/ 

---

SEC00~.5"3 06-25-19A10:·32 RCVD 

Special Exposure Cohort Petition 

under the Energy Employees Occupational 

Illness Compensation Program Act 

U.S. Department of Health and Human Services 

Centers for Disease Control and Prevention 

National Institute for Occupational Safety and Health 

Petitioner Authorization Form 

0MB Number: 0920,0639 Expires: 10/31/2019 

Page 1 of 2 

Use of this form i~ voluntary. f::ailure to use this form will not result in 

the denial of any .right, benefit, or privilege to which you may be entitled. 

Instructions: 

If you wish to petition HHS to consider.adding a class of energy 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 energy 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 instructions, please call the following 

NIOSH toll-free phone number and request to speak to someone in the Division of·compens_ation 

Analysis and Support about an SEC petition: 1-877-222-8570. 

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

Addition to the Special Exposure Cohort 

I, 

Name of Class M

mber or Survivor 

·~. 

A ess 

Zip C 

to petition the Department of Health and Human Services on behalf of a class of energy 

mployees that includes: · 

for the addition of the class to the Special Exposure Cohort, under the Energy Employee's 

Occupational Illness Compensation Pro_gram Act (42 U.S.C. §§ 7384-7385). 

In pr his authorization, I recognize that the· petitioner named above will have all the rights 

of a 

__ _ · Signature of. Class Member or Survivor Date 

'----------------------------------------~'-" 
Special Exposure Cohort Petition 

under the Energy Employees Occupational 

Illness Compensation Program Act 

Petitioner Authorization Form 

U.S. Department of Health and Human Services 

Centers for Disease Control and Prevention 

National Institute for Occupational Safety and Health 

0MB Number: 0920-0639 

P~blic Burden Statement 

Expires: 10/31/2019 

Page 2 of2 

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 unl~ss it displays a currently 

valid 0MB 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 Illness 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 and 

WTC Health 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 researche.rs, 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 t.o all forms and informational requests that you may receive from NIOSH in connection 

with the evaluation of an SEC petition. · 

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. 
·

~ 

Special Exposure Cohort Petition 

under the Energy Employees Occupational 

Illness Compensation Program Act 

Special Exposure Cohort Petition - Form B 

U.S. Department of Health and Human Services 

Centers for Disease Control and Prevention 

National Institute for Occupational Safety and Health 

0MB Number: 0920-0639 Expires: 10/31/2019 

Pa e 1 of 7 

Use.of this form Is voluntary. Failure.to use this form will not result in 

the denial of any tight,. benefit, or rivUege to which you.may be entitle~. 

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: 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 Division of Compensation Analysis and 

Support about an SEC petition: 1-877-222-8570. 

Start at D · , 

lfyou 

are: 

Start at C 

Are you a contact person for an organization? 

Organization Information: 

Name of Organization 

Position of Contact Person 

A.3 Nam 

Mr./Mrs Fir . Middle Initial Last Name 

Address of Petit tative: f 

P.O. Box 

Telephone Number of Petition Representative: 

Email Address of Petition Representative: 

3 
Special Exposure Cohort Petition 

under the Energy Employees Occupational 

Illness Compensation Program Act 

U.S. Department of Health and Human Services 

Centers for Disease Control and Prevention 

National Institute for Occupational Safety and Health 

0MB Number: 0920-0639 

. . .. . .. .. 

B. 1 

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

8.2 Address of Surviv

Apt# P.O. Box 

s.;~ --

8.3 Telephone Number of Survivor: 

· ·' . ·· . Go to Part C. 

D Son/Daughter 

DGrandchild 

DParent 

C. Energy Employee Information Complete Part C UNLESS you are a labor organization. 

C. 1 Name of Energy Employee: 

Middle Initial 

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

Mr./Mrs./Ms. First Name Middle Initial Last Nc1me 

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 

C.6b Dates of Employment: 

C.6c Employer Name: 

C.6d Work Site Location: +:l;.J::....!..2..,..,.L~~,li.2l..!,J~~-.i'-1:-!-..::::!:::...J.1L..J.~~.!.-l...!.L.~~--=:::L..1..~ , 

.· Go to P~rt E, 
Special Exposure Cohort Petition 

under the Energy Employees Occupational 

Illness Compensation Program Act 

0.1 Labor Organization Information: 

Name of Organization 

Position of Contact Person 

0.2 Name of Petition Representative: 

Mr./Mrs./Ms. First Name 

0.3 Address of Petition Representative: 

Street 

City State 

U.S. Department of Health and Human Services 

Centers for Disease Control and Prevention 

National Institute for Occupational Safety and Health 

0MB Number: 0920-0639 

Middle Initial 

Apt# 

Expires: 10/31/2019 

Page 3 of7 

Last Name 

P.O. Box 

Zip Code 

D.4 Telephone Number of Petition Representative: ('-----'--------------

D.5 Email Address of Petition Representative: 

