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

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

7 OMB Number: 0920-0639 Expires: 07/31/2016
Special Exposure Cohort Petition — Form B Page 5 of 7

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

Complete at feast 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.

Fi 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 1 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 energy 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

documentation and/or affidavit(s) indicate that radiation monitoring records for members of the
proposed class have been lost, altered illegally, or destroyed.

Part F is continued on the following page.



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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
illness Compensation Program Act National Institute for Occupational Safety and Heaith

OMB Number: 0920-0639 Expires: 07/31/2016
Special Exposure Cohort Petition — Form B *P Page 4 of 7

Proposed Definition of Energy Employee Class Covered by Petit

E.1 Name of DOE or AWE Facility: CAR BoKVNDYUM

Complete Part E.

E.2. Locations at the Facility relevant to this petition:
BuFPAro AY NIAGARA Falls  (V. Yo

1

E.3 List job titles and/or job duties of energy 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 included in this class:

E.4 Employment Dates relevant to this petition:

stat _ (935 End (W7L
Stat _ 1 GY | End (976
Start End

E.5_ Is the petition based on one or more unmonitored, unrecorded, or inadequately monitored or
recorded exposure incidents?: 1 Yes ONo

If yes, provide the date(s) of the incident(s) and a complete description (attach additional pages as
necessary):

Go to Part F.



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 Program Act National Institute for Occupational Safety and Health
OMB Number: 0920-0639 Expires: 07/31/2016

Special Exposure Cohort Petition — Form B ndix — Petitioner 2
ivor Information — Complete Part B if you are a Survivor or representing a Survivor.

B.1 Name of Survivor:

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

B.2. Address of Survivor:

Street : Apt # P.O. Box

City — State Zip Code

B.3 Telephone Number of Survivor: (_ )

B.4__—_ Email Address of Survivor:
+

B.5 Relationship to Energy Employee:

Go to Part C.

Cc. Energy Employee Information — Complete Part C.

C.1 Name of Energy Employee:

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

C.2 Former Name of Energy Employee (e.g., maiden name/legal name change/other):

Mr./Mrs./Ms. First Name Middle Initial Last Name
C.3 Address of Energy Employee (if living):

Street Apt # P.O. Box
City State Zip Code
C.4 Telephone Number of Energy Employee: ( )

C.5 Email Address of Energy Employee:
C.6 Employment Information Related to Petition:

C.6a Energy Employee Number (if known):

C.6b Dates of Employment: Start ba L End Le

C.6c Employer Name: CARBORUNDUM
C.6d Work Site Location: __ Bu FEaLo AV WiaGAard Falls VY

C.6e Supervisor's Name:

Sign Part G of the original petition.



Leer Nove 2ery

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

OMB Number: 0920-0639 Expires: 07/31/2016
Special Exposure Cohort Petition — Form B umber ” 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
radiation 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 O \We 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 energy
employees covered by the petition.

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

Go to Part G.

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

AlrPotitinnars shauld sian and.date the netitian. A maximum of three wy, may sign the petition.

Lo, /31 fQoLy

Signatuié Date

— fof 3t 1 VF
Signature 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 EEQICPA 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
Division of Compensation Analysis and Support
NIOSH
4676 Columbia Parkway, MS-C-47
Cincinnati, OH 45226

If there are additional petitioners, they must complete the Appendix Forms for additional petitioners.
The Appendix forms are located at the end of this document.

appeared une, Charfe Stateol NewYork
Fe tlm doonty of Meeeras

6. Islam t Sign before me
on 1 at a an Noveaber 1 hee
GQrorpe8 I~ sn RAEI Baba ese
No. 01186288784 Wotery Pobliv

Qualified in Niagara County
My Commission Expires Sept. 09, 2017


Covered Employee NIOSH ID# DOL ID

Summary

References

Page 16 of 19


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

under the Energy Employees Occupational Centers for Disease Control and Prevention

lliness Compensation Program Act National Institute for Occupational Safety and Health
OMB Number: 0920-0639 Expires: 07/31/201

Special Exposure Cohort Petition — Form B ume Pres: Page 1 ons

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.

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 sections appropriate to you. If 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
purpose. A maximum of three petitioners is allowed.

If you 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.

For Further Information: !f 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 Division of Compensation Analysis and
Support about an SEC petition: 1-877-222-8570.

Start at D

If you Start at C
are: Start at B
Start at A

Representative Information — Complete Part A if you are authorized by an Energy Employee or

Survivor(s) to petition on behalf of a class.

A.1— Are you a contact person for an organization? [1 Yes (Goto A.2) 0 No (Go to A.3)

A.2 Organization Information:

Name of Organization

Position of Contact Person

A3 Name of Petition Representative:

Mc/Mrs./Ms. — First Name Middle Initial Last Name

A4 _ Address of Petition Representative:

Street Apt # P.O. Box
City State Zip Code
A5 Telephone Number of Petition Representative: ( )

A6 Emait Address of Petition Representative:

A.7 (1 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 energy employee(s) indicated in Parts B or C of this form.
If you are representing a Survivor, go to Part B;
if you are representing an Energy Employee, go to Part C.



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

under the Energy Employees Occupational Centers for Disease Control and Prevention
lliness Compensation Program Act National Institute for Occupational Safety and Health
OMB Number: 0920-0639 Expires: 07/31/2016

Special Exposure Cohort Petition — Form B Page 2 of 7
B. Survivor Information — Complete Part D if you are a Survivor or representing a Survivor.

B.1 Name of Survivor: ,

First Name "Middle Tnitial Last Nami

B.2. Address of Survivor:

Street Apt # P.O. Box

City State Zip Loue

B.3. Telephone Number of Survivor: (_ -.

B.4__ Email Address of Survivor:

B.5 Relationship to Energy Employee:

Go to Part C.

9 : 5 ° omplete Pa ou are a labor o °
C.1_ Name of Energy Employee:
“First Name Middle Initial Last Name

C.2 Former Name of Energy Employee (e.g., maiden name/legal name change/other):

Mr./Mrs./Ms. First Name Middle Initial Last Name
C.3 Address of Energy Employee (if living):

Street Apt # P.O. Box
City State Zip Code
C.4 Telephone Number of Energy Employee: ( )

C.5 Email Address of Energy Employee:
C.6 Employment Information Related to Petition:
C.6a Energy Employee Number (if known): _
C.6b Dates of Employment: Start 1g 4 | End %

C.6c Employer Name: ( y At h ru wd ur Co. a

C.6d_ Work Site Location: A :
Gutfal) Aue. Niagara Falke Wy

C.6e Supervisor's Name:

Go to Part E.