

the same thing on the public site, but I will 

have to fact check it. I don't go to the public 

site that often.

I can ask John and probably get back 

to you this afternoon.

CHAIR MARKOWITZ: Okay. Thank you.

MEMBER BERENJI: Any other questions?

MEMBER GOLDMAN: Oh, I just -- does 

that mean --- Mani, is that we might end up 

bolding some of those pesticides if we found out 

they might have been used over the last 20 or 30 

years because these would have blatant success 
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then.

MEMBER BERENJI: Absolutely. 

Absolutely. I think we can definitely do that. 

For all intents and purposes, I did do some 

preliminary research on the chemicals listed in 

bold. So I wanted to at least take some time to 

review those, and then we can definitely revisit 

the pesticides.

Next slide.

So I know that America's gone through 

these polybrominated compounds, but this is 

really focused on the polybrominated biphenyl, 

otherwise known as PBB.

I did some review of the IARC 

monograph. For those folks who don't know what 

that is, IARC is this international agency that 

produces information on chemicals, and in 

conjunction with the journal The Lancet, they 

actually are able to compile all this information 

into what are called monographs. So this is 

where I'm getting a lot of this information from, 

and I have that information in case anyone wants 
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to take a peek at that.

So at least for this presentation, 

really, the main focus is to look at the last two 

bullets. There's really limited human

epidemiological studies on this particular 

compound, at least based on the review I did in 

the monograph.

But you can actually see that despite 

that, there's still a lot of evidence in 

laboratory settings where there is evidence of 

carcinogenicity. And that was the basic 

rationale that IARC used to do this upgrade, 2B 

to 2A.

Next slide.

So as part of this review, I actually 

went ahead and looked up each one of these 

chemicals in the SEM just to see what would pop 

up. And I actually have a Word document in case 

anyone really wants to take a look at them. But 

this is just a snapshot.

So if you look at this, there is --

these chemicals do pop up in the SEM. Any 
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comments on that?

Okay. Next slide.

The next chemical is 

tetrafluoroethylene, and --

CHAIR MARKOWITZ: I'm sorry, Mani? 

Mani?

MEMBER BERENJI: Yeah, go ahead.

CHAIR MARKOWITZ: So, in the SEM, when 

you looked at PBBs from the previous slide, were 

there any health effects linked to it?

MEMBER BERENJI: Based on what I see 

here -- I can pull that up. One second. If you 

can see this, this is pretty much what comes up. 

 It just comes up with a chemical name, the 

CAS, all the aliases, but no health effects come 

up when you actually look up a chemical.

CHAIR MARKOWITZ: Okay. Okay. Thank 

you. We can continue. Thanks.

MEMBER BERENJI: Okay. Next slide.

So I know there are a lot of chemicals 

here, so I know that we want to be able to save 

time. But looking at tetrafluoroethylene, this 
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is another chemical that came up in the list from 

IARC.

So when you look at this particular 

chemical, from what I could review, there's only 

one cohort study that was able to identify cancer 

risk. And I actually put that reference right 

there. So there's elevated risk for all cancer 

sites, specifically liver, kidney, and leukemia 

cancers.

Next slide.

Again, I went through the same 

process. I put in tetrafluoroethylene into the 

SEM, and this is what came out. There's actually 

a lot more information, but again, the basic idea 

is that it comes up with the specific chemical 

byproducts but no health effects when you search 

by chemicals.

Next slide.

Silicon carbide whiskers. So this is 

a particular compound that is developed and is 

naturally found in both fibrous as well as nonfibrous form. And if you actually look up the 
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term silicon carbide whiskers, it actually refers 

to monocrystalline forms, which are primarily 

used in high-technology sectors. And in relation 

to the primary route of exposure, it used to be 

fibrous silicon carbide.

There have been some studies looking 

at exposures among worker cohorts. I believe 

this reference that I mentioned in bullet point 3 

was looking at workers -- I believe it was in 

some sort of chemical plant that I can't recall.

And if you look at the fourth bullet, 

this really kind of summarizes all that. So 

really only a few studies that have actually been 

able to directly link exposure to silicon carbide 

fibers to actual occupational cancers.

Next slide.

And again, just to reiterate, when you 

put in a chemical name, it spits out all these 

varieties of different forms that it comes in but 

no health effects directly linked to the 

chemical.

Next slide.
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So methylene chloride. I know I have 

experience with this particular chemical when I 

was an occupational medical resident at UCSF. 

And I remember we actually had to do some site 

visits when I worked at Cal OSHA for folks who 

were actually exposed to it. And Dr. Harrison is 

an expert, as many of you might know.

So it's really only for our purposes 

today. Methylene chloride is used in the 

manufacturing of a variety of different products, 

including polycarbonate plastic, and it's also 

used as a solvent.

There have been two cohort studies 

that have demonstrated exposure to this 

particular chemical and development of cancers, 

most notably liver and biliary tract cancers.

Next slide.

So you can see here that you can see a 

variety of byproducts when you search for 

methylene chloride in SEM, but no direct health

effects listed.

Next slide.
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How are we doing on time? Because I 

don't want to take up your time going through 

every one of these. Are we doing okay?

CHAIR MARKOWITZ: We're okay. By the 

way, how many more do you have?

MEMBER BERENJI: Which slide number am 

I on, Kevin? I can't remember.

MR. BIRD: Let me check.

MS. POND: While they do that, Dr. 

Markowitz, this is Rachel. I did find out that 

you can search on the public SEM by outcome.

CHAIR MARKOWITZ: Okay. Great. Thank 

you.

MR. BIRD: We're on slide 15 of 36.

MEMBER BERENJI: Okay. So for the 

sake of time, I mean, we can kind of scroll 

through these. If anyone wants the slide deck, 

I'm happy to send it to you.

But you can go ahead and keep going. 

Keep going past 17 and 18. Great. So you can go 

back to the previous slide on hand. Actually, 

that's perfect right there, NTP. Yeah. That's 
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great. Thank you.

So, again, at least from my review, 

the IARC chemicals 2A, in our system on the nonpesticides, we can see that there is demonstrable 

evidence with most of these chemicals that 

exposure -- especially among a variety of worker 

cohorts -- can lead to the development of a 

variety of cancers. And that was the rationale 

for IARC chemicals list 2A.

So now, looking here to the NTP, when 

I actually looked into this a few months back, 

the NTP actually had developed -- there are four 

pages for it because we reached back in 2016, and 

we had listed non-carcinogens at 62, and if you 

look at the last bullet, the ones that are 

considered to be reasonably anticipated -- I'm 

sorry. I can't see. I'm not sure what just 

happened.

MR. BIRD: All right. Sorry. One 

second. All right. We're back.

MEMBER BERENJI: There you go. Thank 

you.
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So, again, when you look at the last 

bullet, the reasonably anticipated to be human 

carcinogen, there are 186 chemicals listed in the 

14th Report on Carcinogens. Ideally, if we 

actually had additional resources on this board, 

I would love to be able to take a deep dive and 

look at these 186 chemicals and do an extensive 

analysis to see, are those working at these 

respective plants, had they been exposed to these 

186 chemicals? So far, I just did not have the 

time to take a deeper dive.

But does anyone have any comments on 

that?

MEMBER GOLDMAN: Mani, what about --

this is Rose Goldman again. What about the known 

62 carcinogens on that list, the 62? How many of 

those are ones that we're dealing with here in 

DOE?

MEMBER BERENJI: That I don't know, 

because I didn't really get a chance to really 

get into it with the sheer number and the 

resources we would need. We would be able to do 
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that, but I just didn't have the time. Does 

anyone happen to know?

MEMBER FRIEDMAN-JIMENEZ: This is 

George Friedman-Jimenez. There is a lot of 

overlap between the IARC Class 1 and the NTP 

known carcinogens. It's not a complete overlap, 

but "reasonably anticipated" includes mostly the 

2A and 2B. And you can't really distinguish them 

within the NTP reports. So it's much more 

difficult to decide whether it's probable or 

possible based on the NTP reports. IARC is more 

clear on that.

CHAIR MARKOWITZ: This is Steven. So, 

there is a lot of overlap between the reasonably 

anticipated, which is NTP, and Group 2A, so that 

if you look at Group 2A from IARC, then you will 

have done a bunch of the work for NTP.

But a lot of the NTP reasonably 

anticipated are not an occupational agents. The 

NTP are the much broader emissions, you know, it 

looks at carcinogens. So they're environmental, 

they're dietary, they're pharmaceutical. And so 
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that count is challenging but not quite as 

formidable as it looks from this slide.

MEMBER BERENJI: Well, that's good to 

know. All right. Next slide.

So Haz-Map, at least to my 

understanding, is the main reference for this. 

And they actually recently launched a new 

website. -So if anyone wants to take a look, you 

can. Next slide.

So I took a snapshot of the main 

webpage. So, I've got to be honest, I kind of 

like this layout. You can actually look at these 

respective tabs. You can look at hazardous 

agents. You call look at occupational diseases. 

You can look at high risk jobs. At least from a 

user-friendly perspective, I do like the way that 

they were able to do this. Next slide.

So, this is the most recent update 

when I last checked yesterday. It looks like 

they have been able to incorporate the ACGIH, 

which I believe is the -- I believe that's the 

industrial hygiene group. Is that correct, Dr. 
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Dement?

MEMBER DEMENT: Yes, that's correct.

MEMBER BERENJI: Okay. Do you happen 

to have any information on that with respect to 

the ACGIH update?

MEMBER DEMENT: Well, they publish a 

list every year that's updated. So there's a 

list and there's a designation of whether or not 

it's a carcinogen.

MEMBER BERENJI: Okay. All right. 

Well, you guys can read this for yourselves, but 

there has been additional supplements to these 

chemicals as listed below. 

So I think this was a good starting 

point. I think, hopefully, at least from my 

perspective, I'm always trying to be able to 

educate the public about workplace exposures, and 

having a website that's user-friendly and people 

can look up these chemicals as an adjunct to SEM, 

to me, that's something that's beneficial to 

everyone. Next slide.

So, Rose actually had brought this up 
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during our discussions. And I know that we've 

all been kind of stretched with the COVID 

situation. But, Rose, I wanted to give you this 

forum to give some insight and give us your 

thoughts about what do you think the SEM process 

is currently and how could the SEM improved.

MEMBER GOLDMAN: So, I think -- we 

didn't do an exhaustive run-through on it, but it 

looks like some of the things we discussed where 

some of the chemicals that are there aren't 

necessarily linked to some of these outcomes, for 

example, the cancers, and some are missing from 

there. And I guess we didn't really look at 

pesticides, for example, to have that so much on 

our radar screen.

So, particularly with the carcinogens, 

I think you have to do sort of a deeper dive to 

look at the chemicals that have come to 2A from 

IARC and see if they're in the SEM. And if 

they're in the SEM, are they linked to these 

kinds of potential cancers?

MEMBER BERENJI: Fair point. George 
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or Duronda, any comment on that?

MEMBER POPE: I'm sorry. Repeat the 

question, please.

MEMBER BERENJI: I'm sorry. Go ahead.

MEMBER POPE: I'm sorry. I didn't 

hear the question. So, somebody broke up.

MEMBER BERENJI: Oh, no, I'm sorry. I 

just wanted to see if you guys had any additional 

comments about what Rose just said.

MEMBER POPE: I don't have any 

additional comments to that. But I appreciate 

the report and I think it was well done. Thank 

you.

MEMBER BERENJI: Thank you, Duronda. 

Next slide. So, I know Carrie Redlich has done 

an extensive review, and I know we discussed that 

earlier, but for those of us who are really 

trying to get a better understanding of the SEM, 

you can actually look if I hold this up. And this 

is just to reiterate that point. Next slide.

And, again, I know we've talked about 

this already, as well. So we'll skip that. 
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So, I know, at least with respect to 

our task, incorporating the 2A chemical, I will 

defer to Steven in terms of how to proceed. But 

these are just my general comments about the SEM. 

And I know this is up for debate.

But, generally speaking, I don't feel 

the SEM is user-friendly. I realize what Haz-Map 

has been doing recently with the update on their 

website. And I'm hoping that SEM can follow in 

that direction to make it high-touch so folks can 

actually learn about the chemicals, have some 

sort of visualization, and a way to be able to 

make it more palatable as opposed to just putting 

text. Because sometimes people don't understand 

all the terms, but if you make it more 

interactive for folks, to me, that's the step in 

the right direction.

And that's about it. If anyone else 

has any other comments in the work group, please 

feel free to jump in.

MEMBER POPE: Hi, this is Duronda. I 

just want to agree with Mani that the SEM is --
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it was challenging just to get through, trying to 

figure out where everything was, and then try to 

understand it as it relates to understanding the 

exposure and connecting the dots, so to speak.

