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

under the Energy Employees Occupational Centers for Disease Control and Prevention

iiness Compensation Act National Institute for Occupational Safety and Health

OMB Number; 0920-0839 Expires: 06/31/2007

Petitioner Authorization Form _ 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 @ currently
valid OMB number,

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.

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Name or Social Security Number of First Petitioner. Fe

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uiness Gompensation Act National institute for Occupational Safely and Health

OMB Number: 0920-0639 Expires: 05/31/2007
Form A Page 1 of 2

form,and disclosure of Social Security. Number-are voluntary, Failure:
mber will not reaylt in the denial of any right, benafityor privileg

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Instructions on Completing this Form:

You should use this petition ferm onty if NIOSH has reported to you in writing that it cannot complete the
dose reconstruction needed for your cancer claim,

All other petitioners. should use Petition Form 8 to submit a petition to NIOSH.

For Further Information: tf you have questions about these instructions, 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,

A NIOSH Ctaim Information — Complete as much information as you can in Section A.

A.1 NIOSH Tracking Number (indicated on all NIOSH correspondence):

A.2 Print Nama af Fnarnu Emnlqyag for usham thie claim une filad:

Mr/Mrs.Ms. First Name Middle Initial Last Name
A.3 Social Security Number of Energy Employee for whom this claim was filed: -

Signature of Person Submitting this Petition — Complete Section B.

Print and sign your name betow to indicate that you are petitioning for HHS to consider adding a class
of employees to the Special Exposure Cohort that would include the employee indicated by the
tracking number or name under entry 1 above.

Print your name befow: LC Rian vane manta een? <2 .
. — pf ByOA
First Name —- Middle Initial. Last Name First Name (Middje Initial Last Nam

Please send this form to NIOSH at the address befow.

Once NIOSH receives this form, the U.S, Department of Health and Human Services will consider adding 2
class of employees to the Special Exposure Cohort. Your contact at NIOSH will be available to inform you of
the progress of your petition.

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

Name or Social Security Number of First Petitioner:



uo Nationat institute for Cocupational Safaty and Health|
OMB Number: 0920-0639 Expires; 06/31/2007
Special Exposure Cohort Petition — Form A wi Page 2 of 2

Public Burden Statement

Mines Compensation Act

Public reporting burden for this collection of information ts 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 ta respond to the information collected on this form unless it displays a currently
valid OMB number.

Privacy Act Advisement

Hs pctordance with the Privacy Act of 1974, as amended (5 U.S.C, § 552a), you are hereby notified of the
following:

The Energy Employees Occupational liiness 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 manher, 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; (@) collaborating researchers, under certain limited circumstances to conduct further investigations;
(e) Federal, atate 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 patition.

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 Firet Petitioner. = _ - ¢ 2)


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Under the Energy Employess Occupational Centers for Disease Contro) and Prevention
Niness Compensation Act National Institute for Occupational Safety and Health
-, . OMB Number: 0920-0839 Expires: 05/31/2007
Petitioner Authorization Form ° Page 1 of2
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instructions:
if you wish te petition HHS to consider adding a class of 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 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 inatructions, 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.

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

Addition to the Special Exposure Cohort

Name of Class Member or Survivor _

ae

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

= Le ey ey =
City, State, Zip Code of Class Member or Survivor

do hereby authorize:
Name of Petitioner, 7 . . . ny
=~ -- - wee weve! ‘ asia}
Address | of Petijioner _ maaan Apt. # P.O. Box
City, State and Zif Code of Petitioner °
to petition the Department of Health and Human Services on behalf of a class of employees
that includes: ae ee

Name of Glass Member (employes, not the employea’s survivor)

for the addition of the class to the Special Exposure Cohort, under the Energy Employee's
Occupational Ifiness Compensation Program Act (42 U.S.C. §§ 7384-7386).

in providing this authorization, 1 recognize that the petitioner named above will hava alll the rights

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I Sierenkte offotass Mésaber or Survi¢or] ev : Date , z

Name or Social Security Number of First Patitioner:

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