Special Exposure Cohort Petition 

under the Energy Employees Occupational 

Illness Compensation Program Act 

U.S. Department of Health and Human Services 

Centers for Disease Control and Prevention 

National Institute for Occupational Safety and Health 

 

 

 

Petitioner Authorization Form 

OMB Number: 0920-0639 Expires: 01/31/2026

Page 1 of 2 

Use of this form is voluntary. Failure to use this form will not result in 

the denial of any right, benefit, or privilege to which you may be entitled. 

Instructions: 

If you wish to petition HHS to consider adding a class of energy employees to the Special Exposure Cohort 

and you are NOT either a member of that class, a survivor of a member of that class, or a labor organization 

representing or having represented members of that class, then 42 CFR Part 83, Section 83.7(c) requires 

that you obtain written authorization. You can obtain such authorization from either an energy employee who 

is a member of the class or a survivor of such an employee. You may use this form to obtain such 

authorization and submit the completed form to NIOSH with the related petition. Please print legibly. 

For Further Information: If you have questions about these instructions, please call the following 

NIOSH phone number and request to speak to someone in the Division of Compensation 

Analysis and Support about an SEC petition: 513-533-6825. 

Authorization for Individual or Entity to Petition HHS on Behalf of a Class of Energy Employees for 

Addition to the Special Exposure Cohort 

I, 

____________________________________________________________________________ 

Name of Class Member or Survivor 

____________________________________________________________________________ 

Street Address of Class Member or Survivor Apt. # P.O. Box 

____________________________________________________________________________ 

City, State, Zip Code of Class Member or Survivor 

do hereby authorize: 

____________________________________________________________________________ 

Name of Petitioner 

____________________________________________________________________________ 

Address of Petitioner Apt. # P.O. Box 

____________________________________________________________________________ 

City, State and Zip Code of Petitioner 

to petition the Department of Health and Human Services on behalf of a class of energy 

employees that includes: 

____________________________________________________________________________ 

Name of Class Member (energy employee, not the employee’s survivor) 

for the addition of the class to the Special Exposure Cohort, under the Energy Employee’s 

Occupational Illness Compensation Program Act (42 U.S.C. §§ 7384-7385). 

In providing this authorization, I recognize that the petitioner named above will have all the rights 

of a petitioner as provided for under 42 CFR Part 83. 

_______________________________________ __________________________________ 

Signature of Class Member or Survivor Date 
 

 

 

Special Exposure Cohort Petition

under the Energy Employees Occupational 

Illness Compensation Program Act 

U.S. Department of Health and Human Services 

Centers for Disease Control and Prevention 

National Institute for Occupational Safety and Health 

Petitioner Authorization Form

OMB Number: 0920-0639 Expires: 01/31/2026

Page 2 of 2 

Public Burden Statement 

Public reporting burden for this collection of information is estimated to average 3 minutes per response, 

including time for reviewing instructions, gathering the information needed, and completing the form. If you 

have any comments regarding the burden estimate or any other aspect of this collection of information, 

including suggestions for reducing this burden, send them to CDC Reports Clearance Officer, 1600 Clifton 

Road, MS-E-11, Atlanta GA, 30333; ATTN:PRA 0920-0639. Do not send the completed petition form to this 

address. Completed petitions are to be submitted to NIOSH at the address provided in these instructions. 

Persons are not required to respond to the information collected on this form unless it displays a currently 

valid OMB number. 

Privacy Act Advisement 

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. § 552a), you are hereby notified of the 

following: 

The Energy Employees Occupational Illness Compensation Program Act (42 U.S.C. §§ 7384-7385) 

(EEOICPA) authorizes the President to designate additional classes of employees to be included in the 

Special Exposure Cohort (SEC). EEOICPA authorizes HHS to implement its responsibilities with the 

assistance of the National Institute for Occupational Safety (NIOSH), an Institute of the Centers for Disease 

Control and Prevention. Information obtained by NIOSH in connection with petitions for including additional 

classes of employees in the SEC will be used to evaluate the petition and report findings to the Advisory 

Board on Radiation and Worker Health and HHS. 

Records containing identifiable information become part of an existing NIOSH system of records under the 

Privacy Act, 09-20-147 “Occupational Health Epidemiological Studies and EEOICPA Program Records and 

WTC Health Program Records, HHS/CDC/NIOSH.” These records are treated in a confidential manner, 

unless otherwise compelled by law. Disclosures that NIOSH may need to make for the processing of your 

petition or other purposes are listed below. 

NIOSH may need to disclose personal identifying information to: (a) the Department of Energy, other federal 

agencies, other government or private entities and to private sector employers to permit these entities to 

retrieve records required by NIOSH; (b) identified witnesses as designated by NIOSH so that these 

individuals can provide information to assist with the evaluation of SEC petitions; (c) contractors assisting 

NIOSH; (d) collaborating researchers, under certain limited circumstances to conduct further investigations; 

(e) Federal, state and local agencies for law enforcement purposes; and (f) a Member of Congress or a

Congressional staff member in response to a verified inquiry.

This notice applies to all forms and informational requests that you may receive from NIOSH in connection 

with the evaluation of an SEC petition. 

Use of this form is voluntary. Failure to use this form will not result in the denial of any right, benefit, or 

privilege to which you may be entitled.