(Simultaneous speaking.)

MEMBER GOLDMAN: Okay, sorry. I'm 

also trying to understand how the SEM is used

practically. And I'm sorry, I'm newer to this 

Committee. I know that the claimant and claim 

official is using it. But I'm trying to imagine 

it from the examining, the doctor examiner. Does 

the examining physician who's trying to make a 

determination, is that doctor going to be --

let's say a worker, they see that that worker has 

an exposure to a certain chemical or has asthma 

or some condition.

Would they be going, the doctor, to 

the SEM to see what's there? Or is that 

something that would have already happened and 

this is some kind of documentation that goes to 

the physician?

MS. POND: This is Rachel. I can jump 
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in on that. Usually, we will make an assessment 

of exposure, send it to the doctor so they will 

have that information. We either make 

presumptions or there's information in SEM and we 

submit a determination and it goes to something 

that likely caused and we extend that cause 

contributed to or aggravated, we send it to a 

doctor.

MEMBER GOLDMAN: So would the doctor 

themselves also be looking at the SEM or no? Or 

just rely on whatever you send them?

MS. POND: Normally, the doctors 

aren't going to have access or go to the trouble 

of going to the SEM. So we try to provide them 

with that information. But that's research that 

our claims examiners will do up-front.

MEMBER GOLDMAN: So it really would 

help for the examiners, then, to have an easier 

to use, more robust platform, and to have it with 

more information, easier to use.

MS. POND: The internal SEM is 

probably a little bit easier to use than the 
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external SEM. But, yeah, if we can dedicate 

resources to updating it and changing the look 

and feel we'd probably love to do that. I'd just 

have to see what resources we have for that.

MEMBER FRIEDMAN-JIMENEZ: This is 

George Friedman-Jimenez. I was on this 

committee. Due to a number of factors, I wasn't 

able to really do any work, and I apologize for 

that. But I do have a thought. The SEM is 

really taking on a huge challenge. It serves 

several different functions, and I'm not sure 

it's easy to put them all into one function. 

For example, a doctor needs to know, 

given the patient presenting complaints, what 

they're exposed to. But what they're exposed to, 

what you're looking for, depends on what their 

diagnosis is. And, in some cases, the diagnosis 

depends on what they're exposed to.

So it's an iterative process that they 

have to look and see what the possible exposures 

are. And then, are there diagnoses that would be 

affected by those exposures or caused by them? 
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And then go back and see, really, what was the 

exposure? And then go back and see what is the 

causal link in the literature.

So the SEM is presumably the site 

exposure matrix that tells us about exposures. 

But to add on the functionality of determining 

the causal relationship I think is asking a lot, 

because we really want to cast a wide net when we 

think of, say, what are the diagnoses associated 

with asbestos. And you want to include pulmonary 

fibrosis. You want to include asbestosis. You 

want to include cervical cancer and all the 

diseases. But that doesn't mean the link is 

certain.

So I think that we should take a look 

at how to design the process using the SEM, using 

other sources, and possibly even creating another 

source that would be more user-friendly. I think 

the non-user-friendliness is in part because it's 

such a challenging function to design.

And I think our committee could work 

on that. I wish I had more time to be involved 
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and formulate this more. But I'm proposing that 

we try and rethink the whole process, not just 

looking at the SEM but other sources like Haz-Map 

and others, as well.

CHAIR MARKOWITZ: So, this is Steven. 

I have a couple comments. One is the SEM was 

built 15 years ago, or at least initiated 15 

years ago. And we've learned, since the beginning 

of Board in the last four years, that it is an 

essential resource constructed with great effort 

and also routinely used in the claims evaluation 

process. And it's unlikely that that's going to 

change. I think the Department would appear to 

be receptive to any recommendations about how to 

improve the SEM.

But I want to actually address a 

different issue about this committee, the 2A. So 

one challenge, I think, on the 2A is that there's 

a mix of evidence that IARC uses to come to its 

conclusions. And a part of it's mechanistic 

evidence, part of it's animal evidence, part of 

it's epidemiology.
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If there was strong epidemiology, then 

it wouldn't be classified as a 2A, probably; it 

would be classified as a 1. Which means that, 

more likely than not, the 2As have weaker 

epidemiology, which is compensated for by 

reasonably strong animal evidence or mechanistic 

evidence. So, ultimately, the Department of 

Labor is interested in connecting a chemical, a 

toxic substance, to a particular type of cancer; 

say, methylene fluoride and lubricants or 

whatever.

So in looking at the 2As, the question 

I have for the committee is for which 2As will it 

be able to make a recommendation of a connection 

between that agent and a particular human cancer 

site?

And by way of background -- many 

people on the Board know this, but maybe not 

everybody in the public -- there's not a one-toone correspondence between the animal cancer site 

and a human cancer site.

So I just raise this as a challenge. 
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But I think it could do what we want to do in 

response to the DOL request. I think we probably 

have to sort out the two ways for which we have 

some confidence about a particular human cancer 

site. Does that make sense?

MEMBER REDLICH: Yes. This is Carrie 

Redlich. I just had a similar thought. I mean, 

Mani, this is a really impressive review, which 

is terrific. Because of this -- because, I 

guess, similar in the same vein as Dr. Markowitz, 

either there's an issue of duration and magnitude 

of exposure, and you probably have a sense from 

the literature which ones there is a stronger 

case for than others. And also which ones, 

considering the type of work that was done, would 

likely have been sufficient in the magnitude and 

duration of exposure.

And obviously, with cancer, that's 

always challenging. We don't know what a lowest 

dose is. But I would suspect that, of the list, 

that there are some that are much stronger than 

others.
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MEMBER BERENJI: This is Mani. Thank 

you, Carrie, for those nice words. So, at least 

based on the chemicals that I've reviewed in the 

PowerPoint, there was strong neurological 

evidence for the vast majority. There were 

examples where there wasn't.

We could definitely come up with a 

tiering, or come up with a tiered system by which 

we can identify those 2A chemicals that have 

strong human epidemiological evidence, moderate, 

and weak. I think that might be a good way to 

kind of identify, at least for the purposes of 

DOL, which chemicals they can really get the most 

response.

MS. POND: This is Rachel. I just 

want to comment here that the SEM -- pretty much 

the reason we use just one is that it's causation 

we're kind of relying on. For the 

recommendations that come from the Board, we can 

put them in the policy as contribution or 

aggravation.

And that tiered approach that you're 
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talking about would fit into that scenario where 

we put this into policy as some sort of a 

presumption for aggravation or contribution, 

rather than saying as strongly as we would in the 

SEM or with the first list. You know, here are 

the presumptions, here are the tiers. Those are 

the kinds of things that could be really helpful 

in how we phrase it in our policy.

CHAIR MARKOWITZ: Okay. So shall we 

move on, or?

MEMBER DEMENT: This is John Dement. 

So I just have a question on what's the path 

forward of this. It seems like it's almost an 

agent-by-agent review to determine whether or not

we feel there's sufficient evidence to pull it 

into the SEM based on at least some human data.

MEMBER GOLDMAN: This is Rose again. 

So would there be a proposal, actually, to get 

them to do something along the line of, if it was 

in 2A but a higher level of epidemiological 

evidence, that that could be pulled in to the SEM 

as an aggravating or contributing factor to the 
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cancer?

MS. POND: So, as I said -- this is 

Rachel again -- that would probably be something 

we put in our policy and our procedures that our 

claims examiners would look for, rather than 

putting it in SEM, which is more of a causation -

- direct causation link. But it would be 

something we'd definitely incorporate into our 

process.

MEMBER REDLICH: You know, I guess --

sorry to interrupt again. We can't, obviously, 

create in the SEM, you know, the clinical 

decision-making that George mentioned. But in 

terms of -- obviously, there's some exposures 

where we have very common cancers with other 

common known causes, whether, you know, smoking 

and lung cancer or colon cancer.

And so, realistically, you're 

potentially opening up a large number of cases 

that could be attributable to potentially, you 

know, a variable amount of exposure at some point 

in time that's passed. And so it seems, then, in 
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thinking of the priority, it might be helpful to 

also think in terms of, yes, how strong is this 

literature, but also what are the other common 

risk factors? And how does the magnitude of that 

one compare to other factors?

I mean, something like vinyl chloride, 

you know, with asbestos mesothelioma, that 

linkage, because it's rare, but when we see it, 

there aren't other things that cause it. So, 

when you have cancers like colon or lung, it 

gets, I think, more challenging.

CHAIR MARKOWITZ: Okay. So, this is 

Steven. We need to move on. So let me suggest 

that these issues go back into the working group 

to make some progress on.

MEMBER BERENJI: Thank you, Steven. I 

took some notes and we'll definitely review them 

before June.

CHAIR MARKOWITZ: Okay, great. Thank 

you.

MEMBER REDLICH: Thank you for taking 

on a difficult subject.
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MEMBER BERENJI: Thank you.

MEMBER FRIEDMAN-JIMENEZ: Yeah, I want 

to thank Mani for giving a great review of this 

question and laying out the issues. And it's a 

very difficult topic and I think we'll make more 

progress on it. So I look forward to working 

with you more. Thanks.

MEMBER BERENJI: Great. Thank you, 

guys.

CHAIR MARKOWITZ: Yeah, it would be a 

great contribution. Okay. So we have till 3:15 

or so. What I propose is we're going to skip the 

free-ranging discussion about the assessments of 

the CMC and the IH and use some of the more time 

limited and specific topics, and then get back to 

the issue of CMC and IH.

So we're going to move ahead to the 

2:30 topic. And the first is the B reading issue 

which I will lead. 

Kevin, there's a Word document that I 

sent you as the file that's called "ABSTWH B read 

DOL." And while Kevin is finding that, let me 
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just set out what the issue is. I'm not even 

sure we necessarily need to look at this. But if 

we can, that would be great.

So, the Department asked us, in a 

letter from the Department dated February 12th, 

they asked us certain questions. I'm going to 

paraphrase for the sake of time. 

The program has seen variations in how 

B readers are certified and how their 

certification is documented on test results. And 

that, quote, the OWCP request that the Board 

provide input on the certification requirements 

for B readers and guidance on how claims staff 

can verify test results that originate from a 

qualified B reader, end of quote.

So I prepared a draft on this issue, 

which I sent to the physicians on the Board a 

couple weeks ago to get their initial input. And 

I got some feedback. And let's see. 

So, Kevin, you're still looking for 

it, right?

MR. BIRD: Yeah, that's correct. Do 
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you remember when you sent it to me? And does it 

have B reader in the title or B read in the 

title?

CHAIR MARKOWITZ: No. Is it easier 

for me to just send it again? I could just send 

it to you.

MR. BIRD: That would make sense, 

yeah, if you can.

(Pause.)

CHAIR MARKOWITZ: Okay, I sent it. 

But I can just walk people through it. So, the 

question is about the nature of the B read 

program and certification. And so the draft 

responds that the B reading is administered by 

NIOSH. It is very well described on the NIOSH 

website, and I provide the website to look at.

And then I state that the physicians 

become a B reader after they demonstrate 

competence in applying the ILO classification by 

completing an examination, the NIOSH B reader 

examination. It has to be updated every four 

years.
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So, a physician has gone to 

Morgantown, West Virginia, taken the B read exam. 

And if they pass it, then they're a B reader. 

And that, again, consists of looking at a number 

of films and correctly identifying a certain 

proportion as representing various substances in 

the lungs, asbestosis, silicosis, et cetera. And 

also identifying films that don't have disease.

And the list of certified B readers is 

available on the NIOSH website. So this 

description of how you get to be a B reader and 

the currently certified B readers is all 

publically available for claims examiners or 

others in the Department to check.

Currently, there are 176 B readers. 

Okay. I was reading from my own slide. Okay, 

176 B readers. And, again, they're listed. It 

just says that they're current. It doesn't 

really give a date of how current they are. But 

it's probably pretty up to date. So --

MEMBER GOLDMAN: Actually, it's not 

that up to date. This is Rose. Because we tried 
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contacting a number of them to do B readings at 

Cambridge and they --

CHAIR MARKOWITZ: So the last part of 

your comment dropped off. What did you say?

MEMBER GOLDMAN: This is Rose. We 

checked a number of the people on there for 

getting B readings and they weren't active. So I 

don't know. That was a few months ago.

CHAIR MARKOWITZ: Okay. So I guess, 

for the claims evaluation process, in respect to 

a given claim, the claims examiner is wondering 

whether the person, the claim that contains the B 

read, was actually obtained by a B reader, the 

physician's name is at the bottom of the B read. 

And they can then check the file and they can 

determine whether that person was on the list, at 

least in the recent one.

