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Conflict or Bias Disclosure Form 

Identification 

Name of Individual or Corporate Entity: Mark Rolfes 

Name of Employer: NIOSH/OCAS 

Today's Date: 1/11/2007 

Sites/Facilities addressed on this form: See Attached 

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. 

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

party is completing the form). 
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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. 

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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. 

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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. 

Yes ______, then proceed to Question 10. 

No ____X____, 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 ____, 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. 

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Additional Details for Disclosure Questions 1-11 

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

5
 
X Armour Fertilizer Works Bartow FL 

X Armour Research Foundation Chicago IL 

X Arthur D. Little Co. San Francisco CA 

X Ashland Oil Tonawanda NY 

X Associated Aircraft Tool and Manufacturing Co. Fairfield OH 

X B & T Metals Columbus OH 

X BONUS Reactor Plant Punta Higuera PR 

X BWXT Lynchburg VA 

X Baker Brothers Toledo OH 

X Baker and Company Newark NJ 

X Baker and Williams Warehouses New York NY 

X Baker-Perkins Co. Saginaw MI 

X Battelle Laboratories - King Avenue Columbus OH 

X Battelle Laboratories - West Jefferson Columbus OH 

X Bell Telephone Laboratories Murray Hill NJ 

X Bendix Aviation (Pioneer Division) Davenport IA 

X Beryllium Production Plant (Brush) Luckey OH 

X Besley-Wells South Beloit WI 

X Bethlehem Steel Lackawanna NY 

X Birdsboro Steel & Foundry Birdsboro PA 

X Bliss & Laughlin Steel Buffalo NY 

X Blockson Chemical Co. (Building 55 and related activities) Joliet IL 

X Bloomfield Tool Co. Bloomfield NJ 

X Bowen Engineering, Inc. North Branch NJ 

X Bridgeport Brass Co., Adrian Adrian MI 

X Bridgeport Brass Co., Havens Lab Bridgeport CT 

X Brookhaven National Laboratory Upton NY 

X Brush Beryllium Co. 1 Detroit MI 

X Brush Beryllium Co. 4 Cleveland OH 

X C - B Tool Products Co. Chicago IL 

X C. G. Sargent & Sons Graniteville MA 

X C. H. Schnorr Springdale PA 

X C. I. Hayes, Inc. Cranston RI 

X California Research Corp. Richmond CA 

X Callite Tungsten Co. Union City NJ 

X Carboloy Co. Detroit MI 

X Carnegie Institute of Technology Pittsburgh PA 

X Carpenter Steel Co. Reading PA 

X Chambersburg Engineering Co. Chambersburg PA 

X Chapman Valve Indian Orchard MA 

X Chemical Construction Co. Linden NJ 

X Chupadera Mesa Chupadera Mesa NM 

X Cincinnati Milling Machine Co. Cincinnati OH 

X Clarksville Facility Clarksville TN 

6
 
 