D.6 Period during which labor organization represented energy 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 energy employees (if known}: 

· · Go to :Part E; 
~·-, 

Special Exposure Cohort Petition 

under the Energy Employees Occupational 

Illness Compensation Program Act 

U.S. Department of Health and Human Services · Centers for Disease Control and Prevention 

National Institute for Occupational Safety and Health 

0MB Number: 0920-0639 

E.2. Locations at the Facility relevant to this petition: 

,/ 

E.3 

E.4 

Start 

Start 

s 

End 

End 

E.5 Is the petition based on one or more unmonitored, unrecorded, or inadequately monitored or 

recorded exposure incidents?: 

Go to Part F. 
Special Exposure Cohort Petition 

under the Energy Employees Occupational 

Illness Compensation Program Act 

U.S. Department of Health and Human Services 

Centers for Disease Control and Prevention 

National Institute for Occupational Safety and Health 

Special Exposure Cohort Petition - Form B 0MB Number: 0920-0639 Exp_ires: 10/31/2019 

P 5 . f7 

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

Reconstruction Complete Part 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. 

F.1 I/We have attached either documents or statements provided by affidavit that Indicate that 

1 We have attached either doc~ment~ 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. 

~ > • 

· .• ··'"C P~rfF,i:S continu_ed.on,thefoll9wln · ·., . . ·~ 
Special Exposure Cohort Petition 

under the Energy Employees Occupational 

Illness Compensation Program Act 

U.S~ Department of Health and Human Services 

Centers for Disease Control and Prevention 

National Institute for Occupational Safety and Health 

Special Exposure Cohort Petition - Form B 0MB Number: 0920-0639 Expires:· 10/31/2019 

Paae 6 of 7 

F.3 D I/We 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 D I/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. 

ign and date the petition. A maximum of three persons may sign the petition. 

Sign Date 

~~re ~ 

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. I 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 

1090 Tusculum Ave, 

Cincinnati, OH 45226 

If there. are additional. petitioners, they must complete the _Appendix Forms for additi_onal petitione~ . . 

. . . , ~ . . . . . . .: The Appendix forms are locate~ at the er;id of.this docum~,:it . . :. · 
Special Exposure Cohort Petition 

under the Energy Employees Occupational 

Illness Compensation Program Act 

Special Exposure Cohort Petition - Form B 

U.S. Department of Health and Human Services 

Centers for Disease Control and Prevention 

National Institute for Occupational Safety and Health 

0MB Number: 0920-0639 Expires: 10/31/2019 

Page 7 of7 

Public Burden Statement 

Public reporting burden for this collection of information is estimated to average 5 hours 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; AITN: 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 a currently 

valid 0MB 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 Illness 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 and 

WTC Health Program Records, HHS/CDC/N IOSH ." These records are treated in a confidential manner, 

unless otherwise compelled by law. Disclosures that NIOSH may need ta 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 !:3) 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. 
f 
I 
;l 

'\ 

,:. 

(l ; " 

·- .... -.~ ...... 

Employment History Affidavit for a Claim 

Under the Energy Employees Occupational 

· Illness Compensation Program Act , 

' 

U.S. Deparbnent of Labor 

Office of Workers' Compensation Programs 

Division of Energy Employees OCCJpational 

Ill ness C omnensa ti on e . . 

tigb:: Please read the Instruction on page 3 ~ before fitting out this form. Please do not write In the shaded areas. 0MB Control No. 1240-0002 Sign at the bottom of the second page. z1s form should nQt be completed by the person who Is clalmlng benefits 

under EEOICPA. Use as many ooples of tm EE-4 as necessary. Expiration Date: 03/31/2020 

~emolovee's' Information''-; (print cleai"M ;~ :ji~,?iC€" ,{'·~.»~ ;,.-·.;.~,.;~, ... '",..,;';":ll:>)';· ;.~f.ff::~i'f; ;~·k,i f..i: . 1e:i;. ~ ... ~·4r, -: ' . ,,, , h'<F " ·' •. -i •· -r •• -~.- - "" ., ............ , •• ,~ • ., __ .f .,"'; -~ . .L;,•. - :.,. .,{.~ ~i '· .' ...i,.1 zj,. ~. ·- , _., .. .a '-' .-· ~ .... ~ ."\~ - ~ • ~ .. • .• ,._:),, • V-1 1.c; ~ 