So, further, the draft comments that 

the B reader program is excellent and it's been 

invaluable for its purposes. The purposes have 

traditionally been epidemiologic, surveillance, 

and monitoring studies, not really diagnostic.
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I then write up a comment that there's 

been some well-publicized -- meaning they've been 

in the media -- incidents of B reader abuse or 

alleged abuse over the years. And to our 

knowledge -- and this represents the collective 

knowledge of the people on the Board, so you've 

discussed it -- that there's no highly prevalent 

pattern of abuse has been documented.

NIOSH has proposed a modification of 

the Coal Workers' Health Surveillance Program to 

permit NIOSH to suspend and disqualify B readers 

who are persistently inaccurate. And I think 

that follows a scandal in the Coal Workers' 

Program of misreading of B reads, although I 

don't have the details of that. That may be the 

Johns Hopkins radiologist incident. Maybe 

someone else on the Board knows about that.

But in any event, NIOSH now has at 

least proposed a provision that allows them to 

examine an incident representing possible abuse, 

or a pattern of abuse, and then they can 

disqualify such people.
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And then, finally, Item No. 3. 

Whether a person is a B reader, there's no 

standard way that a B reader labels their B read 

as being performed by a B reader. There is a 

standard form for B reading that could, perhaps 

should, be included, but not necessarily in the 

claims process.

But the fact that there's no 

recognized stamp for B reading that NIOSH hands 

out when you pass the exam is not really a 

problem because if there's any questions about 

whether the person is actually a B reader or not, 

that list on the website could be checked.

And, finally, we make the point that B 

reading is not diagnostic of itself. A B reader 

typically does not have information about the 

clinical status, about the occupational history 

of the person whose film their reading. And that 

the B reading is designed to be used, at least 

for clinical purposes, in association with 

clinical exposure and some research information 

or the general knowledge by the clinician to make 
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the diagnosis.

So, questions, comments? This is 

something that, if there are corrections, if we 

could do them now, that would be great because 

then we could -- well, this is not here. So this 

addresses the questions that OWCP asked us about 

how claims staff can verify test results that 

originate from a qualified B reader. 

So, what this says here is that claims 

examiners can verify that it was a B reader who 

read the film, but cannot directly verify the 

reading itself, for example, by preparing a B 

reading to a routine radiology reading.

The B reading may because they're 

looking -- they're qualified and are looking for 

a dust-related diseases and they have a more 

nuanced or a more accurate reading of the film. 

So a simple comparison of a standard radiology 

reading and any discrepancy doesn't inform you 

that the B reader is not giving an accurate 

reading or not.

Other clinical, medical, occupational 
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information could be used in conjunction with the 

film. But as it says here, it's the last line, 

any discrepancies between a B reading result and 

other physicians' opinion cannot be settled by 

claims examiners. It's really a medical issue. 

And if there's a question about the B reading, 

that would be something that I think would have 

to be reviewed by a qualified CMC.

So, the floor is open for comments.

MS. POND: Dr. Markowitz, this is 

Rachel. I just wanted to give a little context 

to why we're asking the question. And, 

basically, you've been seeing some reports coming 

in. We'll have an original B reader from a 

decade ago and somebody new will come in and 

review the report as a B reader now, review the 

test results and tell us a certain diagnosis. 

And that's why we just needed to check because 

then we have a conflict when somebody who is 

treating a patient ten years ago and isn't now 

but is coming and saying that's it's not what the 

original B reader said.
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So we're just trying to make sure our 

claims examiners are doing their due diligence in 

checking the qualifications, making sure that 

we're doing what we need to do. And as you said, 

obviously, they're not going to try to do any of 

the -- look at the reports themselves and 

determine which is which as far as a medical 

opinion. But we want to first verify that 

they've got the right qualifications as B 

readers.

CHAIR MARKOWITZ: Well, B reading work 

may be done by a B reader who's no longer on the 

list because the CMC chose not to renew their 

certification. So checking, frankly, the 

publically available lists now you can look at a 

reader from ten years ago. The person may not be 

there. So that's typical.

MEMBER GOLDMAN: This is Rose Goldman 

again. So, part of the issue, too, is that ten 

years ago people were doing a B reading on 

regular X-ray films. And what's happened 

recently is that there's been a transition to 
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digital film and, actually, really looking at it.

And so looking at an X-ray that either 

was scanned in from an analog kind of film ten 

years ago and re-reading it now, there could be 

problems with that. Or you get another X-ray now 

which is a digital film.

And so both really could've been 

accurate ten years ago and now they're on 

different media. And also there's a process that 

if there is a disagreement, I believe NIOSH --

and I would defer to Carrie. But NIOSH has a 

program where if two B readers disagree, they 

actually have three B readers then review the 

film, or something like that, because there could 

be differences, particularly at the finer levels 

of it.

MEMBER REDLICH: I think your point 

that the electronic imaging has actually, I 

think, improved the system. It's also made it 

easy to send films to a B reader to review 

electronically.

MEMBER GOLDMAN: I guess the specific 
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issue that is being raised is what?

CHAIR MARKOWITZ: That's a question, I 

think, for Rachel.

MS. POND: I'm sorry. Yeah, I mean, I 

think what we're asking for is basically what it 

sounds like you're going to provide to us. Some 

things that you can look for to make sure that 

we've got a B reader and the cases that you're 

providing now with regard to things might've been 

different before, ten years ago. And now we've 

got doctors that are coming in that are looking. 

They provide us with a B reading and provide us 

with a certain result. This result they're 

providing us with now is different than the one 

we had in our documentation from the last time or 

initially when the system was getting the test 

results. So I was just trying to provide a 

little context as to why we're asking for this 

criteria and how we would use it.

MEMBER REDLICH: Yeah, I think it is a 

problem that the number of certified B readers 

has gone down a lot. We currently do not have 
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anybody in Connecticut. I think the new OSHA, or 

not so new anymore, OSHA's silica standards, one 

good side effect of that is that a lot of 

radiologists are now getting B certified because 

there's an increasing need for B readers.

So, hopefully, in the future, there'll 

be more certified B readers. And I think 

radiologists are a good group to get certified.

MEMBER GOLDMAN: And I'm thinking --

this is Rose again -- we don't have any 

radiologists at our hospital who are B readers, 

and they don't seem to be that interested in it. 

It's the training and very relatively small 

level of reimbursement. And the people who tend 

to be doing it are people that want to do a lot 

of them, perhaps, for some reason. And there's 

just a very few number. 

And there's a transition that's going 

on because they are transitioning from the analog 

film to the digital. And I think they finally 

made that transition this year. And the new 

training and testing will be with the digital 
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film.

So that may improve things and make it 

a little easier for people to get certified. But 

I think, from the point of view of the DOE 

people, that you should be able to see the actual 

form that is filled out by the B reader. That 

should be part of that record. And then you can 

compare it to the old one and see how big a 

difference there is. And if you're really 

concerned there's a really big difference, you 

could then have a third person or another person 

do the re-read if you could find the person.

MEMBER SILVER: This is Ken Silver. I 

have a question for the doctors. Will the move 

to digital films result in more positive 

readings? Is there a systematic increase in 

sensitivity?

MEMBER GOLDMAN: NIOSH, I think, has 

looked at this as far as the reading. It's a 

challenging issue because, from the clinical 

perspective, most patients with respiratory 

disease, the threshold for getting a chest CT 
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scan has gotten so low that that is what is being 

clinically used to diagnose whether there is any 

interstitial process at all.

But there's an epidemiologic and a 

population basis to have B reads and something 

you can follow at the time. Most of the charts 

that I've reviewed, those people that had a 

positive B read also had evidence of lung disease 

in other ways in terms of either lung function 

testing or a CT scan.

So I think if you had a B read, you'll 

have certain criteria to qualify as one. But you 

can also have either a Part B or E condition 

without having a B read.

MEMBER SILVER: Thank you. Going back 

to Ms. Leiton's context for this, is it fair to 

say that a B read of a digital film, if you still 

call it that, is more likely to detect pathology 

that would have missed ten years ago on a 

traditional X-ray? More sensitive?

MEMBER GOLDMAN: No, I mean, my 

understanding is, you know, we pickpocket NIOSH 
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and others that have done side-by-side 

comparisons. And I don't think so. I think a 

general radiologist, their threshold to order a 

CT scan is pretty low, not so much worrying about 

mild interstitial changes but a concern about 

missing a cancer.

But I think in terms of reading 

plaques or markings that could be asbestos or 

silica, I don't know of any data that supports a 

difference --

MEMBER SILVER: Thank you.

MEMBER GOLDMAN: -- of a systematic 

change in the way the reading has been done.

CHAIR MARKOWITZ: Okay. I'm sorry to 

interrupt. I just want to -- finish your 

thought. I apologize.

MEMBER GOLDMAN: No, that's it. 

That's it.

CHAIR MARKOWITZ: Okay. So, I want to 

close out this topic here. So I've added -- I've 

Kevin has now written in Item No. 6, the B 

reading has evolved over recent decades to 
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incorporate digital films that are currently the 

radiology standard. This has produced some 

variation of B readings between current and 

previous B reading. So, are there proposed 

changes to this draft response to DOL that we can 

address here and now?

MEMBER SILVER: If we back up from the 

technical aspects of this and return to the theme 

of EEOICPA as a claimant-friendly program, would 

we want to entertain language to the effect that 

discordant results between B readers ought to be 

resolved in favor of the claimant?

CHAIR MARKOWITZ: Oh, I would say 

discordant results ought to be resolved by CMCs. 

The issue -- I think Dr. Redlich really -- well, 

maybe somebody, I'm not sure who -- addressed you 

don't really look at the B read in isolation. We 

really look at it in terms of pulmonary function 

and exposure to make sense of it. And so that 

picture has to be done by a physician who's 

familiar with the diseases. And it should be a 

CMC who's familiar with that.
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MEMBER GOLDMAN: This problem predates 

digital films. I don't know how many times that 

they see the quality of the film or whatever, a 

discrepancy. And then I think what was said is 

to look at that in the context of all the 

information.

CHAIR MARKOWITZ: So --

MEMBER GOLDMAN: So I would second 

what Dr. Markowitz said. I think the good thing 

about the digital films is, if one wanted to, one 

can more easily get another opinion on them. 

Hopefully, that would not be needed.

CHAIR MARKOWITZ: This isn't really a 

recommendation. This is just a response to a DOL 

request. But our only means of consensus is to 

vote on it. So I think we should probably take a 

vote on this. Are there any -- I guess I need a 

proposal to adopt this response.

MEMBER GOLDMAN: I propose that we 

adopt the response.

CHAIR MARKOWITZ: Thank you. Is there 

a second?
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MEMBER BERENJI: I second. This is 

Mani Berenji.

CHAIR MARKOWITZ: Okay. So it's open 

for discussion, further discussion, including any 

amendments or tweaking of this language before we 

vote on it.

(Pause.)

CHAIR MARKOWITZ: So if there are no 

suggested changes, then I'd say we should just 

vote on it. Carries Rhoads, do you want to do 

this by roll call?

MS. RHOADS: Mike, do you want me to 

do this or do you want to?

MR. CHANCE: I'll take it.

MS. RHOADS: Okay.

MR. CHANCE: Okay. Here we go. Dr. 

Berenji?

MEMBER BERENJI: Yes.

MR. CHANCE: Okay. Dr. Dement?

MEMBER DEMENT: Yes.

MR. CHANCE: Okay. Mr. Domina?

MEMBER DOMINA: Yes.
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MR. CHANCE: Okay. Dr. FriedmanJimenez?

MEMBER FRIEDMAN-JIMENEZ: Yes.

MR. CHANCE: Okay. Dr. Goldman?

MEMBER GOLDMAN: Yes.

MR. CHANCE: Okay. Mr. Mahs?

MEMBER MAHS: Yes.

MR. CHANCE: Okay. Dr. Markowitz?

CHAIR MARKOWITZ: Yes.

MR. CHANCE: Dr. Mikulski?

MEMBER MIKULSKI: Yes.

MR. CHANCE: Okay. Ms. Pope?

MEMBER POPE: Yes.

MR. CHANCE: Okay. Dr. Redlich?

MEMBER REDLICH: Yes.

MR. CHANCE: Okay. Dr. Silver?

MEMBER SILVER: Yes.

MR. CHANCE: All right. And Mr. 

Tebay?

MEMBER TEBAY: Yes.

MR. CHANCE: Okay. It looks like we 

have a unanimous yes.
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CHAIR MARKOWITZ: Thank you. So 

before we take a break, I just want to announce 

to the public at 3:30, we will have our public 

comment session. If you would like to make a 

public comment, if you could email Carrie Rhoads 

now, that would be helpful. Her email address is 

capital R-H-O-A-D-S dot capital C-A-R-R-I-E at 

DOL dot gov.

