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: 09/20/2013

Special Exposure Cohort Petition — Form B

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.

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

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ued on the following page.

Name or Social Security Number of First Petitioner:



Special Exposure Cohort Petition Bey 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: 09/20/2013

Special Exposure Cohort Petition — Form B Pas
Proposed Definition of Employee Class Covered by Pe Complete Section E
E.1 Name of DOE or AWE Facili oslyn Manufact aning andSupaly Lo tm pan,

E.2 _ Locations at the Facility relevant to this petition: a | { ARrZas

jo 4 Of 7

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

included in this class: a | { empleo vee
V

E£.4 Employment Dates relevant to this petition:

Start i ] 44 End l G5 2.

Start End
Start End’
E.5 Is the petition based on one or more unmonitored, unrecorded, or inadequately monitored or
- recorded exposure incidents?: O Yes & No :

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

— ~ ee

“ Goto 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
Iliness Compensation Act National-Institute for Occupational Safety and Health

OMB Number: 0920-0639 Expires: 09/20/2013
Special Exposure Cohort Petition — Form B Page 6 of 7

F.3. I/We have attached a report from a health physicist or other individual with expertise in
tadiation 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 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 identifi ies 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.)

aximum of three persons may sign the petition.
Danch1e-2000,
” Date
DW ox Br 19.) 20/9

- ~~ 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
Division of Compensation Analysis and Support
NIOSH
4676 Columbia Parkway, MS-C-4% “/G
Cincinnati, OH 45226
— _ —_— eran emma
it there: are additional: ‘petitioners lust complete the ‘Appendi Forms for additional petitioners.
The Appendix forms are. located at the end of th document,

Name or Sociat 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
Iliness Compensation Act National Institute for Occupational Safety and Health

03-15-12P01:40 RCVDonp Number: 0920-0639 Expires: 09/20/2013
Special Exposure Cohort Petition — Form B Page 1 of 7

Use of this form and disclosure of Social Security Number are voluntary. Failure to use this form or disclose
this number 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 parts appropriate to you. |f 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.

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.

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.

Q A Labor Organization, Start atD on Page3
Ifyou Q An Energy Employee (current or former), StartatC on Page 2
are: GA Survivor (of a former Energy Employee), Start atB on Page 2
cA Representative (of a current or former Energy Employee), Start atA 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.

A.1_ Are you a contact person for an organization? 0 Yes (Go to A.2)
A.2__ Organization Information:

& No (Go to A.3)

Name of Organization

Position of Contact Person
1A3 Name of — Danracantativa: — y

po. .

A4 nacies

Street ‘ “eae P.O. Box

City ra cine me nae
A.5 Telephone Number:
A6 Email Address:

A.7 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:



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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
liiness Compensation Act National Institute for Occupational Safety and Health
OMB Number: 0920-0639 Expires: 09/20/2013

Special Exposure Cohort Petition — Form B

Survivor Information — Compl

Page 2 of 7
Section B if you are a Survivor or representing a Survivor

B.1 Name) :

ifst Name iia Tina
B.2 Social Security Number of Survivor:
BQ Rastennn Ae Oem
rear Ant # P.O. Box
City” State Tin CRAB

B.4 Telephone Number of Survivor:
B.5 Email Address of Survivor:

B.6 _ Relationship to Employee:

Employee Information p 2 a labor organization.

C.4 Name of"

irst Name = * ft

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

Mr./Mrs./Ms. First Name Miele Initiat Lact Name
C.3 Social Security Number of Employee: © —_—_
C.4_ Address of Employee (if living):

Street Apt # P.O. Box

City State Zip Code
C.5 Telephone Number of Employee: ( d 2
C.6 _ Email Address of Employee:

C.7 Employment Information Related to Petition:
C.7a Employee Number (if known):

C.7b Dates of. Employment:
C.7c Employer Name:
C.7d_ Work Site Location: ral |

C.7e Supervisor's Name:

G

Name or Social Security Number of First Petitione ——



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: 09/20/2013

Special Exposure Cohort Petition — Form B

Labor Organization Information — Complete Section D ONLY if y
D.1 Labor Organization Information:

organization.

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):
: ; Goto PartB. .< |

Name or Social Security Number of First Petitioner: