Special Exposure Cohort Petition U.S. Department of Health and Human Services
under the Energy Employees Occupational Centers for Disease Control and Prevention
Ulness Compensation Act National Institute for Occupational Safety and Health

OMB Number: 0920-0639 Expires: 05/31/2007
Sp Page 2 of 7

ecial Exposure Cohort Petition — Form B
Survivor Information — Complete Section B if you are a Survivor or representing a Survivor.

B.1 Name of Survivor:

Mr/Mrs./Ms. First Name Middle Initial Last Name
B2 Social Security Number of Survivor:
B.3 Address of Survivor:

Street Apt # P.O. Box

City State Zip Code
B.4 Telephone Number of Survivor: ( y =

B.5 Email Address of Survivor:

B.6 Relationship to Employee: Q Spouse Q Son/Daughter O Parent
Q Grandparent Q Grandchild

Employee Informatiot

C.1_ Name of Employee:

M&. -

DAWN. _
Mr/Mrs/Ms. . ..-. sans Middle Initial Last Name
C.2 Former Name of Employee (e.g., maiden name/legal name change/other):

Mr/Mrs./Ms. First Name Middle Initial Last Name
C3 Social Security Number of Employee: —
C4 Address of Employee (if living):

Apt# : P.O. Box
C.5 Telephone Number of Employee:
C.6 Email Address of Employee:
C.7 Employment Information Related to Petition:
C.7a Employee Number (if known):
C.7b Dates of Employment: Stat Doe 1 1860 End MAY Bt 1999

C.7c Employer Name: AMES LAB
C.7d Work Site Location:

C.7e Supervisor's Name:

“Go'to. Part E.

Name or Social Security Number of First Petitioner: _s oo rv—nV OOD
)



Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention

tiness Compensation Act National Institute for Occupational Safety and Health

. - OMB Number: 0920-0639. Expires: 05/31/2007

Special Exposure Cohort Petition — Form B Page 7 of7
Public Burden Statement

Public reporting burden for this collection of information is estimated to average 300 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 0920-0638. 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 lliness 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.
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 the NIOSH petition forms (A and B) is voluntary but your provision of information required by these
forms is mandatory for the consideration of a petition, as specified under 42 CFR Part 83. Petitions that fail to
provide required information may not be considered by HHS.

Name or Social Security Number of First Petitioner: _|



Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention
Uiiness Compensation Act National Institute for Occupational Safety and Health
OMB Number. 0920-0639 Expires: 05/31/2007

ecial Exposure Cohort Petition — Form B Page 4 of 7

Proposed Definition of alas Class Covered by Petition — Complete Section E.

Ea
E2

E.3 List job titles and/or job duties of employees included in the class. In addition, you can list by
name any individuals other than petitioners identified on this form who you believe should be

-Go to Part F.

-
Name or Social Security Number of First Petitioner: . |



Special Exposure Cohort Petition U.S. Department of Health and Human Services
under the Energy Employees Occupational Centers for Disease Control and Prevention
{lines Compensation Act National Institute for Occupational Safety and Health
. OMB Number: 0920-0639 Expires: 05/31/2007
Special Exposure Cohort Petition — Form B 30f7
bor Organization Information — Complete Section D ONLY if you are a labor orga
D.1 ‘Labor Organization Information:
Name of Organization
Position of Contact Person
D.2 Name of Petition Representative:
D.3 Address of Petition Representative:
Street Apt # P.O. Box
City State Zip Code
D.4 Telephone Number of Petition Representative: ( : :
D.5 Email Address of Petition Representative:
D.6 Period during which labor organization represented employees covered by this petition
(please attach documentation): Start End
D.7 Identity of other labor organizations that may represent or have represented this class of
employees (if known):

Name or Social Security Number of First Petitioner: _



Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention
Niness Compensation Act National Institute for Occupational Safety and Health

. OMB Number: 0920-0639 Expires: 05/31/2007
Special Exposure Cohort Petition — Form B Page 6 of 7

F.3. O iWe have attached a report from a health physicist or other individual with expertise in
radiation dose reconstruction documenting the limitations of existing DOE or AWE records on
tadiation exposures at the facility, as relevant to the petition. The report specifies the basis for
believing these documented limitations might prevent the completion of dose reconstructions for
members of the class under 42 CFR Part 82 and related NIOSH technical implementation
guidelines.

(Attach report to the back of the petition form.)

F.4. Q@ IMWe have attached a scientific or technical report, issued by a government agency of the
Executive Branch of Government or the General Accounting Office, the Nuclear Regulatory
Commission, or the Defense Nuclear Facilities Safety Board, or published in a peer-reviewed
journal, that identifies dosimetry and related information that are unavailable (due to either a lack
of monitoring or the destruction or loss of records) for estimating the radiation doses of
employees covered by the petition,

{Attach report to the back of the petition form.)

Signature of Person(s) Submitting this Petition — Complete Section G.

All Petitioners should sign and date the petition. A maximum of three persons may sign the petition.

1613-2006

Date

Date

Signature ; Date

Notice: Any person who knowingly makes any false statement, misrepresentation, concealment of

fact or any other act of fraud to obtain compensation as provided under EEOICPA or who
knowingly accepts compensation to which that person is not entitled is subject to civil or
administrative remedies as well as felony criminal prosecution and may, under appropriate
criminal provisions, be punished by a fine or imprisonment or both. | affirm that the information
provided on this form is accurate and true.

Send this form to: SEC Petition
Office of Compensation Analysis and Support
NIOSH
4676 Columbia Parkway, MS-C-47
Cincinnati, OH 45226

and appeared before me thc.
dak, October 24 206.
Sor mecha “Story County Taea
og”

I ! —

Name or Social Security Number of First Petitioner: - =



_°. THE fiir

UNIVERSITY

OF lowA COLLEGE OF PUBLIC HEALTH
aaa

Department of Occupational and
Environmental Health

October 13, 2006 10-23-06A11:28 RCVD

RE: SEC for Ames Lab Workers exposed to residual radiation from AEC activities
The following is the result of interviews with former Ames Lab Mechanical Services and Industrial
Hygiene staff and the current Health and Safety staff of the Ames Laboratory:

Mr., _ isa former maintenance worker from the Ames Laboratory on the Iowa
State University Campus in Ames, lowa. He was continuously employed at the Lab from
1960 through 1999. His job titles included .

He has filed for: through EEOICPA Part B and is pending a dose
reconstruction. We are enclosing supportive information for a Special Exposure Cohort, SEC
for’ and his coworkers in the shop.

He began work as an Worker after the period currently covered in the

Ames SEC, however his work history is very clear for unmonitored, unprotected, potentially
or likely high dose exposure to various radiologic hazards including predominantly large
masses of Thorium dust entrained in the exhaust duct work and structural materials including
ceiling tiles of the Metallurgy Building, subsequently called Wilhelm Hall.

His primary responsibility from 1960 -1966 was to tear out and renovate all the ductwork,

fume hoods and stacks from the Metallurgy Building, Wilhelm Hall. The basement of

this building had become the predominant production area for Thorium processing and

related activities since the move of metals processing from "Little Ankeny, the former Women's
Gymnasium. Although work began after the Thorium processing activities

had ceased in 1954, he and his coworkers were exposed to the re-entrained particulates from

all the processes performed in this facility. These workers removed the original Rotoclone

exhaust system with it's blower on the roof, the welded ductwork including the supply duct

from the roof to the basement, the supply and exhaust ductwork running the length of the

basement including all the fume hoods. This workforce also tore out all the acoustic tile and

much of the wall materials in the basement. The ceiling tile was porous acoustic tile which

was glued to the concrete ceilings and removed with chisels. They also removed all the

associated machinery and fume hoods, upgraded the facility to a cleaner operating laboratory

and upon completion of renovations in the basement proceeded to replace all the original
ventilation system in the entire building. The primary tear out work in this building and replacement
of structural materials and replacement of the ductwork and ventilation system took all of six years,
from 1960 — 1966. After 1966, several other major removal and renovation activities were performed
in Wilhelm Hall that involved potential significant exposure to radiological contamination. One
example, related by was the addition of vitroliners to the fume hood exhaust stacks,
which went on for several months and resulted in on-going exposure to radiologically contaminated

re 205 Westlawn

. Sowa City, lowa 52242
bh Toll Free 1-866-282-5818
wb dE rax3is-353-5009
eRcamege et



Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention
Illness Compensation Act National Institute for Occupational Safety and Health
OMB Number. 0920-0639 Expires: 05/31/2007

Special Exposure Cohort Petition — Form B Page 5 of 7

Basis for Proposing that Records and Information are Inadequate for Individual Dose —
Complete Section F.

Complete at least one of the following entries in this section by checking the appropriate box and providing
the required information related to the selection. You are not required to complete more than one entry.

We have attached either documents or statements provided by affidavit that indicate that
radiation exposures and radiation doses potentially incurred by members of the proposed class,
that relate to this petition, were not monitored, either through personal monitoring or through area
monitoring.

{Attach documents and/or affidavits to the back of the petition form.)

Describe as completely as possible, to the extent it might be unclear, how the attached
documentation and/or affidavit(s) indicate that potential radiation exposures were not monitored.

F.2 O I/We have attached either documents or statements provided by affidavit that indicate that
radiation monitoring records for members of the proposed class have been lost, falsified, or
destroyed; or that there is no information regarding monitoring, source, source term, or process
from the site where the employees worked.