So we're going to break now and then 

we'll resume at 3:30. It doesn't look like we're 

going to need the entire public comment period 

for public comment in which case we'll just 

resume the Board meeting during this period. 

Thank you.

MEMBER REDLICH: Can we keep our 

phones on? Can we keep these phones on, or are 

we re-dialing back in?

MR. BIRD: If you can keep it on, 

that's great. But if you have to re-dial, that's 

okay, too.

MS. POND: Dr. Markowitz, this is 

Rachel. I was planning to get off at this point. 
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But if you need me to stay on after the comments, 

I can do that. Do you think you'll need me this 

afternoon?

CHAIR MARKOWITZ: It's hard to say. 

Of course, we always need you. But we're going 

to talk about the occupational questionnaire and 

then we're going to talk about the assessments of 

CMC and IH performance. I don't know that we'll 

have any more questions. I'm sure Mr. Vance or 

Mr. Pennington are around who could probably 

answer them. But --

MR. VANCE: Hey, Steven. This is 

John. I can barely pick you up.

MS. POND: I'll just come back on, Dr. 

Markowitz, and I'll be available if you need me.

CHAIR MARKOWITZ: Okay. Thank you.

(Whereupon, the above-entitled matter 

went off the record at 3:18 p.m. and resumed at 

3:32 p.m.)

CHAIR MARKOWITZ: Mr. Chance, do you 

need to say anything at the beginning of the 

discussion?
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MS. RHOADS: No, you can present the 

meeting.

CHAIR MARKOWITZ: Okay. Thanks. 

Okay. We'll start the public comment session. 

We have only two comments. And normally, we 

limit people to five minutes. But in this case, 

you can take a little longer.

So we're going to start with -- oh, 

let me just say that if anybody is on the phone 

from the public and you decide you would like to 

make a public comment, then you should say so. 

Let me ask Kevin. Is the public who's on the 

line, are they muted or unmuted?

MR. BIRD: Every member of the public 

right now is currently muted. When you call on 

them, I will unmute them so we can hear them.

CHAIR MARKOWITZ: Okay, okay. So 

again, if there's any member of the public on the 

phone and you would like to make a comment, just 

email to the email address that's on the board 

which is energyadvisoryboard@dol.gov. Okay. 

We'll start with Terrie Barrie. Welcome.
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MS. BARRIE: Thank you, Dr. Markowitz. 

I appreciate this opportunity. And, members of 

the Board, thank you for a lively discussion 

today. My name is Terrie Barrie, and I'm from the 

Alliance of Nuclear Worker Advocacy Groups.

I want to call your attention to a 

recent issue that came across my desk. The 

Seattle Times published an investigative report 

which found that the respirators Hanford workers 

used between 2012 and October of 2016 leaked. 

The Department of Energy contractor admitted the 

respirators did not properly protect the workers 

from the exposures and identified over 500 

workers who were affected.

A similar situation occurred with Y-12 

respirators from at least 2009 until 2012. In 

that situation, the respirators were not properly 

cleaned. I will supply the link to the articles 

when I submitted these written comments.

I have no idea how many claims were 

submitted to the OIG for these two sites during 

this time period. But according to the Seattle 
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Times, at least one claim was filed by a Hanford 

worker. I am worried about these workers.

The Board has expressed concerns in 

the past over the OIG's contracted industrial 

hygienist reports. Some reports seem to be 

written using boilerplate language which tends to 

assume that workers employed after 1995 would not 

have been exposed to toxic substances above the 

regulatory limit.

I ask the Board, and I actually 

respectfully request the Board that they get a 

sampling of claims from the OIG submitted from 

the Hanford and Y-12 workers during this time 

period so that you can review not only the 

industrial hygienist reports but also the types 

of documents the Department of Energy provided to 

the OIG when DOE was complying with our request.

Claims examiners and subsequent 

industrial hygienists and contract medical 

consultants cannot adjudicate claims in a fair 

manner as they do not have all the facts from the 

Department of Energy.
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I had to admit I was quite 

disappointed to say the least with Department of 

Labor's position on the Board's request for a 

support contractor. This recommendation/request 

is more than two years old, so it's not a 

surprise to the OIG.

If this process was started as soon as 

the Board first requested assistance, they would 

have a contractor by now. Department of Labor 

just added another burden to prepare to the 

Board. They want the Board to prepare a formal 

request which would include the number of hours, 

the job category, and the pay rate for a future 

contractor.

Isn't that something Department of 

Labor's contracting office would have more 

experience with? It seems to me that the 

Department of Labor just doesn't want to provide 

the assistance the Board needs.

When it comes to -- I'm still opposed 

to just giving the Board ten days to review 

policy changes. I believe it is necessary that 
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the Board be consulted in the very early stages 

of the deliberations. The OIG says it can 

because the policy changes at this stage are predecisional and cannot be discussed in public.

However, NIOSH does it all the time. 

They publically discuss their pre-decisional 

documents with the Advisory Board on Radiation 

and Worker Health Work Groups. Meetings of the 

work groups do not need to abide by the FACA 

regulations to publish -- like subcommittees do 

to publish meetings in the Federal Register.

I think something should be done 

similar -- something similar should be done with 

the Board. The language in both -- in the 

statute for both this Board and the one for NIOSH 

is very similar.

And unless I'm missing something, the 

process could be easily adopted. You already 

have established work groups. Perhaps a work 

group could be formed so that all proposed policy 

changes are reviewed by the work group.

For example, the OIG notified the 
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Board five months ago that this new procedure 

manual change was happening in the spring. If 

the OIG has shared with that work group the 

details of what was being changed, the work group 

could've just determined whether or not the full 

Board needs to weigh in.

As explained earlier today by Mr. 

Vance, most of the changes in the procedure 

manual are administrative. And the Board doesn't 

need to deal with whether there should be a cover 

letter to a recommended decision or not.

But they should have the opportunity 

to say yes or no, it does fall under our purview. 

And especially when there are things like the 

changes to the presumption of non-Hodgkin's 

lymphoma. They should have the opportunity to 

weigh in on this.

And it's hard for me to understand why 

the OIG refuses to draw on the highly qualified 

expertise of this Board. It's just unfathomable 

that they wouldn't say, hey, what do you think?

The other issue I have is the 
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continuing complaint I hear that Department of 

Labor drags their feet in getting the claims to 

the Board so they can review as part of their 

responsibilities. There must be an option to 

expedite this information. And I would hope that 

the OIG would work on that.

And in closing, I want to thank the 

Board for their work these past two years. And I 

hope all of you will continue. Like I said, you 

offer so much expertise to help the OIG with this 

program.

And I also want to thank Department of 

Labor for issuing the notice requesting 

nominations for the Board who don't want to 

continue so early in the process. This will 

result in the continuity of the Board's work.

I thank you again and look forward to 

listening to more of the Board's discussion. 

Thank you.

CHAIR MARKOWITZ: Thank you. I hope 

you put some of those comments in writing.

MS. BARRIE: Yes, sir. I did.
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CHAIR MARKOWITZ: Are there other 

public commenters?

MR. BIRD: Carrie, who do you want to 

go next?

CHAIR MARKOWITZ: I don't think there 

is anybody next.

MR. BIRD: We have one more. Hold on 

one second. Sorry. Yeah, I think Carrie just 

got dropped off for a second. We will --

MS. RHOADS: Hi, I'm back.

MR. BIRD: Is Stephanie Carroll on the 

line? Ms. Carroll, are you on the line. Carrie, 

is that the only other request that you received?

MS. RHOADS: That's the only other 

request. I'm sending her an email to let her

know what the number is. Maybe you can find her.

MR. AVERY: I have a request.

CHAIR MARKOWITZ: Sure. Who's this?

MR. AVERY: My name is Ronald Avery.

CHAIR MARKOWITZ: Okay. Go ahead, Mr. 

Avery.

MR. AVERY: Yeah, I was employed at 
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Rocky Flats from February 1970 to March 1989. I 

was in the plutonium recovery for about the whole 

time I was out there. I was a chemical operator 

for the first nine years, and I was a radiation 

monitor for three and a half years. And then 

back to chemical operator and then a technical 

foreman.

And I was diagnosed with sensorineural 

hearing loss. And according to the criteria, 

they say you had to have ten consecutive years in 

one of the categories. And chemical operator is 

one of the categories, but I was a radiation 

monitor for three and a half years. And even 

though they were exposed to one or more of those 

toxins, they're not listed in the job category.

And I can't understand because they 

turned it down. I filed on it. But even a 

contributing factor or aggravated because the 

hearing test from the time that I started out 

there until I quit, the hearing loss was notable.

And I just don't understand. Is SEM -

- do they actually know what the job categories 
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does? Because a radiation monitor works in the 

same room with the chemical operators right 

alongside of them. And I just have a little bit 

-- and even the technical foremen do too.

So I'm having a little bit hard trying 

to understand how they go about picking those job 

categories. I know you can talk about hearing 

loss today, but I wanted to say something about 

it.

CHAIR MARKOWITZ: Thank you. So this 

public comment period is not meant to be a 

discussion back and forth. But I do want to make 

a comment.

The Board did discuss the issue of 

hearing loss and solvents exposure at the site. 

And we made a recommendation several years ago 

that Department of Labor not require ten 

consecutive years of exposure to the solvents in 

the relevant job title. Actually we recommend 

that they reduce it to seven years and that it 

not be consecutive and also that a greater number 

of job titles be accepted.
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And so they did not agree. They did 

not change the consecutive year criteria. They 

did open up the job titles. I'd have to look at 

the -- if you look at the exposure manuals to see 

exactly what the phrasing is. But I just wanted 

to give you that feedback in terms of the Board 

thinking about this.

MR. AVERY: Thank you. I appreciate 

that.

CHAIR MARKOWITZ: Are there other 

public commenters?

MS. RHOADS: Just Stephanie Carroll.

CHAIR MARKOWITZ: I'm sorry. Is this 

Ms. Carroll? And I see we accepted an email, 

3:40. She just sent an email to make a public 

comment, right?

MS. RHOADS: That's right. Ms. 

Carroll, if you're on the call, we're trying to 

find you so you can make your comment. Kevin, do 

you see her number anywhere?

MR. BIRD: No, and all of the lines 

are open. So if she was here, she could.
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CHAIR MARKOWITZ: Okay. I would just, 

while we're on public comment, point the Board to 

a site where a written comment was submitted 

today from Ms. Vina Colley whom we've heard from 

before from Portsmouth Gaseous Diffusion Plant.

And what she says summarizes a letter 

from 2008 actually from the contractor to the 

Radiation Advisory Board and SC&A and which they 

refer to a site profile. A review of the site 

profile of the plant and that there was an 

attachment to that report called the Summary of 

Site Expert Interviews which is undergoing 

clearance and was not included in that 

submission.

And Ms. Colley's point she wants to 

raise is that the summary may still not be 

available publically. So I think that captures 

her public comment.

Okay. So are there no other public 

comments? I'll make one last effort for Ms. 

Carroll if you're there. Ms. Carroll? Okay. So 

are we permitted then to close the public comment 
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period and go back to Board business?

MR. CHANCE: I'm fine with that, Dr. 

Markowitz, if you would like.

CHAIR MARKOWITZ: Okay, good. Okay. 

So --

MR. BIRD: Dr. Markowitz, it's really 

hard for me to hear you. I don't know if that's 

the case with others as well. But I'm having a 

little difficulty.

CHAIR MARKOWITZ: Is this any better?

MR. BIRD: Yes, sir.

CHAIR MARKOWITZ: Okay. I'll do the 

best I can. If I drop off again, let me know. 

So let's move back to the discussion of the 

occupational health questionnaire, the OHQ. 

We've been given revised drafts by Department of 

Labor. And we're going to open it up for 

discussion. And I think Dr. Dement has some 

initial comments.

MEMBER DEMENT: Yes. I'll sort of 

lead it off if that's okay. And others can --

CHAIR MARKOWITZ: Sure.
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MEMBER DEMENT: -- join in. There's a 

document.

MEMBER REDLICH: Can you speak a 

little louder, please?

MEMBER DEMENT: Yeah. It's on page 2 

of the occupational history questionnaire. If 

you could get it up for us, please. It was part 

of the materials for the meeting.

CHAIR MARKOWITZ: It should be in the 

meeting briefing part of our website.

MR. BIRD: The OHQ examples to cite?

MEMBER DEMENT: Well, so yes, the 

second page. Let me find the exact title.

MR. BIRD: Dr. Dement, could you 

please speak a little closer to the microphone. 