1, Employee's Name (Last, First, Middle Initial) 2, Malden/Former Name 3. Sodal Security Number (If known) 

'

:.voui·Iilfonnation·<orint.tlearJv)~_.r;,;:!t;;.ii"r;·~.<:.r~.~rs.f.':;f,:;_~i;;?)f~'.1~~:~,X:tf,?;.'<ij"'~?",.~ii3,~lr"~r,~t-,,:i:;·•.'._.,."i.~,:i,"~.;.1.i~,..:.·.,,~,1;.;i., __ ':,,: 

4. Your Name (Last, Arst, Middle Initial) 5. Your Telephone 

6,, Your Address (Street, Apt.#, P.O, Bnx}. , .. -· ..... _ .. ·---.. ..... ~ .. ~-- ·- "- -· .,. --- ,ti! ......... 

b. Work: ( ) - (Oty, State, ZIP Code) 

c. Cell/Other: ( ) - 7. Your Relationship to the Employee (O,eck all that apply) 

EJ Work Associate D Spouse D Son/Daughter D Step-chlld D Parent 

D Grandparent D Friend D Neighbor D Other: 

·Emolovee•s·work:Histi>rv 'i:Use'ii"NewForm:for..Each,Pe'riod·of PJace·ot Emolovmerit• .: 

Your know.ledge of where Faclllty Name: 1WJC /.)fo'-1~ .l:P': ell YI a,.tJ..o 11 C!.-~ 

and for whom Im 

employg worked ' f:tm;i;J..nQ.toYJ, ::1v Facllity Location (City/State): 

(Provide as much identifying 

information as possible about ::educ:U .. 0:1 ?.Uof: Pfon:t f P.PP) the name of the employer and Bullding(s): 

location. Spell out all names.) 

Contractor or sub-contractor name{s): Sam~ a.~ ~!Jove. 

Employee's OCcupatlon 

andTitle Occuoatlon: Title: 

Dates you know the 

Start Date:! I I 1 r;.s 1 I employee worked at End Date:! 

this fadllty Month Dav Year .Month 

If you worked with the Your oosltlon and title: 

employee during this Dates you worked at this faclllty: period, provide the 

following: 

From:! I I 1964 I To:\ 

Month Dav Year Month 

Page 1 

I I 

Dav 

i I 

Dav 

H''J3 I 

Year 

19;,3 I 

Year 

Form EE-4 

November 2016 

/4 
. . . 

- ,, • )! 

'·_W arrative for1'hls Ei;nploy_ment: (Be as jpeclflc: h

~:·::· 1<:~7,~·;' 1:t?ri:,;:i.f

Describe In detail the type of work the employee performed at this facility. For Instance, describe the work processes or work duties the 

employee was engaged In at this facility. Explain how you know of the employee's presence at this facility and the type of work the 

emolovee Mrformed. Indude anv Information vou believe would be useful In conflrmlno the emolovment hlstorv. 

1--------·-------·---·----- -----------------------·--·----

----------·----·--------·------------------------------------

Any person who knowingly makes any false statement, misrepresentation, a>ncealment of fact or any other 

act of fraud In a statement to the U.S. government Is subject to civil or administrative remedies as well as 

felony crtminal prosecution and may, under appropriate criminal provisions, be punished by a fine or 

imprisonment or h. I affirm that the Information provided on this form Is accurate and true. 

• I /(Slgrfature)' Date) • 

Page2 

Form EE-4 

November 2016 ~ I~ 
., •_. 

.,' 

Form·Ei-4 

This form Is used to affirm the employment history of a living or deceased employee. The EE-4 is an acceptable format for 

providing an affidavit in support of an otherwise unverified work history and can be filled out by anyone with knowledge of 

an employee's work history. Use as many EE-4 forms as needed. If you require additional space to provide comments, 

attach a signed supplemental statement. .. 

Privacv Act $tateriient ; '. -

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) The Energy 

Employees Occupational Illness Compensation Program Act (42 USC 7384 et seq.) (EEOICPA) is administered by the Office 

of Workers' Compensation Programs of the U.S. Department of Labor, which receives and maintains personal information 

on claimants and their immediate families. (2) Information received wlll be used to determine eligibility for, and the 

amount of, benefits payable under EEOICPA, and may be verified through computer matches or other appropriate means. 

(3) Information may be given to the Federal agencies or private entitles that employed the employee to verify statements 

made, answer questions concerning the status of the claim and to consider other relevant matters. (4) Information may be 

disclosed to ,physlelans--and other- health care providers for·use 1n-provtd1r1g"treatrneflt, · peifoffilin1fevaluat1ons for ffie Office 

of Workers' Compensation Programs, and for other purposes related to the medical management of the claim. (5) 

Information may be given to Federal, state, and local agencies for law enforcement purposes, to obtain information 

relevant to a decision under EEOICPA, to determine whether benefits are being paid properly, including whether prohibited 

payments have been made, and, where appropriate, to pursue debt collection actions required or permitted by the Debt 

Collection Act. (6) Failure to disclose all requested information may delay the processing of the clalm or the payment of 

benefits, or may result in an unfavorable decision. 

. Public lluriteri Statement . - . ,•-

.. 

According to the Paperwork Reduction Act of 1995, no persons are required to respond to the Information collections on 

this form unless It displays a valid 0MB control number. Public reporting burden for this collection of Information Is 

estimated to average 30 minutes per response, including time for reviewing instructions, searching existing data sources, 

gathering the data needed, and completing and reviewing the collection of Information. The obllgatlon to respond to this 

collection ts voluntary. Send comments regarding the burden estimate or any other aspect of this collection of Information, 

including suggestions for reducing this burden, to the U.S. Department of Labor, Office of Workers' Compensation 

Programs, Room 53524, 200 Constitution Avenue N.W., Washington, D.C. 20210, and reference 0MB Control No. 1240-

0002 and Form EE-4. Do not submit the completed form to this address. 

Page3 Form EE-4 

November 2016 
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WELD, NJLO, BRIGHfRA Y, CORRONEL and UDIMET are registered trademarks of Special Metals Corporation 
Special Exposure Cohort Petition 

under the Energy Employees Occupational 

Illness Compensation Program Act 

U.S. Department of Health and Human Services 

Centers for Disease Control and Prevention 

National Institute for Occupational Safety and Health 

Instructions for Completing Special Exposure 

Cohort Petition - Form B 

0MB Number: 0920-0639 Expires: 10/31/2019 

Page 1 of 10 

Use of Form B is voluntary. Failure to use Form B will not result in 

the denial of any right, benefit, or privilege to which you may be entitled. 

Instructions on Completing Special Exposure Cohort Petition - Form B 

Introduction 

The Energy Employees Occupational Illness Compensation Program Act (the Act) authorizes the U.S. 

Secretary of Health and Human Services (HHS) to consider petitions by classes of current and/or former 

employees at facilities of either the Department of Energy (DOE) or Atomic Weapons Employers (AWEs) 

requesting to be added to the Special Exposure Cohort. HHS has issued procedures that explain how such 

employees, their survivors, or individuals or organizations authorized in writing to represent them, can submit 

_a petition and how the outcome of the petition will be decided. The procedures,.titled: "Procedures for 

Designating Classes of Employees as Members of the Special Exposure Cohort" (federal regulations at 42 

CFR Part 83), are available from HHS at the address provided below. 

SEC Petition Division of Compensation Analys-is and Support 

NIOSH 

1090 Tusculum Avenue, 

Cincinnati, OH 45226 

. . Use this form unless NIOSH has reported to you in writing that it cannot complete the dose reconstruction 

needed for your cancer claim. If so, use Special Exposure Cohort Petition - Form A. You do not have to use 

either form to submit a petition. The forms are intended to assist petiti6ners in providing the complete 

information required by HHS as efficiently as possible. 

Hardcopy Submissions: Submit completed forms to the following address: 

SEC Petition Division of'Compensation Analysis and Support 

NIOSH 

1090 Tusculum Avenue,

Cincinnati, OH 45226 / 

For Further Information: If you have questions about these instructions, please call the following 

NIOSH toll~free phone n.umber and request to speak to someone in the Division of Compensation 

Analysis and Support about an SEC petition: 
Special Exposure Cohort Petition 

under the Energy Employees Occupational 

Illness Compensation Program Act 

U.S. Department of Health and Human Services 

· Centers for Disease Control and Prevention 

National Institute for Occupational Safety and Health 

Instructions for Completing Special Exposure 

Cohort Petition - Form B 

0MB Number: 0920-0639 Expires: 10/31/2019 

Page 2 of 10 

,mrvn., ,.., .. , . rcuuu, '" uv NOT need to be submitted by all potential members of a class of energy 

employees. ("Class" has a very specific legal meaning under the HHS rule. Petitioners should consider 

"class" to mean the group of energy employees who worked at the same DOE or AWE facility and who 

believe they, as a group, should be added to the Special Exposure Cohort). A single member of a class of 

energy employees, the survivor of a member, or an individual or entity authorized in writing by a member or 

survivor can petition on behalf of the entire class. Petitioners are not required by HHS to contact other 

members of the class or obtain their consent to submit a petition, although petitioners may wish to obtain 

information useful to the petition from other members of the class. 

