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 Program Act National institute for Occupational Safety and Health

OMB Number: 0920-0639

Expires: 07/31/2016
Page 5 of 7

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.

Fa UWe 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,

F2 J We have attached either documents or statements provided by atiidavit that indicate mat
tadiation 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.



[Special Exposure Cohort Petition ‘US. Department of Health and Human Services
under the Energy Employees Occupational Centers for Disease Contro! and Prevention

iiness Compensation Program Act National institute for Occupational Safety and Health
‘OMB Number: 0920-0639 pirés; 07/34/2016
Special Exposure Cohort Petition — Form B u Appendix — basen Pa

Continuation.Page.— Photocopy and complete as necessary.

Attach to Form B if necessary.



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 Program Act National institute for Occupational Safety and Heaith
OMB Number, 0920-0639 Expires: STB Z016

Pi

Covered by- P:

E14 Name er DOE or AWE Facity: Blockson Chemual Colm

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

Welet, Lb

E3 List job titles andlor 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:

£4 Employment Dates relevant to this petition:

stat \TSX End \A be 2
sat 1A? ena \AA\
Start End

£.5 Is the petition based on one or more unmonitored, unrecorded, or inadequately rhonitored or
recorded exposure incidents?;

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

__.Go to Part F.



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

under the Energy Employees Occupational Centers for Disease Control and Prevention
iliness Compensation Program Act National Institute for Occupational Safety and Heaith
5 s 8 Baas, OMB Number: 0920-0639 ines: O7/31/2016
Special Exposure Cohort Petition — Form B Par Page 6 of 7
F3 \We have attached a report from a health physicist or other individual with expertise in j

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 te the back of the petition form.)

F4 We have attached ¢ scientific or technical report, issued by a goverment 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.

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

Signature Date
Signature Date
————— eee

Notice: Any person whe knowingly makes any false statement, misrepresentation, concealment of
fact or any other act of fraud to obtain compensation as provided under REOICPA of 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
étiminal provisions, be punished by a fine or imprisonment or both. | affirm that the information
provided of this form is accurate and true.

Send this form to: SEC Petition
Division of Compensation Analysis and Support
NIOSH
4876 Columbia Parkway, MS-C-47
Cincinnatl, 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.





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

under the Energy Employees Occupational Centers for Disease Contrat and Prevention

Hiness Compensation Program Act National Institute for Occupational Safety and Health |
: 0920-0639 eS, 4

Special Exposure Cohort Petition — Form B ONG Nanbar Ernires payetot?

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 afe available in a separate packet):
Except for signatures, please PRINT ail 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 compiete those sections of Parts A — C of the form that apply

fo them. Additional copies of the first two pages of this form are provided at the end of the form for this
purpose. A maximuin of three petitionefs is allowed.

i to ide addit i
the form and attach the completed continuation pa

For Further information: tf you have question
toll-free phone number and request to speal
Support about an SEC petition: 1-877-222-$8

}

ation, use the continuation page provided at the end of
B.

form, please call the following NIOSH
jon of Compensation Analysis and
m

if you
are:

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

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

A2 Organization Information:

Name of Organization

Position of Contact Person

A3 Name of Petition Representative:

MrJMirsijMs. First Namie Middle initial Last Name
A4 = Address of Petition Representative:

Street —— Apt# “P.O. Box
City ~~ State a ~ Zip Code ~
AS Telephone Number of Petition Representative: ( ).

AS Email Address of Petition Representative;

A7 (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.
\f 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. Departent of Heaith and Human Services

under the Energy Employees Occupational Centers for Disease Controi and Prevention

illness Compensation Program Act National institute for Occupational Safety and Health

ein) § petit ent 5 0820-083 Expires: 07/3

Special Exposure Cohort Petition — Form B OMB Number 8 aie 7 of 4
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 aspact 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 a currently
valid OMB number.

Privacy Act Advisement

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. § 5522}, you are hereby notified of the
following:

The Energy Employees Occupational Iliness Compensation Program Act (42 U.S.C. §§ 7384-7385)
(EEQICPA) authorizes the President to designate additional classes of employes t6 be included in the
Special Exposure Cohort (SEC). EEOICPA authorizes HHS te 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 wilf be used to evaluate the petition and report findings to the Advisory
Board of Radiation and Worker Health and HHS.

Records containing identifiable information become part of an existing NIOSH system of records under the
Privacy Act, 08-20-147 “Occupational Health Epidemiotogical Studies and EEOICPA Progiam Records and
WTC Health Program Records, HHS/CDC/NIOSH,” These tecords afe teated in a confidential manner,
tiles 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
Tetrieve 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 8) 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.



Special Exposure Cohort Petition U.S. Departnent of Heaith and Human Services

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

7 y an = 5 OMB fF, O920-0633 expires: OF/31/72016
Special Exposure Cohort Petition — Form 8 Numbe are aged of?

B. Survivor information — Complete Part D if you are a Survivor or representing a Survivor.

B41 Name of Survivor:

MriMrs/Ms. FirstNavie = Middie Initial “Last Name
B.2 = Address of Survivor:

Streat Ant # 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: (J Spouse WSon/Daughter OParent
(Grandparent OiGrandchild _ secitast ge
Go to Part C.

Energy Employee information —- Complete Part C UNLESS you are a labor organization.

CA Name of Eneigy 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):

MirMis/Ms. First Name Middle Initial Last Name
C38 Address of Energy Employee (f living):

Street Apt # P.O, Box
Gity State Zip Code
C4 Telephone Number of Energy Employee: ( }

c.5 Email Address of Energy Employee:
C6 Employment Information Related to Petition:
C.6a Energy Employee Number (ifknown):
Cb Oates ofEmployment stat AGL —L.1959 eng

C.6c Employer Name: B\ eckson C hemica 1

Cd Work Site Location Yo bet, LL

a) fd ABS

C.Ge Supervisor's Name:

Go to Part E.



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 Program Act National institute for Occupational Safety and Health
OMB Number 0820-0639 Expires: 07/31/2016

3 of?

bor Organization lafore mnplete Part D ONLY if you area labor organizatio

D.1 Labor Organization Information:

Name of Organization

Position of Contact Person

D.2 Name of Petition Representative:

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

D3 Address of Petition Representative:

Street Apt # P.O. Box
City State Zip Cade
D.4 ‘Telephone Number of Petition Representative: ( .).

D.5 Email Address of Petition Representative:

D.6 Period during which tabor organization represented energy employees covered by this petition
(please attach documentation):
Start —_ End

D.7 Identity of other fabor organizations that may represent or have represented this class
of energy employees (if known):

Go to Part E.