X Colonie Site (National Lead) Colonie (Albany) NY 

X SAM Laboratories, Columbia University New York City NY 

X Combustion Engineering Windsor CT 

X Connecticut Aircraft Nuclear Engine Laboratory Middletown CT 

X Copperweld Steel Warren OH 

X Crane Co. Chicago IL 

X Crucible Steel Co. Syracuse NY 

X Dana Heavy Water Plant Dana IN 

X Dorr Corp. Stamford CT 

X Dow Chemical Co. Walnut Creek CA 

X Du Pont - Grasselli Research Laboratory Cleveland OH 

X Du Pont Deepwater Works Deepwater NJ 

X ERA Tool and Engineering Co. Chicago IL 

X Edgerton Germeshausen & Grier, Inc. Boston MA 

X Electro Circuits, Inc. Pasadena CA 

X Electro Metallurgical Niagara Falls NY 

X Elk River Reactor Elk River MN 

X Area IV of the Santa Susana Field Laboratory Santa Susana CA 

X Environmental Measurements Laboratory New York NY 

X Extruded Metals Co. Grand Rapids MI 

X Extrusion Plant (Reactive Metals Inc.) Ashtabula OH 

Feed Materials Production Center (FMPC) Fernald OH 

X Fenn Machinery Co. Hartford CT 

X Fenwal, Inc. Ashland MA 

X Fermi National Accelerator Laboratory Batavia IL 

X Foote Mineral Co. East Whiteland Twp. PA 

X GSA 39th Street Warehouse Chicago IL 

X Gardinier, Inc. Tampa FL 

X General Atomics La Jolla CA 

X General Electric Company Cincinnati / Evendale OH 

X General Electric Plant Shelbyville IN 

X General Electric Vallecitos Pleasanton CA 

X Grand Junction Operations Office Grand Junction CO 

X General Steel Industries Granite City IL 

X Great Lakes Carbon Corp. Chicago IL 

X Gruen Watch Norwood OH 

X Hallam Sodium Graphite Reactor Hallam NE 

X Hanford Richland WA 

X Harshaw Chemical Co. Cleveland OH 

X Heald Machine Co. Worcester MA 

X Heppenstall Co. Pittsburgh PA 

X Herring - Hall Marvin Safe Co. Hamilton OH 

X Hooker Electrochemical Niagara Falls NY 

X Horizons, Inc. Cleveland OH 

7
 
 