Instructions 

Please read each of Parts A - G in the form and complete only those sections appropriate to you, according 

to these instructions. A checklist has been provided on the last page of these instructions to help ensure that 

you have properly completed all of the sections applicable to you. Except for signatures, please PRINT all 

information clearly and neatly on the form. 

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, but only one petitioner is required. Limiting 

the number of petitioners to three for each petition does not limit the number of members of the class covered 

by a petition, but will enable HHS to consider and decide petitions more efficiently. 

· If you need more space to provide additional information, use the continuation page provided at the end of 

: the form and attach the continu·ation page(s) to Form 8. 

· Part A 

. Petitioner Information: Complete Part A if you are an individual or entity (other than a labor organization) 

authorized by an energy employee or a survivor to petition on behalf of a class of energy employees, as 

provided for under 42 CFR Part 83.?(c). 

A.1 - Are you a contact person for an organization (other than a labor union): If you are a contact 

person for an organization, other than a labor organization, check Yes and go to A.2; if you are not a contact 

person, check No and go to A.3. . 

A.2 - Organization Information: If you are a contact person for a legally constituted organization, a firm, or 

another type of entity, enter the name of the organization and your position as the person who will serve as 

the principal contact with HHS for this petition. If you are NOT a contact person, leave this entry blank. 

A.3 - Name of Petition Representative: Enter your full legal name (applies to both a contact person and 

an authorized representative of an energy employee or survivor). 

A.4 - Address of Petition Representative: Enter your current mailing address. 

A.5 - Telephone Number of Petition Representative: Enter the telephone number at which you can be 

reached from 8:00 am to 5:30 pm Eastern Standard Time on weekdays. Please specify more limited hours 

when you are available, if necessary. 

A.6 - Email Address of Petition Representative: (Optional) Enter your email address at work or home: 

A.7 -Authorization: Check the box and attach the written authorization, as indicated. A separate 

authorization form, "Petitioner Authorization Form", is available for this purpose. 

If you are representing a survivor, go to Part B; 

if ou are representing an ener em lo ee, 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 

Illness Compensation Program Act ' National Institute for Occupational Safety and Health 

Instructions for Completing Special Exposure 0MB Number: 0920-0639 Expires: 10/31/2019 

Cohort Petition - Form B Page 3 of 10 

Part B 

Petitioner Information: Complete Part B if you are a Survivor of a former Energy Employee. Also complete 

this Part if you are an individual or entity (other than a labor organization) authorized by an energy employee 

o·r survivor to petition on behalf of a class of energy employees. 

B.1 - Name of Survivor: Enter the full legal name of the survivor. 

B.2 - Address of Survivor: Enter the survivor's current mailing address. If 'you are authorized to petition by 

an energy employee or a survivor under Part A of this form, you do not need to complete this entry. 

B.3 - Telephone Number of Survivor: Enter the telephone number at which the survivor can be reached 

from 8:00 am to 5:30 pm Eastern Standard Time on weekdays. Please specify more limited hours of 

availability, if necessary. If you are authorized to petition by an energy employee or a survivor under Part A of 

this form, you do not need to complete this entry. 

B.4 - Email Address of Survivor: (Optional) Enter the survivor's email address at work or home. If you are 

authorized to petition by an energy employee or a survivor under Part A of this form, you do not need to 

complete this entry. 

B.5 - Relationship to Energy Employee: Check the relationship of the survivor to the energy employee 

that applies. 

Go to Part C. 
Special Exposure Cohort Petition 

under the Energy Employees Occ\Jpational 

Illness Compensation Program Act 

Instructions for Completing Special Exposure 

Cohort Petition - Form B 

Part C 

U.S. Department of Health and Human Services 

Centers for Disease Control and Prevention 

National Institute for Occupational Safety and Health 

' 0MB Number: 0920-0639 Expires: 10/31/2019 

Page 4 of 10 

Petitioner Information: Complete Part C if you are an Energy Employee or a Survivor. Also complete this 

Part if you are an individual or entity (other than a labor organization) authorized by an energy employee or 

survivor to petition on behalf ofa class of energy employees. 