{Attach documents and/or affidavits to the back of the petition form.)

Describe as completely as possible, to the extent it might be unclear, how the attached
docurhentation and/or affidavit(s) indicate that radiation monitoring records for mernbers of the
proposed class have been lost, altered illegally, or destroyed.

Part F is continued on the following page.

OS

Name or Social Security Number of First Petitioner: | —_

ft



Special Exposure Cohort Petition
under the Energy Employees Occupational
Itiness Compensation Act

U.S. Department of Health and Human Services
Centers for Disease Control and Prevention
National Institute for Occupational Safety and Health

“OMB Number: 0920-0639 Expires: 05/31/2007
Page 1 of 7

General Instructions on Completing this Form (complete instructions are available in a separate packet):

Except for signatures, please PRINT all information clearly and neatly on the form.

Please read each of Parts A— G in this form and complete the parts appropriate to you. ff there is more
than one petitioner, then each petitioner should complete those sections of parts A - C of the form that apply
to them. Additional copies of the first two pages of this form are provided at the end of the form for this pur-
pose. A maximum of three petitioners is allowed.

IEyou need more space to provide additional information, use the continuation page provided at the end of
the form and attach the completed continuation page(s) to Form B.

If you have questions about the use of this form, please call the following NIOSH toll-free phone number and
request to speak to someone in the Office of Compensation Analysis and Support about an SEC petition:
1-800-356-4674,

GA Labor Organization, StartatD on Page3

Ifyou “in Energy Employee (current or former), StartatC on Page 2
are: GA Survivor (of a former Energy Employee), StartatB on Page 2
GA Representative (of a current or former Energy Employee), StartatA on Page 1

Representative Information — Complete Section A if you are authorized by an Employee or
Survivor(s) to petition on behalf of a class.

Are you a contact person for an organization? Q Yes (Go to A.2) Pf No (Go to A.3)

A.2 Organization information:

Name of Organization

Position of Contact Person
A3 Name of Petition Representative:

Mr/Mrs./Ms. First Name Middle Initial Last Name

A4 Address:
Street Apt # P.O. Box
City State Zip Code

AS Telephone Number: (_ )
A6 Email Address:

AT OG Check the box at left to indicate you have attached to the back of this form written authorization to
petition by the survivor(s) or employee(s) indicated in Parts B or C of this form. An authorization

if you are representing a Survivor, go-to-Part B; if you are representing an Employee, go to Part C....

Name or Social Security Number of First Petitioner: *



October 20, 2006

Mr. , former worker at Ames Laboratory and Mr.
former at Ames Laboratory concur with
letter dated Oct. 13, 2006 addressing the subject of a Special Exposure Cohort for Mr.
and other coworkers from Jan. 1, 1955 to Dec. 31, 1970. This letter shall become an
attachment to said letter.

Signed:

Signea:

The chore named individuals, : and
me this, date, Octobee <20, 2004.

Gage S: hurt

County Lowa,

Qppearcd before

» JEWETT
of \aas Seeing Story

DEBE



dust. The majority and most significant of these activities appear to have been completed by the
early 1970’s. These workers maintained all the ventilation systems in the entire Ames Lab.

It appears that no systematic area monitoring, quantitative exposure assessment nor plan for
worker protection was implemented. describes being completely covered with
dust and ‘looking like a coal miner’ on many days during this period, especially after tearing
out ceiling panels. He did not have any respiratory protection, (‘not even a 3-M dust mask’), and no
personal radiation exposure monitoring. Workers took their breaks at the worksite,
smoked cigarettes and ate their lunches in the same area in which they were tearing out the
aforementioned ductwork. The sole Ames Lab during that period, Mr.

relates that he was concerned at that time regarding unprotected, unquantified
exposure to thorium dusts. _ began his employment at the Ames Lab in 1963 but
relates concem dating back to that date for the health and safety of these workers because he, as the
Lab’s and Health Physics staff were apparently not involved with oversight of
worker monitoring and protection for these workers at that time.

There are several other workers who should be considered as a part of this SEC including

- (all of whom are deceased), and other
workers as yet to be identified but who worked on the tear out work in the Metallurgy
Building, Wilhelm Hall.

A review of industrial hygiene and health physics reco from 1960’s through the
1980’s indicate that, before approximately 1970, facilities services workers were not consistently
provided industrial hygiene and health physics oversight including respiratory protection from
airbome contaminants. Also, according to the Laboratory’s review of available records, these same
workers were not provided external dosimetry monitoring or intemal dosimetry services, except
during work activities at the Ames Laboratory Research Reactor (ALRR).

Sincerely,

3 2115 Westiawn
4 Towa City, lowa 52242
<2 y Toll Free 1-866-262-5818

Fox 319-353-5649