X Hunter Douglas Aluminum Corp. Riverside CA 

X Huntington Pilot Plant Huntington WV 

X Idaho National Laboratory Scoville ID 

X International Minerals and Chemical Corp. Mulberry FL 

X International Nickel Co., Bayonne Laboratories Bayonne NJ 

X International Rare Metals Refinery, Inc. Mt. Kisco NY 

X International Register Chicago IL 

X Iowa Ordnance Plant Burlington IA 

X Ithaca Gun Co. Ithaca NY 

X J. T. Baker Chemical Co. Phillipsburg NJ 

X Jessop Steel Co. Washington PA 

X Joslyn Manufacturing and Supply Co. Ft. Wayne IN 

X Kaiser Aluminum Corp. Dalton IL 

X Kansas City Plant Kansas City MO 

X Kauai Test Facility Kauai HI 

X Kellex/Pierpont Jersey City NJ 

X Kerr - McGee Guthrie OK 

X Koppers Co., Inc. Verona PA 

X La Pointe Machine and Tool Co. Hudson MA 

X LaCrosse Boiling Water Reactor LaCrosse WI 

X Laboratory for Energy-Related Health Research Davis CA 

X Laboratory of Biomedical and Environmental Sciences Los Angeles CA 

X Laboratory of Radiobiology and Environmental Health San Francisco CA 

Lake Ontario Ordnance Works Niagara Falls NY 

X Landis Machine Tool Co. Waynesboro PA 

X Latty Avenue Properties Hazelwood MO 

X Lawrence Berkeley National Laboratory Berkeley CA 

X Lawrence Livermore National Laboratory Livermore CA 

X Linde Air Products Buffalo NY 

X Linde Ceramics Plant Tonawanda NY 

X Lindsay Light and Chemical Co. W. Chicago IL 

X Los Alamos Medical Center Los Alamos NM 

X Los Alamos National Laboratory Los Alamos NM 

X Lovelace Respiratory Research Institute Albuquerque NM 

X DOW Chemical Co. (Madison Site) Madison IL 

X Magnus Brass Co. Cincinnati OH 

X Mallinckrodt Chemical Co., Destrehan St. Plant St. Louis MO 

X Massachusetts Institute of Technology Cambridge MA 

X Mathieson Chemical Co. Pasadena TX 

X Maywood Chemical Works Maywood NJ 

X McKinney Tool and Manufacturing Co. Cleveland OH 

X Medart Co. St. Louis MO 

X Medina Facility San Antonio TX 

X Metals and Controls Corp Attleboro MA 

8
 
X Middlesex Municipal Landfill Middlesex NJ 

X Middlesex Sampling Plant Middlesex NJ 

X Midwest Manufacturing Co. Galesburg IL 

X Mitchell Steel Co. Cincinnati OH 

X Mitts & Merrel Co. Saginaw MI 

X Monsanto Chemical Co. Dayton OH 

X Mound Plant Miamisburg OH 

X Museum of Science and Industry Chicago IL 

X National Bureau of Standards, Van Ness Street Washington DC 

X National Guard Armory Chicago IL 

X National Research Corp. Cambridge MA 

X Naval Research Laboratory Washington DC 

X Nevada Test Site Mercury NV 

X New Brunswick Laboratory New Brunswick NJ 

X New England Lime Co. Canaan CT 

X New York University New York NY 

X Norton Co. Worcester MA 

X 

Nuclear Materials and Equipment (NUMEC) - Parks 

Township Parks Township PA 

X Nuclear Materials and Equipment Corp. (NUMEC) - Apollo Apollo PA 

X Nuclear Metals, Inc. Concord MA 

X Oak Ridge Gaseous Diffusion Plant (K-25) Oak Ridge TN 

X Oak Ridge Hospital Oak Ridge TN 

X Oak Ridge Institute for Science Education Oak Ridge TN 

X Oak Ridge National Laboratory (X-10) Oak Ridge TN 

X Oliver Corp. Battle Creek MI 

X Pacific Northwest National Laboratory Richland WA 

X Pacific Proving Ground Marshall Islands MH 

X Paducah Gaseous Diffusion Plant Paducah KY 

X Painsville Site (Diamond Magnesium Co.) Painsville OH 

X Pantex Plant Amarillo TX 

X Peek Street Facility Schenectady NY 

X Penn Salt Co. Philadelphia / Wyndmoor PA 

X Philadelphia Naval Yard Philadelphia PA 

X Pinellas Plant Clearwater FL 

X Piqua Organic Moderated Reactor Piqua OH 

X Podbeliniac Corp. Chicago IL 

X Portsmouth Gaseous Diffusion Plant Piketon OH 

X Precision Extrusion Co. Bensenville IL 

X Princeton Plasma Physics Laboratory Princeton NJ 

X Project Chariot Site Cape Thompson AK 

X Project Faultless Nuclear Explosion Site Central Nevada Test Site NV 

X Project Gasbuggy Nuclear Explosion Site Farmington NM 

X Project Gnome Nuclear explosion Site Carlsbad NM 

X Project Rio Blanco Nuclear Explosion Site Rifle CO 

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X Project Rulison Nuclear Explosion Site Grand Valley CO 