This section is to be completed by petitioners who are energy employees of DOE/AWE facilities or their 

survivors, or by petitioners authorized by energy employees or their survivors. This section does not have to 

be completed by labor organizations submitting.a petition (labor organizations should complete Part D). 

Please complete all the entries in this section, as applicable. The form allows for as many as three petitioners 

to provide this complete information if they so desire, but this is not necessary. We only require that a single 

petitioner provide complete information for this section. -

C.1 - Name of Energy Employee: Enter the full legal name of the energy employee. 

C.2 ...,.. Former Name of Energy Employee: If the energy employee had a different name at the time of 

employment at the DOE or Atomic Weapons Employer facility (for example, a maiden name), enter that 

name. 

C.3 - Address of Energy Employee (if living): Enter the current mailing address ofthe employee. If you 

are authorized to petition by an employee or a survivor under Part A of this form, you do not need to complete 

this entry. 

C.4 - Telephone Number of Energy Employee: Enter the telephone number at which the energy 

employee can be reached from 8:00 am to 5:30 pm Eastern Standard Time on weekdays. Please specify 

more limited hours of availability, if necessary. 

If you are authorized to petition by an energy employee or a survivor under Part A of this form, you do not 

need to complete this entry. 

C.5 - Email Address. of Energy Employee: (Optional) Enter the energy employee's email address at work 

or home. I 

If you are authorized to petition by an energy employee or a survivor under Part A of this form, you do not 

need to complete this entry. 
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 

Instructions for Completing Special Exposure 0MB Number: 0920-0639 Expires: 10/31/2019 

Cohort Petition - Form B Page 5 of 10 

C.6 -Employment Information Related to Petition: Enter the following employment information about this 

petition: 

C.6a -Employee Number (if known): Enter the energy employee number, if you know it. Not all employers 

assigned employee numbers. · 

C.6b - Dates of Employment: Enter the dates of employment at the facility (or approximate dates, if 

employment records are unavailable), from start date to end date. 

C.6c - Employer Name: Enter the name of the employer. 

C.6d -Work Site Location: Enter the location of the facility and work site relevant to the petition. Be as 

specific as possible about the work site, naming the specific building or work area if possible, as well as the 

facility location (e.g., Idaho National Engineering Laboratory). 

C.6e - Supervisor's Name: Enter the Supervisor's name, if known. 

Go to Part E. 

Part D 

Petitioner Information: Complete Part D if you are a labor organization. 

' . 

This section is to be completed only by labor organizations submitting a petition on behalf of energy 

employees they represent or represented. If you are not such a labor organization, you should skip this part. 

D.1 - Labor Organization Information: Enter the name of the labor organization and the position of the 

person who will serve as the principal contact with HHS for this petition. 

D.2 - Name of Petition Representative: Enter the name of the official who will serve as the principal 

contact for HHS communications and inquiries regarding this petition. 

D.3-D.5 - Contact Information: Enter the address, telephone number,"and e-mail address of the labor 

official who will serve as the principal contact for HHS. 

D.6 - Period during which labor organization represented energy employees covered by this petition: 

Enter dates as indicated. For active facilities at which your labor organization continues to represent energy 

employees, enter the date of the petition for the "end date." Please attach related documentation (e.g., 

relevant pages of labor-management contracts or NLRB certification). 

D.7 - Identity of other labor organizations that may represent or have represented this class of - energy employees: Enter the names of any other labor organizations who may currently represent some 

members of the class of energy employees or have represented members of this class in the past, if you are 

aware of any. This information may assist HHS in contacting members of the petitioning class for information 

or to notify them: should HHS add their class t~ the Cohort. 

Go to Part E. 

\ 
Special Exposure Cohort Petition 

under the E;nergy Employees Occupational 

Illness Comp.ensation Program Act 

Instructions for Completing Special Exposure 

Cohort Petition - Form B 

Part E 

U.S. Department of Health and Human Services 

Centers for Disease Control and Prevention 

, National Institute for Occupational Safety and Health 

0MB Number: 0920-0639 Expires: 10/31/2019 

Page 6 of 10 

Proposed Definition of Energy Employee Class Covered by Petition 

The information provided in this section will assist HHS in evaluating the petition. Petitioners should note that 

it is possible that, as HHS conducts its evaluation of a class, it may revise the definition proposed by the 

petitioner, making the class more expansive or more specific, and possibly combining. the classes of several 

petitions or dividing the class of a single petition into two or more classes. Ultimately, HHS must define 

classes consistent with the criteria for determining whether or not the. class should be added to the Cohort. 