It's hard to hear you.

MEMBER DEMENT: Okay. Is this better?

MR. BIRD: Yes.

MEMBER DEMENT: Okay. I'm having a 

hard time hearing people as well. So the 

occupational history questionnaire is something 

we've been working on for a good while. And we 
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heard at the last Board meeting about the updated 

draft. And subsequently, we asked to take a look 

at the draft. And we were given one that was 

sort of a completed example. And then the other 

was the actual questionnaire itself.

And so what I'm trying to get up, 

Kevin, is the actual questionnaire. It's OHQ 

Interview Site-Specific page. In the briefing 

book materials, it's third from the bottom. Are 

you still on? Hello?

MR. BIRD: Oh, yeah. Yeah, I'm sorry. 

I had you on mute. Do you know the title of the 

documents you're looking for?

MEMBER DEMENT: OHQ Interview SiteSpecific Question input form.

MR. BIRD: Okay.

MEMBER DEMENT: So the first page of 

the OHQ is just basic information -- basic 

demographic information, the unions that the 

individual might have been associated in some 

cases, whether or not they were part of a former 

worker program, and their history outside of DOE.
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The second part of it is actually sort 

of a continuation of maybe multiple parts. And 

so a separate site-specific section is supposed 

to be filled out for each site. And it goes 

through a series of structured questions.

And I think this is good. And I think 

there are many changes to the OHQ that I think 

are very positive. The structure for this part 

is when you get into the actual work task and 

exposures is pretty much free text. Okay. 

That's the --

MR. BIRD: Sorry, Dr. Dement. I think 

I have it pulled up if you can look on the WebEx.

MEMBER DEMENT: Yeah. Scroll down. 

And so this is it right here. Scroll further. 

Yeah, scroll. There we go. Here's the 

information where it really gets to be detailed.

For each job title, the claimant 

isactually asked to describe the areas of work 

activity, the toxins, and years of employment and 

to give some idea of frequency. And while I 

think this is helpful and the example that was 
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completed actually is very interesting and quite 

good, I'm still a little concerned that workers 

are not going to recall this level of detail.

But another comment is I think with 

having more free text in this questionnaire, it 

really places a lot of burden on the interviewer 

to have a fairly consistent scripted approach to 

asking questions so that it's delivered 

appropriately and consistently to each 

interviewee.

And I think it really is a challenge 

on recall issues with regard to trying to 

actually recall specific tasks. But nonetheless, 

I think it's an improvement over before. Can you 

scroll down a little bit further?

So this is where exposure information 

is entered into the form, and it's in categories. 

This one starts with metals, for example. And 

there's some examples given in red.

I'm not sure what it might be for 

presenting this. But I think that script, if 

it's going to be used in the free text form like 
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this, that script and examples is going to be 

very important.

For example, under the welding --

under the specific category of welding and 

metals, you see a lot of metals listed. But we 

don't see anything with regard to welding or 

cutting and stainless steel or application and 

removal of paints that might contain cadmium and 

chromium as tasked.

So I think this part of the 

questionnaire in particular is going to be a 

challenge to write a script and train the 

interviewers to ask questions and then follow up 

with appropriate detailed questions based on the 

claimant's response.

So that's sort of that section. If 

you look down at some of the other sections, it 

goes by different categories. For example, in 

the plastics and adhesives, application of 

urethane paints and epoxies are important tasks 

to be considered.

Under dust and fibers, there's 
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asbestos, of course, listed. Workers might 

remember working with drywall and doing drywall 

finishing. They may or may not associate that 

with asbestos exposure historically.

Under solvents, for example, a lot of 

different solvents are listed. But there are no 

tasks. And so if the interviewers administer the 

questionnaire, they might want to ask, did you do 

solvent degreasing as a task?

So it's not structured -- so my 

comment -- overall comment, it's not necessarily 

structured. How I would've probably gone about 

it is this section is not consistent with how the 

Board recommended that had to be structured.

I have some concerns about it, and I 

think training of the interviews tend to be very 

important. I also think it's likely that it will 

be helpful prior to the interview workers were 

given some materials to fill out beforehand 

before they do the interview, sort of as a memory 

trigger.

And I would probably suggest that some 
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tasks under each one of these types of exposure 

categories might be appropriate as triggers for 

the worker themselves.

My understanding is this questionnaire 

was pretty close to final. So I'm not sure what 

we say right now is going to make much 

difference. I understand they're going to have a 

pilot and see how well it works.

I guess I'd be interested in taking a 

look at that and what the criteria are for that 

and it works like it's supposed to or not. I 

think it's improvement, but it's been a four-year 

process. Look forward to seeing what it might 

look like in the industry.

So for comments about it, yeah, I 

think it's -- I do think it's an improvement of 

the questionnaire that exists currently.

CHAIR MARKOWITZ: This is Steven. I 

have a question. Looking at those same 

categories that Dr. Dement, you were just going 

over, where by category of material they ask 

about form and how exposed. If they asked about 
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task, maybe listing some of the major tasks as 

triggers, maybe not.

So if they asked about tasks, wouldn't 

the industrial hygienist get the information that 

they need to weigh in about form and method of 

exposure from the task.

MEMBER DEMENT: Well, that was the 

original recommendation from the working group on 

the OHQ to be more task oriented. That would be 

my preference. I think the alternative here is 

the part you see in red which I assume is some 

script that will be used. That script in this 

format is going to be extremely important.

For example, there's nowhere in here 

in any of these categories that welding is 

actually mentioned as an exposure. I see 

soldering. But welding is an important exposure 

for a lot of reasons and a lot of the conditions 

we discussed today.

So unless there's some -- a more workrelated trigger. For example, did you do welding 

as opposed were they exposed to chromium or 
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nickel or cadmium? I think it's probably not 

going to achieve the objective. But I'm open 

minded, and I think this -- how it's presented by 

the interviewer is going to drive how successful 

this is.

I also think by having it structured 

as it is and not having sort of specific tasks 

that individuals are asked. I think it's more --

you're going to see a lot more variability by the 

interviewer -- between interviewers in particular 

and how this thing is administrated. Some may 

drill down very deeply in some of this and some 

may not drill so deeply at all without some 

scripted process.

CHAIR MARKOWITZ: So here's a devil's 

advocate question. This is Steven. Where it 

says, how did you use the substance, won't the 

person being interviewed come up with their 

tasks?

MEMBER DEMENT: That's what they have 

to do now. They have to describe how they were 

exposed to beryllium, chromium, whatever. I 
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think it's a challenge for -- just a recall 

challenge, I think, for older worker population.

CHAIR MARKOWITZ: So you're suggesting 

thing to have some short examples of tasks with 

metals and then having the interviewer ask about 

those specific tasks?

MEMBER DEMENT: Well, if they don't 

ask specifically, I think sort of working in the 

background, the questionnaire has to be some 

information about work tasks that are related to 

these exposures. And I think the interviewers 

and the interviewees need to be working from the 

same page in terms of what these tasks might be.

I'm suggesting that in our BTMed 

program, we put these tasks on a single page. So 

there's about 55 to 60 of them. A single page of 

information might be very helpful to give to the 

interviewer before they come for their interview.

CHAIR MARKOWITZ: I'm sorry. Is that 

page administered to the DOE worker?

MEMBER DEMENT: The page is -- we mail 

it out to them before they have their -- most of 
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the interviews are by phone now. But they're 

given this questionnaire beforehand, a few weeks 

beforehand usually. So they have it and they've 

had a chance to think about it. They've had a 

chance to read it, to digest it. And when they 

come to the interview, they're better prepared to 

try to respond to questions.

CHAIR MARKOWITZ: So I'll open this up 

to other people. But just one last question. So 

how specifically -- looking at this form, how 

specifically would you change it?

MEMBER DEMENT: Well, it would be 

without sort of redoing substantially, I think 

the part in red which I think is intended to be 

the triggering questions need to be thought out 

very carefully.

For example, I'm looking at the dust 

and fibers thing that's up, and it has asbestos, 

pipe wrap, and asbestos board. But there's some 

other less obvious tasks. Did you do brake work? 

Some of them did. Did you work with packing and 

gaskets? The pipe fitters certainly did.
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I think in some of this, there's some 

tasks that really need to be incorporated in and 

the introduction to the worker, they describe 

their task. They describe their work.

CHAIR MARKOWITZ: Are there other 

comments, or --

MEMBER POPE: This is Duronda Pope. I 

think that this is so critical. Thank you, Dr. 

Dement. By saying that -- by putting the task 

down there and making it specific, having those 

recall triggers there.

You have to keep in mind most of these 

claimants are sick and they're trying to recall 

where they worked, what they worked with. It's a 

very challenging process that they have to go 

through.

So by making it more specific, you are 

enabling that claimant to better be able to 

formulate this form because it's in the 

developing stages of building this case.

MEMBER DEMENT: Well, I guess it's 

targeted to go for a pilot. And the Board will 
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have an additional chance, I hope, to take 

another look at the pilot and the pilot results 

and make recommendations to change it.

My recommendation right now is these 

scripted questions need to be thought out very 

carefully to make sure that everybody in the 

administers the questionnaire in a consistent way 

and that work tasks are at least mentioned.

I don't see welding mentioned anywhere 

on the form, just as an example. I don't see 

degreasing mentioned anywhere on the form. And 

there are others.

CHAIR MARKOWITZ: So this is Steven. 

What I'm trying to figure out is you've got this 

enormous diversity of job titles among claimants 

that we're all aware of. And it's hard to think 

about generic list of tasks that could be used in 

this questionnaire that would cover a lot of 

different job titles. That's kind of where I get 

stuck.

MEMBER POPE: This is Duronda. Didn't 

we at one point as a Board say that we wanted the 
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IH to interview the claimant to better try to 

understand the processes that claimants might've 

been exposed to?

CHAIR MARKOWITZ: Yes, we made that 

recommendation. That was accepted.

MEMBER POPE: Okay.

CHAIR MARKOWITZ: And we heard this 

morning that I think that one interview has been 

completed.

MEMBER POPE: Thank you.

MEMBER DEMENT: Steven, I agree with 

you. There's not going to be one set of specific 

tasks that covers everybody. But really based on 

the claims that I've reviewed on the Board, there 

are some reasonable ones that are pretty 

consistent.

And I think somewhere along the way 

that there needs to be some presentation of 

these. And I don't know exactly where the place 

is based on this history form right now. The 

only place I can see that you can incorporate it 

is under the discussion introduction part where 
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it's sort of scripted. Where you give examples, 

you could give more examples.

Anyway, that's just my thought. I 

guess it is what it is currently. It'll be 

piloted, and you'll see sort of what the result 

is.

MEMBER FRIEDMAN-JIMENEZ: This is 

George Friedman-Jimenez. I have a comment. Rose 

and Carrie, you do even more teaching medical 

students than I do. But when we teach how to 

take an occupational history, one of the first 

things we teach is that the job title doesn't

tell you everything and you have to ask about 

what people do.

So could we -- is there a question on 

how to title work? In other words, could you put 

in a question, do you have any exposures that 

you're concerned about that are not typical for 

your job title?

And that would trigger then an open 

ended interview by someone would can take -- who 

has the skills to take a careful occupational 
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history. Because I find it very difficult to 

boil this down to an algorithmic approach like a 

questionnaire that's going to cover all the 

possibilities.

The questionnaire should just kind of 

divulge the easy cases. But people do out of 

title work frequently. I think that's where a 

lot of some of these exposures are going to be 

found.

MEMBER GOLDMAN: And this is Rose. 

This is really difficult. I mean, when we 

interview somebody for an occupational health 

visit, yes, you're right, George. Somebody could 

pay their plumber or whatever. You have no idea 

what they do. And I usually just start by 

saying, tell me a typical day. Or what is it 

that you do? And just have them write a 

paragraph.

And then based on that paragraph, that 

leads to additional questions. And your point is 

well taken because you could follow that initial 

those are your main job duties. But what else do 
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you do that might be different from that?

And the problem with that approach is 

that's usually what we use when it's more recent 

for somebody. But if they're trying to remember 

back 10 or 15 or 20 years, it's very difficult. 

And yet just having a check off, X, Y, and Z, 

even though it's easy to interview, you're really 

missing what could be the real exposures.

CHAIR MARKOWITZ: But is there a 

question that they could ask on this 

questionnaire that would address those concerns?

MEMBER FRIEDMAN-JIMENEZ: Yeah. You 

could ask them, do you feel that there are any 

hazardous exposures that you had at work that are 

not represented in the questions that you've 

answered on this questionnaire? If they say, 

yes, that would be a trigger for an industrial 

hygienist to ask them a detailed, open-ended 

history.

