_____________________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

_________

 

________________________________________________________________ 

________________________________________________________________ 

________________________________________________________________ 

________________________________________________________________ 

 

Conflict or Bias Disclosure Form 

Identification 

Name of Individual or Corporate Entity: Samuel E. Glover 

Name of Employer: NIOSH 

Today's Date: 1/24/2007 

Sites/Facilities addressed on this form: LOOW 

Questions to Identify a Conflict or Bias 

1. Are you1 currently engaged in any capacity (paid or unpaid) by the U.S. Department of 

Energy (DOE)? Check Yes or No. 

“Site” and “facility” are defined to include DOE, AWE and other federally-owned or -operated sites. For 

purposes of brevity, the "other federally-owned or -operated sites" category shall be referred to in this 

document as “other” sites. 

Yes ____, a COB exists and the individual with the COB cannot perform any key Program 

function for any site. If yes, please provide details about each DOE location (specific site or sites) 

at which you are currently engaged, a description of your activities for DOE, and whether you are 

paid or unpaid. Stop. 

 No __X____ proceed to Question 2. 

2. Do you, or did you, work either at or for this DOE or Atomic Weapons Employer (AWE) 

site? Check Yes or No. 

"Work" means employment at or for the site, site contractor or site subcontractor that includes 

management, direction, or implementation of radiation protection and/or health physics program policies, 

procedures or practices related to atomic weapons activities at the site. 

Yes ___ ____, a COB exists and the individual with the COB cannot perform a key Program 

function related to this site or sites. Please provide details below about the DOE or AWE site(s) 

you work/worked at or for. Stop. 

No ___X_____, proceed to Question 3. 

1

 For purposes of completing this form, “you” refers to an individual or an employer (depending on which 

party is completing the form). 
________________________________________________________________ 

________________________________________________________________ 

________________________________________________________________ 

________________________________________________________________ 

 

________________________________________________________________ 

________________________________________________________________ 

________________________________________________________________ 

________________________________________________________________ 

3. Do you, or did you, work for any of the past or current operators of this site? Check Yes 

or No. 

"Operator" refers to the governmental and/or corporate entities responsible for performing and overseeing 

day-to-day activities at the site, and includes work, as defined above, performed by the operator's 

(sub)contractors 

Yes _______, provide the names of the past or current operators, the name of the site that the 

operator did or does administer and the specific times (starting and stopping dates) that you 

worked, or continue to work, for the operator and proceed to Question 4. 

No ____X____, proceed to Question 6. 

4. During the time you worked for that operator, was that operator responsible for this 

site? Check Yes or No. 

Yes _______, proceed to Question 5. No ________, proceed to Question 6. 

5. Did your work for the operator have an impact on this site? Check Yes or No. 

"Impact" means that your work involved decision-making authority over management, direction, or 

implementation of radiation protection and/or health physics program policies, procedures or practices 

related to atomic weapons activities at the site. 

Yes _______, then a COB exists and the individual with the COB cannot perform a key Program 

function for this site or sites. Please provide details about the nature of the impact your work for 

the operator had on the site below. Stop. 

No ________, proceed to Question 6. 

6. Did you work for DOE in the past? Check Yes or No. 

"Work for DOE" does not include work, as defined above, for DOE of less than four months’ continuous 

duration as a student intern, graduate fellow or in another primarily educational capacity. It also does not 

include having received a financial stipend from DOE for graduate study, a fellowship in the context of an 

established DOE fellowship program intended to support graduate-level work, or receipt of a federal 

government retirement pension for prior DOE service. 

Yes _______, please provide details about each DOE location (specific site or sites) you worked 

for in the past and a description of your work for DOE (you may use a checklist listing DOE/AWE 

sites) and then proceed to Question 7. 

2
 
________________________________________________________________ 

________________________________________________________________ 

________________________________________________________________ 

_______________________________________________________ 

 

________________________________________________________________ 

________________________________________________________________ 

________________________________________________________________ 

________________________________________________________________ 

________________________________________________________________ 

________________________________________________________________ 

________________________________________________ 

No ________x____, proceed to Question 8. 

7. Did your work for DOE have an impact on this site? Check Yes or No. 

"Impact" means that your work involved decision-making authority over management, direction, or 

implementation of radiation protection and/or health physics program policies, procedures or practices 

related to atomic weapons activities at the site. 

Yes _______, then a COB exists and the individual with the COB cannot perform a key Program 

function for this site or sites. Please provide details below about the nature of the impact your 

work for the operator had on the site. Stop. 

No _____, then proceed to Question 8. 

8. Do you have a familial relationship, or a supervisory or subordinate work relationship 

with an EEOICPA claimant whose claim involves this site? Check Yes or No. 

“Familial relationship” encompasses a current spouse, child, parent, sibling or grandparent that worked at or 

for the site; or any survivors a current spouse, child, parent, sibling or grandparent that are eligible to file 

claims under the Program. 

“Supervisory or subordinate work relationship” is one where (a) the individuals in question are/were in the 

same reporting chain and within two organizational levels of one another; and (b) "Work" means 

employment at or for the site, site contractor or site subcontractor that includes management, direction, or 

implementation of radiation protection and/or health physics program policies, procedures or practices 

related to atomic weapons activities at the site. 

Yes ______, then a COB exists and the individual with the COB cannot perform a key Program 

function for this site or sites. Please provide below details about the nature of your relationship 

with the EEOICPA claimant. Stop. 

No ____X_______, then proceed to Question 9. 

9. Do you have a familial relationship, or supervisory or subordinate work relationship with 

anyone who has had an impact related to the site? Check Yes or No. 

3
 
________________________________________________________________ 

________________________________________________________________ 

________________________________________________________________ 

________________________________________________________________ 

________________________________________________________________ 

________________________________________________________________ 

________________________________________________________________ 

________________________________________________________________ 

Yes __X____, then proceed to Question 10. 

No ________, then proceed to Question 11. 

10. If you have a subordinate relationship to someone who has (had) an impact on the site, 

has a different person been designated to review your job performance as it relates to the 

site? Check Yes or No. 

Yes __X__, a COB does not exist. Proceed to Question 11. 

No ______, then a COB exists and the individual with the COB cannot perform a key Program
 

function for this site or sites. Please provide more detailed information about your relationship
 

with the person having an impact on the site. Stop. 

11. Do or did you have a familial, financial or non-financial professional (e.g., providing 

expert advice) relationship with any attorney at the time the attorney represented an 

EEOICPA claimant, DOE or the operator? 

Yes _______, then a COB exists and the individual with the COB cannot perform a key Program 

function for this site or sites. Please provide details about the relationship with the attorney, to 

include (if applicable) a list of cases for which you assisted the attorney as well as the names of 

parties on whose behalf you testified or otherwise provided assistance. Stop. 

No ____X____, then a COB does not exist. 

4
 
________________________________________________________________ 

________________________________________________________________ 

________________________________________________________________ 

________________________________________________________________ 

________________________________________________________________ 

________________________________________________________________ 

________________________________________________________________ 

________________________________________________________________ 

________________________________________________________________ 

________________________________________________________________ 

________________________________________________________________ 

________________________________________________________________ 

Additional Details for Disclosure Questions 1-11 

Please specify the number of the question(s) for which you are giving additional details. 

5