E.1 - Name of DOE or AWE Facility: Enter the name of the DOE or AWE facility where the class of energy 

employees covered by this petition was employed. 1 . 

NOTE: Although individual energy employees may have worked at more than one facility during their career, 

a petition must be specific to a class of energy employees at a single facility, as specified by the Act. It is 

acceptable to file petitions for more than one facility; however, you must file a separate petition for each 

facility. 

E.2 - Locations at the Facility relevant to this petition: Name or describe the location(s) at the facility 

relevant to this petition; the locations where members of the class were exposed to radiation. If the location 

does not have a name, such as a building number or floor or room of a building, describe the location by its 

more specific characteristics, such as the operation or process conducted there, or the equipment, fixtures, or 

facilities in that location. Be as specific as possible. 

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

and/or job duties that characterize energy employees who you believe belong in the class, to the extent 

necessary to define the class. 

Examples: 

• If you can define the class by job duties alone, and you believe that anyone with s~ch job duties shoJld 

be included in the class, listing the job duties would be sufficient. 

• If you believe all energy employees in a location during a period of time should be included in the class, 

regardless of job title or job duty, enter an "all" here instead of specifying job titles or job duties. 

• However, if you believe that only persons with certain job duties involved in certain operations or 

processes should be included in the class, you must specify this. . . 

The point is to define the class carefully and specifically, so that it includes all energy employees for whom 

you believl:l radiation doses cannot be estimated and whose health could have been endangered, and only 

such employees. To be certain your definition covers all energy employees that you intend to include, you 

may choose to list by name individuals who should be included in the class and.who hav~ not already been 

identified among the petitioners you have listed in this form. 

E.4 - Employment Dates relevant to this petition: Enter the approximate or precise dates of .the period of 

employment that applies to the petition. For example, the potential exposures to radiation may have occurred 

during a period of a certain operation, during a period when certain radiation protection policies were in place, 

during a period when radiation monitoring was omitted, or during a period for which exposure and monitoring 

records are lost. 

/ 
I 

Special Exposure Cohort Petition 

under the Energy Employees Occupational 

Illness Compensatiori Program Act 

Instructions for Completing Special Exposure 

Cohort Petition - Form B 

U.S. Department' of Health and Human Services 

Centers for Disease Control and Prevention 

National Institute for Occupational Safety and Health 

0MB Number: 0920-0639 Expires: 10/31/2019 

Page 7 of 10 

E.5 - ls the petition based on one or more unmonitored, unrecorded, or inadequately monitored or 

recorded exposure incidents?: If the petition is based on one or more radiation exposure incidents 1for 

which exposures were unmonitored (unplanned events that resulted in radiation exposures, versus routine 

operations which may also result in radiation exposures), provide the date when the incident(s) began and 

ended and describe the incident(s) in as much detail as possible. ' . 

For example, you might describe the source of the radiation exposure or emission, its cause, the response to 

the incident, and the potential number of energy employees involved. You should report everything you know 

about the incident. NIOSH will use this information to identify the event and obtain additional information from 

the Department of Energy· and other sources. If NIOSH finds it cannot confirm the occurrence of the event 

through information from the Department of Energy or any other sources, it will require that you obtain and 

provide medical evidence relating to the incident and/or one or more affidavits providing information about the 

incident, as provided under section 83.9(c)(3) of the Special Exposure Cohort Rule (42 CFR Part 83). 

Go to Part F. · 

Part F 

Basis for Proposing that Records and Information are Inadequate for Individual Dose Reconstructions 

Complete at least one of the entries under this part. You are not required to complete more than one entry, 

although you should complete more than one entry when such additional information is available to you. This 

additional information may assist HHS in evaluating your petition. 

F.1: Complete this entry if you are petitioning on the basis that certain radiation exposures and doses to the 

class were not monitored. By completing this entry, you do not need to establish (through documentation or 

affidavit) that there was no monitoring whatsoever, of any radiation exposures and doses incurred by the 

class of energy employees. You need only establish that some types of radiation exposures and doses 

incurred by the class were not monitored, or that during certain periods of time, certain operational 

procedures, or certain exposu·re incidents, the exposures and doses incurred by the class were not 

monitored·. , 

For example, if the energy employees in the class were instructed to remove their radiation dosimetry badges 

for certain operations involving radiation exposures, this might qualify as unmonitored exposures, despite the 

fact that the employees might have routinely worn their radiation dosimetry badges during most operations. 