MEMBER DEMENT: Well, there actually 

is a place on the form, and I think Kevin 

scrolling down. It goes through introduction, 
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has a place for additional information. If that 

were scripted appropriately, and it looks like it 

almost is now, it would provide that. I mean, 

it's just a discussion.

MEMBER TEBAY: This is Calin Tebay.

CHAIR MARKOWITZ: Calin?

MEMBER TEBAY: This is Calin Tebay. I 

have a comment. At the Hanford Workforce 

Engagement Center, we see this every day, right? 

We have people come in that try. Actually, 

they're here to find out what their benefit 

options are and how to prepare to submit claims, 

including work history.

And what we find out a lot is either 

they forget, they're unaware of the exposures. 

They're unaware of a byproduct of welding or an 

exposure. When they go to the resource center, a 

lot of times the person doing the interview 

doesn't understand the exposures or what 

questions to try and draw out of these people.

My question is is there a specific 

question that would trigger? And I just heard 
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this. But there's a specific question that would 

trigger an IH to have that interview. And is it 

realistic? Is the DOL going to provide the 

resources to have that one-on-one interview with 

these individuals?

What we've been doing is telling 

people just to write an addendum to all these 

before they even go in. Because what happens is 

that they go in and they're put under -- you've 

got an hour or an hour and a half in there. A 

lot of times, they don't get communicated via the 

occupational work history questionnaire 

everything they've done.

So we try to get to them before that 

and just say, write an addendum, whether that be 

a page, a half a page, two pages, of everything 

you can think of you've done in your career on 

the site and all the processes you've been 

involved in, all the tasks, what those were 

daily, weekly.

But I'm with everybody else. This is, 

like, the most difficult part of the claim in my 
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opinion where we see somewhat of a disconnect, 

right? Because if you don't get this piece 

right, the claim doesn't go the same. It's not 

the same all the way through.

And then if you get through the claim 

and you miss some information, it's really hard 

to unwind and walk back and start over. Is the 

Department of Labor going to provide the 

resources to have an IH reach out to each one of 

these individuals? And is that IH going to be 

qualified to try and draw out the information 

they could or they should for that person's craft 

or whatever, you know, their employment was, 

whatever they were during their employment at the 

site?

So I'm still at a loss on how to put 

all those pieces together. But this is a very 

sticky one for here we see every day.

CHAIR MARKOWITZ: This is Steven. 

Does anybody know? Are these mostly done over 

the phone, the interviews? Or were they done 

before COVID?
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MEMBER TEBAY: Face to face.

CHAIR MARKOWITZ: Face to face?

MEMBER TEBAY: They're done face to 

face here, unless you have some kind of 

disability or you can't make it in. Then they'll 

do them over the phone. But like a lot of those, 

if you're just going through the general 

questionnaire.

And we're saying that at our resource 

center, we really enjoy our resource center. I 

think they're pretty good at what they do. But 

they still, you know, it's hard for somebody that 

didn't ever work on site or doesn't understand 

the trade or the craft or what that individual at 

the site, what those exposures may have been. 

It's hard for them to even ask the correct 

questions, right? You know what I mean?

Trying to get the most information out 

of the claimant that you can get so the claims 

examiner starts with the information they really 

need to start putting the pieces of the puzzle 

together.
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MEMBER FRIEDMAN-JIMENEZ: This is part 

of the art of doing occupational medicine is 

honing in on what are the important exposures. 

So I think the key here is to identify the people 

for whom the occupational health questionnaire 

does not represent all the important exposures 

relevant to the health condition that they have.

So what we're looking for is the 

method for doing that, whether it's a yes/no 

question or an essay question, having them list 

the exposures, which in some cases, they may not 

even know the names of the chemicals. But just 

have them identify that they, with the 

questionnaire, didn't capture all of the relevant 

exposures. And they often have that knowledge 

themselves.

Now about resources, I think we're 

obligated to provide resources to take a careful 

history and identify the relevant exposure for 

someone that is claiming to have a work-related 

illness. So I think that's part of what we 

should be providing.
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MEMBER SILVER: I think Calin -- this 

is Ken Silver. I think Calin Tebay's point about 

the occupational health questionnaire being 

pivotal for what happens downstream in the claims 

process is really important. And if we can flip 

this on its head, it would be a training program 

and the workers before they go in to answer the 

questionnaire.

But short of that, a nice brochure 

from the Department of Labor that says, your 

occupational health questionnaire, what to 

expect. And maybe a lot of the tasks that take up 

a lot of space could be laid out on there.

Maybe there could be a worksheet 

analogous to what the IRS provides before they 

put out the platform that helps you jot down in 

round numbers and approximations what you think 

is important so that the person knows that this 

is a really important encounter.

In that brochure, I would also say 

something about respirators. Your use or disuse 

of a respirator will not be held against you. In 
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fact, if you were issued one, it's a sign that 

you were probably in a high exposed job. And the 

resource center people could make sure that the 

worker and their spouse or their advocate have 

been over that brochure before coming in to this 

pivotal encounter.

MEMBER TEBAY: This is Calin Tebay 

again. I agree with you. We get so many people 

in this office daily that will come back and say, 

I didn't turn that information in or I didn't 

disclose it or I didn't know I should have when I 

did the interview. Or I got to the interview and 

I didn't expect to have to answer such specific 

questions.

I think somewhat of a flyer that was 

very detailed on what PPE or what processes you 

were -- I mean, just a reminder to say, you need 

to jot down these points before you come in. 

Anything you can think of date-wise, exposurewise, process-wise, PPE, area, all that stuff so 

they can be prepared.

Because that's exactly what we do 
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right now. We tell them, you write down as much 

as you can remember on this page. And if you 

have to, you just submit that with the 

occupational questionnaire. Because if we get it 

wrong now, going back and trying to start this 

back over or add these is not the easiest place 

to be for these folks.

CHAIR MARKOWITZ: This is Steven. 

Well, actually, they took off PPE from the 

questionnaire, in part, I think because we 

pointed out that it's unreliable information and 

it was a waste of precious time.

But what about proposing that prior to 

the interview that some sort of worksheet be sent 

to the claimant with the idea that they would put 

down whatever they want and bring that to the 

interview?

MEMBER SILVER: With the triggers that 

John and you, Steve, were mentioning at the 

beginning of this conversation.

MEMBER DEMENT: I think it would be 

helpful and I think you're going to get better 
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information. That's sort of the reason we've 

been doing that in BTMed for ever since this 

program started.

We know that we're missing a lot of 

information. But we feel that by using some kind 

of trigger, be it materials, be it tasks, be it 

work areas that we can at least generate 

hopefully better information from the workers 

than we would have otherwise. It's never going 

to be perfect, but we think it's better.

But that discussion, either with a 

physician or with an industrial hygienist or the 

person doing the interview wherever the training 

might be, that discussion is really key. And 

their training in terms of being able to 

understand the exposures and drill down with 

additional questions where needed is sort of key.

And we suggested that former workers 

be given priority for those positions to do the 

interviews. And I think at least our experience 

at BTMed is that that is -- I think it's helped 

us in two areas.
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One is identification of somebody 

that's been at the site by the person coming to 

interview. And also, it leaves some information 

and knowledge about the work at the site, the 

actual work that gets done.

MEMBER SILVER: If I were designing 

the brochure, I would include a sketch of a 

worker, claimant, age appropriate, dressed 

appropriate sitting around with a few of his 

former workmates, like, in a coffee shop putting 

their heads together before going in to the 

questionnaire.

MEMBER DEMENT: Actually, you know 

what? Calin describes that the resource centers 

is doing a really good job of trying to prepare 

them before they go in. So if you walk in and 

you ask these questions sort of out of the blue, 

it'd be hard for anybody, myself or any worker to 

actually fill this thing out with great detail 

without some prior thinking about what's being 

asked.

CHAIR MARKOWITZ: This is Steven. 
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Other comments?

So I have a question. If you could 

scroll this up to one of the exposure classes. 

I'm still -- I want to ask. Do people think

asking the form of the substance and how exposed 

in the way that the examples are given if that's 

useful?

MEMBER DEMENT: This is John. I think 

that information is minimally useful. I think 

the more important stuff is how were you exposed? 

Tell me how and what did you do. Most of the 

time, we're going to know the form of the 

material. If it's trichloroethylene, we're going 

to know what it is unless they have skin contact.

MEMBER TEBAY: This is Calin Tebay 

again. I just wanted to add this quick note 

here. Apparently, there is a -- and we get this 

from our resource center which is not too far 

from us. There's a handout. It's an FAQ. So 

it's United States Department of Labor frequently 

asked questions.

It goes through what is the EEOICPA. 
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It goes through what is covered under Part B. 

What are the benefits? What's covered under Part 

E, presumption, benefit amounts, what medical 

conditions may be compensable, causation, what 

are the eligible survivors for Part B and Part E, 

and then what evidence is required for my claim 

to be accepted.

And under that, it says, your case 

file must contain evidence of covered employment, 

a diagnosed medical condition, causation. 

Causation means a demonstrated relationship 

between employment exposure and a diagnosed 

condition. If the employee is deceased, the file 

must contain evidence establishing that you are 

an eligible survivor.

So there is an FAQ. Obviously, that 

doesn't cover what we're talking about here. But 

they already do currently have an FAQ that's 

available at this resource center where we may be 

able to add to the FAQ some additional 

documentation that would trigger these folks to 

start preparing for this claim interview before 
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they get there.

MEMBER DOMINA: Hey, this is Kirk. I 

don't know why they can't send it out because 

under Part B, the claimant gets a copy from NIOSH 

on the CATI interview, the computer-assisted 

telephone interview, ahead of time, a list of the 

questions. So I don't know why this can't be 

done.

CHAIR MARKOWITZ: What's this? What 

are you referring to, Kirk?

MEMBER DOMINA: On the Part B side, 

radiation side, the claimant --

CHAIR MARKOWITZ: No, no, no. I get 

that. When you said you don't understand why 

this can't be done, what's this?

MEMBER DOMINA: Oh, a copy of the 

questions they're going to ask them. That's the 

same thing that NIOSH does. They give them a 

list a couple weeks ahead of time.

CHAIR MARKOWITZ: That would be kind 

of the simplest thing. Do you think, though, 

that this questionnaire would be user-friendly 
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enough for people to begin to fill out themselves 

and serve that function as a trigger?

MEMBER DOMINA: Well, I think it needs 

work. But either, somewhere, you've got to 

start. And I think Dr. Dement is our expert on 

the right track for this because my opinion it's 

kind of like Labor asking us help with on the 

Part B readers. But yet the IHs, in my opinion, 

can't possibly know the environment that we've 

worked at in all these years.

I mean, in all the places that some of 

these have take place at, you might as well shove 

them into a box. And you're expected to because 

that's what we do. And I think that without them 

physically being there and being in that 

environment, you can't physically -- very few 

people, I guess, could put it into words to make 

them understand what our people have done.

CHAIR MARKOWITZ: So what do people 

think? Just simply recommending that they send 

this questionnaire to people prior to the 

interview so people know what's going to be 
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asked?

MEMBER TEBAY: This is Calin Tebay 

again. And I think Dr. Dement is on the right 

track with this occupational health 

questionnaire. But I definitely think, like Dr. 

Silver, that we need at minimum something to 

trigger these people, the thought process to 

prepare for this before they get in to go over 

the health questionnaire or the work history 

questionnaire.

What happens here at our resource 

center is I don't think they're a huge fan of 

sending that questionnaire out beforehand from 

the simple fact that they like to have that 

verbal discussion and populate that as they're 

talking to you rather than having you take that 

and fill it out yourself and then transferring it 

from a handwritten form into a digital form so 

they can submit it.

But at minimum, I think we have to 

develop something to trigger these people to 

prepare for the occupational health questionnaire 
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and that interview process.

MEMBER GOLDMAN: Why -- this is Rose 

Goldman again. Why can't they get the 

questionnaire ahead of time but the person would 

still go through the whole interview process? So 

the person would've been triggered to try to fill 

in part of it first. And then the interviewer 

would just still keep going over everything and 

help them fill it in and flesh it out more.

MEMBER DEMENT: This is John. That's 

what happens in the BTMed. They're just given 

the questions and the task and the materials. 

And so they have sort of the structure of what to 

expect when they come in. And they're more 

prepared. I mean, they can describe better and 

having some of these triggers. Okay. You were 

exposed to metals. How were you exposed to 

metals?

So I think you could probably send the 

occupational history questionnaire. Maybe with a 

little more -- a few pages of description of how 

some of these exposures, for example, solvents 
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and fumes and vapors, how that might happen in 

the examples that are given. It might help. I'm 

sure it would help.