X Project Shoal Nuclear Explosion Site Fallon NV 

X Puerto Rico Nuclear Center Mayaguez PR 

X Purdue University Lafayette IN 

X Quality Hardware and Machine Co. Chicago IL 

X R. Krasburg and Sons Manufacturing Co. Chicago IL 

X R. W. Leblond Machine Tool Co. Cincinnati OH 

X Radium Chemical Co. New York NY 

X Rare Earth/W. R. Grace Wayne NJ 

X Reed Rolled Thread Co. Worcester MA 

X Revere Copper and Brass Detroit MI 

X Rocky Flats Plant Golden CO 

X Roger Iron Co. Joplin MO 

X Sacandaga Facility Glenville NY 

X Salmon Nuclear Explosion Site Hattiesburg MS 

X Sandia Laboratory-Salton Sea Base Imperial County CA 

X Sandia National Laboratory Albuquerque NM 

X Sandia National Laboratories - Livermore Livermore CA 

X Savannah River Site Aiken SC 

X Sciaky Brothers, Inc. Chicago IL 

X Seaway Industrial Park Tonawanda NY 

X Separations Process Research Unit (at Knolls Lab) Schenectady NY 

X Seymour Specialty Wire Seymour CT 

X Shattuck Chemical Denver CO 

X Shippingport Atomic Power Plant Shippingport PA 

X Shpack Landfill Norton MA 

X Simonds Saw and Steel Co. Lockport NY 

X South Albuquerque Works Albuquerque NM 

X Southern Research Institute Birmingham AL 

X Spencer Chemical Co., Jayhawks Works Pittsburg KS 

X Sperry Products, Inc. Danbury CT 

X St Louis Airport Storage Site (SLAPS) St. Louis MO 

X Standard Oil Development Co. of NJ Linden NJ 

X Stanford Linear Accelerator Center Palo Alto CA 

X Star Cutter Corp. Farmington MI 

X Staten Island Warehouse New York NY 

X Stauffer Metals, Inc. Richmond CA 

X Superior Steel Co. Carnegie PA 

X Sutton, Steele and Steele Co. Dallas TX 

X Swenson Evaporator Co. Harvey IL 

X Sylvania Corning Nuclear Corp - Bayside Laboratories Bayside NY 

X Sylvania Corning Nuclear Corp - Hicksville Plant Hicksville NY 

X Tech-Art, Inc. Milford OH 

X Tennessee Valley Authority Muscle Shoals AL 

10
 
X Texas City Chemicals, Inc. Texas City TX 

X Thomas Jefferson National Accelerator Facility Newport News VA 

X Titanium Alloys Manufacturing Niagara Falls NY 

X Titus Metals Waterloo IA 

X Tocco Induction Heating Div Cleveland OH 

X Torrington Co. Torrington CT 

X Trinity Nuclear Explosion Site 

White Sands Missile 

Range NM 

X Tube Reducing Co. Wallington NJ 

X Tyson Valley Powder Farm St. Louis MO 

X U.S. Steel Co., National Tube Division McKeesport PA 

X United Lead Co. Middlesex NJ 

X United Nuclear Corp. Hematite MO 

X University of California Berkeley CA 

X Metallurgical Laboratory Chicago IL 

X University of Denver Research Institute Denver CO 

X University of Florida Gainesville FL 

X University of Michigan Ann Arbor MI 

X University of Rochester Atomic Energy Project Rochester NY 

X University of Virginia Charlottesville VA 

X Utica St. Warehouse Buffalo NY 

X Ventron Corporation Beverly MA 

X Virginia-Carolina Chemical Corp. Nichols FL 

X Vitro Corp. of America, Chattanooga Chattanooga TN 

X Vitro Corp. of America, West Orange West Orange NJ 

X Vitro Manufacturing Canonsburg PA 

X Vulcan Tool Co. Dayton OH 

X W. E. Pratt Manufacturing Co. Joliet IL 

X W. R. Grace Erwin TN 

X W. R. Grace Co., Agricultural Chemical Div. Ridgewood FL 

X W. R. Grace and Company Curtis Bay MD 

X Wah Chang Albany OR 

X Waste Isolation Pilot Plant Carlsbad NM 

X Watertown Arsenal Watertown MA 

X Weldon Spring Plant Weldon Spring MO 

X West Valley Demonstration Project West Valley NY 

X Westinghouse Atomic Power Development Plant East Pittsburgh PA 

X Westinghouse Electric Corp. Bloomfield NJ 

X Winchester Engineering and Analytical Center Winchester MA 

X Woburn Landfill Woburn MA 

X Wolff - Alport Chemical Corp. Brooklyn NY 

X Wolverine Tube Division Detroit MI 

X Wyckoff Drawn Steel Co. Chicago IL 

X Wykoff Steel Co. Newark NJ 

X Y-12 Plant Oak Ridge TN 

11
 
X Yucca Mountain Site Characterization Project Yucca Mountain NV 

X Carborundum Company Niagara Falls NY 

X Oak Ridge Thermal Diffusion Plant (S-50) Oak Ridge TN 

X Westinghouse Nuclear Fuels Division Cheswick PA 

X Tonopah Test Site North Las Vegas NV 

X Ore Buying Station at Globe Globe AZ 

X Green Sludge Plant Uraven CO 

X Uranium Mill in Durango Durango CO 

X Ore Buying Station at Grants Grants NM 

X Ore Buying Station at Shiprock Shiprock NM 

X Ore Buying Station at Edgemont Edgemont SD 

X Ore Buying Station at Marysvale Marysvale UT 

X Ore Buying Station at Moab Moab UT 

X Ore Buying Station at Monticello Monticello UT 

X Ore Buying Station at White Canyon White Canyon UT 

X Uranium Mill in Monticello Monticello UT 

X Ore Buying Station at Crooks Gap Crooks Gap WY 

X Ore Buying Station at Riverton Riverton WY 

X General Electric X-Ray Division Milwaukee WI 

X Nevada Site Office North Las Vegas NV 

X High Energy Rate Forging (HERF) Facility Oxnard CA 

X Mill at Moab Utah Moab UT 

X Clinton Engineer Works (CEW) Oak Ridge TN 

X Canoga Avenue Facility (Vanowen Building) Los Angeles CA 

X De Soto Avenue Facility Los Angeles CA 

X Downey Facility Los Angeles CA 

X Kirtland Operations Office Albuquerque NM 

X Ross Aviation Albuquerque NM 

12