Similarly,. if there was a period of time during an operation when there was no monitoring of int~rnal doses, 

this might qualify as unmonitored exposures. 
Special Exposure Cohort Petition 

under the Energy Employees Occupational 

Illness Compen~ation Program Act 

Instructions for Completing Special Exposure 

Cohort Petition - Form B 

U.S. Department of Health and Human Services 

Centers for Disease Control and Prevention 

National Institute for Occupational Safety and Health 

0MB Number: 0920-0639 Expires: 10/31/2019 

Page 8 of 10 

F.2: Complete this entry if you are petitioning on the basis that radiation monitoring records for members of 

the proposed class have been lost, falsified, or destroyed. Do.cumentation or affidavits demonstrating that 

monitoring records are missing for a clas~ of workers might be sufficient to indicate that the records have 

been lost or destroyed. Documentation or affidavits demonstrating differences between exposures or 

monitoring results and the current official records of these exposures or monitoring results might be sufficient 

to indicate that records might have been falsified. You should note, however, that records can be changed to 

reflect corrections to faulty monitoring results. 

Also complete this entry if there is no information regarding monitoring, source, source term, or process from 

the site where the members of the proposed class worked. 

By completing this entry, you do not need to establish (through documentation or affidavit) that there are no 

monitoring records whatsoever, for personal or area monitoring th~t was conducted for the class of energy 

employees, or that all the relevant records have been falsified. You need only indicate that the records 

relating to some types of radiation exposures and doses incurred by the class, or relating to certain periods of· 

time, certain operations, or certain exposure incidents involving the class, have been lost, falsified, or 

destroyed, or that there is no such information. · \ 

F.3: Complete this entry if you are petitioning on the basis of an unpublished expert report addressing record 

limitations for the class of energy employees proposed in your petition. You are not required to use this 

approach to support your petition. Most petitioners are unlikely to be in a position to employ an expert to 

evaluate the limitations of DOE records on exposures to a particular class of energy employees. However, 

this is an option that might be used by some petitioners, particularly organizations. If you are considering this 

option, we suggest the expert you employ contact NIOSH before completing such an evaluation. NIOSH will 

ensure that the expert is aware of the availability of relevant information concerning the procedures by which 

NIOSH estimates radiation doses for cancer claims under the Act, including the HHS regulations on dose 

reconstruction methods (42 CFR Part 82) and related.implementation guidelines. 

F.4: Complete this entry if you are petitioning on the basis of a scientific or technical report that was published 

in a peer-reviewed journal or 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. Federal agencies most likely to have funded or to fund such studies are DOE and NIOSH. It is 

possible that state environmental protection agencies might have funded such studies related to AWE 

facilities. Such reports· are likely to have been issued either as scientific or technical reports available directly 

by request from government agencies or as research reports published in scientific journals. 

Go to Part G. 
' 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 

Instructions for Completing Special Exposure 0MB Number: 0920-0639 Expires: 10/31/2019 

Cohort Petition - Form B Page 9 of 10 

Part G 

Signature of Person(s) Submitting this Petition 

Go to Part G. 

Each petitioner should sign and date the petition as indicated. A maximum of three petitioners may sign the petition. 

Summary of Form Requirements 

To ensure that you have completed the required sections of the petition, please refer to the table below: 

If there is an additional petitioner (not a labor organization), he or she must complete the Appendix - Petitioner 2 and 

sign Section G of the original petition. Please refer back to pages 2 - 5 of this instruction set for more information on 

completing the appendix. 

Aooendix -

If there is a third petitioner (not a labor organization), he or she must complete the Appendix~ Petitioner 3 and sign 

Section G of the original petition. Please refer back to pages 2 - 5 of this instruction set for more information on 

completing the appendix. 

Appendix - Continuation Page ,.. " 

The Continuation Page is provided for you if you need more space to provide additional information. Please photocopy as 

needed, and attach to the petition. 
Special Exposure Cohort Petition 

under the Energy Employees Occupational 

·111ness Compensation Program Act 

Instructions for Completing Special Exposure 

Cohort Petition _;, Form B 

U.S. Department of Health and Human Services 

Centers for Disease Control and Prevention 

National Institute for Occupational Safety and Health 

0MB Number: 0920-0639 Expires: 10/31/2019 

. Page 10 of 10 

Public Burden Statement 

Public reporting burden for this collection of information is estimated to average 5 hours 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 bwden, 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 a currently 

valid 0MB 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 Illness 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 and 

WTC Health Program Records, HHS/CDC/NIOSH." These records are treated in a confidential manner, 

unless qtherwise 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 ~equests that you may receive from NIOSH in connection 

with the evaluation of an SEC petition. 

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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