MEMBER FRIEDMAN-JIMENEZ: This is Dr. 

Friedman-Jimenez. In our occupational medicine 

clinic, we give a written questionnaire to every 

patient. I'd say 10 to 20 percent of them can't 

fill it out at all and needs help to go through 

the whole thing. And probably 80 percent of them 

as the doctor goes through it with them, we wind 

up filling in parts of the questionnaire.

So I'm thinking maybe if you had an 

online questionnaire, the person could fill it 

in, whatever percentage of it they felt 

comfortable with. And then the interviewer would 

just go through the questionnaire that they've 

already filled in online and either answer 

questions or correct what they've done or confirm 

that that's really what the questionnaire meant.

That way, they will have had time to 

think about. You won't have to have them double 

fill out the questionnaire. And you'll confirm 
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the important parts of it.

MEMBER DEMENT: Let me just read --

this is a paragraph that comes out of the DOL 

response to specifically the question that we're 

trying to address.

It says, applying techniques to supply 

preselected information that employee could 

attest to absent any collaborating connection or 

to other evidence obtained during the development 

may produce unauthentic and unreliable outcomes.

So it's a double edged sword. I mean, 

so you stimulate the recall. And they phrase it 

-- I didn't know from reading this, that workers 

may actually claim exposures that maybe they 

didn't have. But that's not been our experience 

over 20 years.

I won't say that's always the case. 

For the vast majority, we're more concerned with 

not recalling exposures than we are creating 

exposures that are not there.

MEMBER FRIEDMAN-JIMENEZ: In our 

clinic, I find that to be extremely rare. Rose 
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and Carrie, you have any other perceptions?

MEMBER REDLICH: You mean that workers 

are going to sort of fudge things or add things 

that by giving them a form ahead of time? I 

think that we give them a bit of a form to fill 

out ahead of time and it's very basic. And then 

we delve deeper.

But I don't think -- I wouldn't think 

that would be the issue here. I mean, I could 

see somebody calling up somebody that they worked 

with and said, hey, do you remember something 

about that process we used to do or what's the 

name of that building?

I mean, I would be less suspicious of 

them sort of expanding on things that didn't 

really happen. But maybe I'm naive.

MEMBER FRIEDMAN-JIMENEZ: I mean, you 

could imagine that someone with sarcoidosis will 

look up and find out that beryllium exposure 

produces something similar. And say they worked 

in a beryllium exposed job.

So I think that's extremely unlikely. 
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I actually haven't seen that among our patients 

that I'm aware of. And we do try and confirm the 

exposures.

MEMBER REDLICH: I mean, in this 

situation, I think it's even less likely because 

you can confirm the exposure. Somebody can say 

they've worked in a beryllium factory as a DOE 

worker and they haven't had any exposure to that.

So I think it's actually less likely 

and it could be helpful. I don't see the harm in 

sending it ahead of time. But I wouldn't use 

whatever they write there to automatically be 

digitally inputted. I do agree that one needs to 

be talking to them additionally about whatever 

they were thinking about.

MEMBER POPE: I don't see anything 

wrong with -- I think we're talking about time 

here. So if you give the individual, the claimant 

time to think about that process, that job that 

they did, that exposure that they received, then 

that enables them to give that information to 

you. You're just going over what you've already 
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-- what they've already given you.

And so you just can confirm what 

they're already saying to you, what they already 

put on paper. So I think if you allow that 

claimant time to think about what they've been 

exposed to, that job that they did. That will 

enable them to help the claims examiner to 

examine that information.

MEMBER TEBAY: I agree. This is Calin 

Tebay again. If we call today -- if I called the 

resource center from my office for a claimant 

that's a potential claimant and they've got an 

opening tomorrow, they schedule that opening for 

tomorrow morning.

That does not give somebody enough 

time for them to prepare for that interview, at 

least to accurate document what they've done. So 

there's got to be something put in place because 

we need to give these people this amount of time 

to trigger them to start documenting their work 

history, wherever they worked, before they come 

into this interview.
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MEMBER GOLDMAN: This is Rose Goldman 

again. We noticed too in our clinic that 

sometimes people do need an urgent visit and we 

bring them in right away. But in your situation, 

how much of the time is it that somebody really 

needs to come in? Is that something that's 

really thought of or is that a small percentage?

MEMBER TEBAY: Well, here's the thing 

is you don't necessarily -- I don't believe that 

you need to fill out the occupational 

questionnaire -- the work history questionnaire 

to submit the claim. I don't know if it needs to 

be complete.

The only time it would be an emergency 

is if, for instance, you know with the DOL, they 

only reimburse back to the day you filed a claim. 

So if I was to come down or be diagnosed with 

some sort of occupational disease and I wanted to 

get that claim filed as soon as possible so I 

could get reimbursed back to that day, right?

Because some people miss that, right? 

They end up getting a cancer or some kind of 
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disease going through a bunch of treatment, then 

coming to file the claim and they miss out on 

four or five months of reimbursement for medical 

expenses.

So my point is, is that if I needed to 

file that claim immediately, I can go file the 

claim immediately and add the other information 

as I have time. So if somebody needed to file 

immediately, the resource center should be able 

to file a claim to establish the claim date which 

will get them folks reimbursed back to that day 

potentially.

And then they could have time to 

really put their mind together because that's 

another part of this process. If you have an 

emergency where you need to file that claim 

today, the last thing on your mind is putting 

together your work history in the next 24 to 48 

hours so you can fill out the claim. Or a family 

member can go do it for you. That even makes it 

tougher. So do you see the hurdle here with 

that?
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(Simultaneous speaking.)

MEMBER MAHS: This is Ron.

MEMBER GOLDMAN: Is it required or is 

it something optional, I guess?

MEMBER TEBAY: Normally, if we don't 

have specific information, the resource center 

says, if you don't have the specific information, 

you can continue to submit that via the portal. 

You can go back to the resource center and submit 

it there. But you don't have to have all the 

information at the beginning.

So like I said, if there was an 

emergency where the individual had to file the 

claim for benefit purposes, then file the claim. 

But don't require them to fill out the 

occupational work history questionnaire if 

they're not prepared, right? Let them have some 

time to put those thoughts together and get 

prepared for that so it's accurate.

MEMBER MAHS: What we've done over the 

years, we save time sheets for workers in 

construction. Not like they're working in the 
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same building. There might be two or three 

different buildings at least. And in ten years, 

that comes to hundreds and hundreds of different 

buildings.

So our resource, I don't know how many 

times over the years of asking for time sheets. 

We've got time sheets since the '50s. And within 

the time sheets, it shows where they worked, what 

they worked on, and what they processed in that 

building, what kind of toxic chemicals. And 

they've been listed to get some more information.

MEMBER TEBAY: To be honest, Ron, I 

wish we had that same database because we don't 

have that here in our building trade. I was a 

building trade sheet welder for 20 years.

I worked at Hanford for probably 10 or 

11 of those total of that 20 years as a 

subcontractor. And not one -- I mean, I have my 

dispatch from the union hall, right? But I don't 

have anything. It dispatches to the contractor. 

The contractor doesn't have anything specific 

that I actually worked on this site or the 
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processed I did at that point.

MEMBER MAHS: Well, the employers or 

even DOE, they've got a record where you work 

through radiation tracking.

MEMBER TEBAY: Yeah, but they -- yeah, 

on our site, we have those. We have dosimetry 

records. But as a subcontractor, a lot of times, 

you're working where you're welding. But you're 

not required to wear dosimetry. So it doesn't 

cover all of it is my point. You know what I'm 

saying? There's still big gaps in the 

documentation part.

MEMBER POPE: This is Duronda Pope. 

I'd just echo what Calin and Ron are saying about 

the gaps and unable to track everything because a 

lot of times when we were assigned jobs, just 

that specific job, that job classification, you 

could be doing outside of that that wasn't 

documented as you do in that specific job.

But back to the people having time, 

the claimants have time. I don't know how many 

times that you get into an interview and you're 
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trying to recall things and you feel like you're 

under the gun. And then you miss things. So 

that makes it even more important to have this 

form ahead of time so you can have time to think 

about it.

MEMBER TEBAY: And we can't fault the 

claims examiner for processing a claim with a 

recommended denial if they don't have half the 

information. You know what I'm saying? I mean, 

they're doing the best they can with the 

information they got. So I agree with Ron. We 

have to have as much time as possible in order to 

prep these people to go in there and fill out 

this questionnaire as accurately and as full as 

we can so the claim starts on the right foot.

CHAIR MARKOWITZ: This is Steven. I 

got dropped for a couple of minutes. So it seems 

to be general agreement that we recommend the 

Department send around this questionnaire or 

perhaps a simplified version of the questionnaire 

to the claimant prior to the interview. Is that 

right?
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MEMBER TEBAY: Yeah, I agree with 

that.

MEMBER POPE: Yes.

CHAIR MARKOWITZ: I think the 

advantage of giving a choice between this 

questionnaire or a simplified version is that if 

the Department is set on not giving the exact 

version of the questionnaire over, a simplified 

version would still -- user-friendly -- would 

still serve the same purpose that we're talking 

about.

MEMBER DEMENT: This is John. I agree 

with the questionnaire being sent out prior to. 

I think that's important. I also think if this 

particular questionnaire is sent out, then for 

some of these materials, there needs to be, in my 

opinion, an addendum that goes with it that sort 

of describes how exposure to some of these things 

might occur.

CHAIR MARKOWITZ: So let me just 

interrupt. This is Steven. We have Stephanie 

Carroll who was a public commenter who had 
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trouble getting on or something who would like to 

make a public comment. So if I could just 

interrupt this discussion for a few minutes and 

allow her to make her public comment. And we can 

get back to the discussion which we may need to 

complete tomorrow morning, if that's all right.

So Kevin, are we set up to allow 

Stephanie Carroll to make her public comment?

MR. BIRD: Give me one second.

MR. CHANCE: Dr. Markowitz, this is 

Mike.

CHAIR MARKOWITZ: Yeah.

MR. CHANCE: I'm not sure if anyone 

from the program is on, but we are tabulating the 

discussion for questions that we can pass forward 

on the OHQ, the discussion that you guys --

CHAIR MARKOWITZ: Okay.

MR. CHANCE: -- just had.

CHAIR MARKOWITZ: Okay, good.

MR. CHANCE: So we're trying to keep 

track of that.

CHAIR MARKOWITZ: Okay. Thank you.
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MR. BIRD: Okay. So Stephanie, are 

you there with us?

MS. CARROLL: I am, thanks. Are you 

ready? You can all hear me? I am -- my Stephanie 

Carroll and I'm an authorized rep specializing in 

lung disease and specifically chronic beryllium 

disease. And I would like to address the 

question posed by the DEEOIC staff concerning the 

DOE.

As you may know, OWCP for years 

ignored the very suspicious DOE reports done by 

Johns Hopkins that virtually never found 

significant disease among the coal miner 

population.

In 2011, I used a NIOSH certified B 

reader that was bullied out of the program. He 

was harassed and questioned in such a manner that 

it resulted in his withdrawal from ever doing B 

reads for the Department of Energy workers again. 

The claims examiners were not accepting a B read 

without a signature in order to discount the 

validity of the claimant's B reader.
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I met with John Howard of NIOSH and he 

wrote a letter claiming that at the time his 

signature was not required on the NIOSH form. By 

then, the B reader had quit the program. We 

could never use him again.

This is what claimants are 

experiencing now. A certified B reader evaluates 

a digital film without benefit of reading the 

original radiology report. The CE is requesting 

a copy of the original radiology report and then 

disregarding the opinion of the B reader if it 

does not match the original report.

In other words, if pneumoconiosis or 

findings consistent with pneumoconiosis are 

notindicated on the original radiology report, 

the B reader is put under suspicion.

The problem is not a conflict between 

two B reads as was stated by Rachel earlier. 

It's usually a conflict between the original 

radiology report which was not doing a 

occupational lung disease review and the B 

reader's report.
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And the conflict contain, yes, the 

original radiology. The conflict is not advised 

unless it benefits the claimant. I never see any 

questions about to B reader looking at the same 

radiology and coming up with two different 

findings that come from, say, Rocky Flats. 

Sometimes they would have two B readers read the 

same film. There has never been questions when 

part of it benefits the claimant.

The conflict often results in a 

threatening letter being sent to claimant's B 

reader questioning the veracity of his or her 

report. Of course, this heightened scrutiny 

appears to only be done in a -- there's a 

particular B reader, records findings of 

pneumoconiosis in favor of the claimant. That's 

what I've seen.

And we've gotten some really 

threatening letters sent to our current B reader. 

And I believe it's just a way to get them to quit 

the program. When an official sends a letter, 

he's a small business owner usually, from the 
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Department of Labor questioning a report that he 

did in such a manner to suggest that you may be 

submitting fraud or lying about the report.

It's pretty threatening and keeps the 

claimant from being able to have a source of a 

non-biased physician to review their radiology. 

So it's been really awful, and I've noticed it 

more so lately.

And I think that's because some 

claimants have -- there's been an uptick of 

claimants getting their own B readers to look at 

their chest x-rays. And this is why this has 

become an issue now, and it wasn't an issue back 

in the day when Johns Hopkins was doing B reads 

at 750 bucks a pop and always finding in favor of 

the companies against the coal miners.

So now that there's some B readers out 

there supporting workers, I think they would like 

to get rid of that. So that's where that 

question came from. It was strange that it was 

suggested that it was the conflict between two B 

reads. I haven't seen that. That's not really 
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the issue. It's claims examiners writing letters 

saying, we want to see the original radiology 

that the B reader looked at.

So that's what's going on with the B 

reads. And then also I looked up glyphosate on 

the SEM. It does show up, but it reads that 

there are no diseases that are listed in NLM 

guides. And that, quote, NLM has not identified 

any occupational disease where glyphosate is a 

question.

So if he goes on SEM to see if 

glyphosate may have had something to do with his 

cancer, he's going to find that there are no 

disease relationships there.

So the other thing about SEM you 

should know is the Department of Labor has a 

library of all the documents and studies that 

support everything within the SEM. They used to 

have it on the SEM that was only seen by claims 

examiners before it became public. It was with 

the documents related to each of the, I guess, 

things that were in the SEM.
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So if there was asbestos in SEM, there 

would be a library document number, a Department 

of Labor library document number. It wasn't DOE. 

It was Department of Labor. And that library has 

all the documents to support SEM.

So it might be helpful for anybody 

working on the SEM project to know what 

documentation we already have that supports what 

chemicals and toxins and illnesses they have in 

SEM. But they do have that library.

That's all I have to say for today, 

and thank you all for your work. I appreciate 

it.

CHAIR MARKOWITZ: Thank you very much. 

Thank you, Ms. Carroll. So I propose -- it's 

eight minutes before 5:00, that we try to, if we 

can, finish this occupational health 

questionnaire discussion now. If not, we can 

continue tomorrow morning. But let's try to 

finish it now. And then we will pick up tomorrow 

morning at 11:00 a.m. with the other items on our 

agenda.
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We do have time tomorrow. There's a 

lot of soft spots. So I'm not terribly worried 

about that. So let's go back to the occupational 

health questionnaire discussion. Were there 

other comments that I interrupted the middle of?

Okay. So the general sense from the 

discussion from the people who spoke is that it 

would be useable to the process if this 

questionnaire, the occupational health 

questionnaire, or a simplified version were sent 

to the claimants ahead of time with sufficient 

time for them to fill it out or use it as a 

memory trigger so that they're better able to 

participate in the interview.

Were there any -- on the questionnaire 

itself as we're looking at it, this is the draft, 

was one change in particular I heard which was 

under additional information to add some 

language, add some text in addition to -- I think 

it's under -- yeah, keep going. It's section --

there it is.

Actually, this digital information is 
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specifically about incidents. But it could be 

broadened. And this is Dr. Friedman-Jimenez's 

idea. Is there any additional information about 

other exposures or exposures that are sort of 

unexpected for your job title that you would like 

to add to the data here? It would be phrased a 

little better than that.

But were there any other specific 

changes in this questionnaire we're looking at 

that people were proposing?

MEMBER DEMENT: This is John Dement. I 

think in the area specifically under metals, I 

think welding needs to be added. And so the red 

text is describing tasks. And under solvents, I 

think solvent degreasing needs to be added under 

that red descriptive information.

CHAIR MARKOWITZ: Okay. That's easy 

enough. Personally, I think you're asking about 

the form of the toxic substances and how a person 

is exposed with the inhalation and skin as 

examples. I personally find that to be mostly a 

waste of time and a waste of space because that 
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same information will either come out or be 

interpretable in the process.

I personally would augment the how do 

you use this substance with an additional 

question of what tasks did you perform with this 

material instead of the form and how exposed in 

order to get at this information that we've been 

discussing.

MEMBER REDLICH: This is Carrie. I 

may have missed it. But in terms of asking about 

PPE, there's a question at the end. Were there 

any others?

CHAIR MARKOWITZ: Where are you 

looking at exactly?

MEMBER REDLICH: I saw it somewhere. 

I'm just trying to remember where I saw it. Hold 

on. Oh, under the incidents, what protective 

equipment were you wearing? Now I must say I 

find the PPE question frequently more informative 

of indicating that there was a hazard that you 

needed to wear PPE for rather than reassurance 

that there was some kind of full protection. But 
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I was just wondering if that was addressed 

anywhere else.

(Simultaneous speaking.)

CHAIR MARKOWITZ: This is Steven. 

Actually, I do see it in Section 4E in the red 

ink where it says, information for each job title 

from Section 4D. Okay. No, no. Go back. Yeah, 

you see in the second row there. Or actually, 

both, both examples. They give examples of 

people who were wearing -- they specify what PPE 

they were using.

MEMBER REDLICH: Okay.

CHAIR MARKOWITZ: So what was your 

thought about this? It's useful? It's not 

useful?

MEMBER REDLICH: Well, I would 

probably defer to others, but I was just even 

looking to just see where it was included. And I 

see it is. It wasn't just on the events at the 

end.

CHAIR MARKOWITZ: Well, this is 

Steven. So correct me if I'm wrong. But I 
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believe we recommended previously that they 

remove questions about PPE, mostly because it 

really didn't provide useable information. And 

if that is our view, then we should probably 

apply it to this version of the questionnaire as 

well. Comments?

MEMBER DEMENT: Steven, this is John 

again. I think our comment about the PPE on the 

last questionnaire, it was very voluminous and 

extensive. I mean, it asked about great detail. 

I don't object to it being in a description of, I 

do this work and I used rubber gloves, for 

example. think that's sort of helpful.

But it's just in an example. You're 

not going to get it all the time. It's whatever 

the worker provides. I don't object to it being 

in this portion of it.

CHAIR MARKOWITZ: Okay. I defer to 

the industrial hygiene expert. Other comments?

MEMBER TEBAY: Well, what about for 

those -- I guess my idea is -- this is Calin 

Tebay -- was not to document the PPE or maybe the 
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lack of PPE. For instance, I mean, there's been 

a lot of times where you work out of the field, 

you don't have the same PPE that's set up, 

ventilators, exhaust systems, stuff like that you 

don't have.

So my thought was when you're filling 

out this occupational questionnaire is I perform 

this task. Did you wear PPE? No, I didn't have 

PPE.

For instance, let's go back to 

welding. It's an easy one. I welded in the field 

upside down in a confined space or what I would 

say a confined space. And there's no such thing 

as an exhaust fan or a localized exhaust in that 

situation, right? And there was no special PPE 

for that.

So I guess to kind of go back on what 

I said is I'm not trying to document that I did 

wear PPE. Maybe it's a question, were you 

provided PPE? In that situation, was there PPE 

available? Or I performed these tasks with no 

PPE. I mean, and that's not uncommon to not have 
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the PPE in prior years. So that was kind of my 

thought process on PPE.

MEMBER POPE: Great point. This is 

Duronda Pope. That reminds me of laborers that 

were outside maintaining the grounds, had no PPE.

CHAIR MARKOWITZ: So does that 

translate into a recommendation that they 

specifically have asked about PPE? Or in other 

words, above and beyond it's currently phrased 

where they give it in the examples? And if so, 

what would you ask?

MEMBER SILVER: This is Ken Silver. 

We've been back and forth on this I think in our 

very first meeting in D.C. Dr. Sokas got 

everyone's head nodding to what we've heard. A 

couple of the physicians say today which is that 

presence of PPE is a marker for a hazardous 

environment.

But claims examiners were rumored to 

be interpreting it to mean that the person had 

low exposures. So rather than reintroducing a 

trigger about PPE, perhaps it could be captured 
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in a field that says, anything else to add.

And if the worker has recollections 

like Calin described, like Duronda described for 

the grounds keepers, that would be the place for 

them to volunteer that they had no gear. But I 

hate to put debate in there for the claims 

examiners to misinterpret what an affirmative 

answer to PPE means.

CHAIR MARKOWITZ: So right now in the 

examples, there is a trigger or a suggestion that 

the PPE either be addressed or the lack thereof. 

It's a soft -- as it stands now, it's a soft 

question or soft trigger. Is that sufficient?

Personally, I think it is because it 

reminds the claimant to talk about it if they 

want to. It doesn't give that very specific 

information that was previously collected that 

could be misinterpreted in the claims evaluation 

process.

It gives them the opportunity to say, 

yeah, I did that and we had nothing. Or we had 

cotton gloves, or something like that. But it 
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doesn't sort of force them into a box on that 

question.

MEMBER FRIEDMAN-JIMENEZ: We could ask 

several questions. For example, first ask, have 

you worked in situations where you believe PPE 

would be necessary? And then the next question, 

did you have adequate PPE in those situations? 

So that would be harder to misinterpret as PPE 

indicating that they weren't exposed.

CHAIR MARKOWITZ: Other comments?

MEMBER DOMINA: This is Kirk. I agree 

with George because so many times it's not the 

proper PPE. And that's where I think that things 

get misinterpreted, especially on a respiratory 

when it's not the right PPE, right respirator 

because we just didn't have them. And the same 

thing --

MEMBER FRIEDMAN-JIMENEZ: The other 

thing is to boil down three or four thousand work 

days to did you get PPE or not, just there's no 

way to do it. So you have to rely on the worker 

to make a judgment whether PPE was necessary and 
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then whether they had adequate PPE. Otherwise, 

you have to ask so many questions about when was

the PPE provided and when wasn't it and for which 

exposures. It's very complicated.

CHAIR MARKOWITZ: So what question --

or maybe we can't resolve this now. It's five 

after 5:00. But we can resume it tomorrow. If 

there's specific questions that you would add and 

where you would add it, that would be helpful.

MEMBER FRIEDMAN-JIMENEZ: I'll draft 

two questions.

CHAIR MARKOWITZ: Okay. Send them to 

Kevin, and we can take a look at them tomorrow.

MEMBER FRIEDMAN-JIMENEZ: Okay.

CHAIR MARKOWITZ: Actually, if you 

wouldn't mind on that, also just playing with the 

text of that other question at the end where it 

says additional information. That addresses the 

concern you raised earlier about unexpected 

exposures given job title. You know what I mean?

MEMBER FRIEDMAN-JIMENEZ: Okay.

CHAIR MARKOWITZ: Okay, great. 
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Thanks.

MEMBER FRIEDMAN-JIMENEZ: Just a 

little more detail in the question, whether all 

relevant occupational history information 

wasaddressed, because that may not jog their 

memory enough. Okay. I'll work on those three 

questions.

CHAIR MARKOWITZ: Right. And then the 

additional information section wouldn't be just 

about incidents. It would be in general.

MEMBER FRIEDMAN-JIMENEZ: Yeah.

CHAIR MARKOWITZ: Thank you. Okay. 

So I think we should wrap it up and resume 

tomorrow at 11:00 a.m. We'll close out this 

discussion. I think we'll probably vote on a 

recommendation about this as part of that 

discussion.

We will come back to the issue of 

assessing CMC and industrial hygienist 

performance and we'll need a hopefully not very 

long discussion on site-wide job titles, our 

response to their response. And then we can deal 
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with a few miscellaneous issues.

The item for tomorrow morning at 11:30 

a.m., revisions in the Procedure Manual and 

bulletins. That's an open agenda item. If there 

were any bulletins or Procedure Manual changes 

that you -- since our last meeting that you 

wanted to discuss. So I don't have a 

premeditated discussion about that.

And I don't think there are any new 

issues that I'm aware of, except we're going to 

review the public comments and maybe something 

new will come out of that. We'll see. But I 

don't expect any problem finishing tomorrow by 

2:00. And in fact, we may finish a little bit 

early.

Can everybody attend tomorrow? Or let 

me put it this way. Is there anybody who either 

cannot attend or has to be off at a certain time?

Okay, great. Then Mr. Chance, you 

want to close the meeting or shall I close it?

MR. CHANCE: Yeah. No, I can do it. 

Thank you, Doctor. I want to thank everybody for 
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their participation today. We've had a very, 

good robust discussion. And we will adjourn for 

the evening and reconvene at 11:00 tomorrow 

morning. So everyone have a great evening. Be 

safe.

(Whereupon, the above-entitled matter 

went off the record at 5:10 p.m.)