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

under the Energy Employees Occupational Centers for Disease Contro! and Prevention
Riness Compensation Act Nationat Institute for Occupational Safety and Health
OMB Number: 0920-0639 Expires: 05/31/2007

Special Exposure Cohort Petition — Form B Page 3 of 7
ion Information — Complete Section D ONLY if you are a labor orga

D.1—_ Labor Organization information:

& 0: on) BF Mipertais 7s ¢beresppce bet
Name of Organization fl

D.2 Name of Petition Representative;

D3

ity ‘State Tin Prada
D.4 ‘Telephone Number of Petition Representativ
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 CRRA
D.7 identity of other tabor organizations that may represent or have represented this class of
employees (if known):

sheet Meinl _ifonuses Kers

i

Fo)

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
Winess Compensation Act National institute for Occupational Safety and Health
OMB Number: 0920-0639 Expires: 05/31/2007

Special Exposure Cohort Petition — Form B Page 8 of 7

F Basis for Proposing that Records and Information are inadequate for Individual Dose —
Complete Sectian 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. Yau are not required to complete more than one entry.

FA WW Ie have attached either documents or statements provided by affidavit that indicate that
tadiation exposures and radiation doses potentially incurred by members of the proposed class,
that relate to this petition, were not monitored, either through personai 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,
The. mask _eeleverc Ao comments
exe We Miosk cite geSles By
SARE amd  Pawkx omc ite  emckeraolh
jetors Grow ttre Daivesty of Towa
yo MW tic Los.

F.2  S/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.

Part F is continued on the following page.

Name or Social Security Number of First Petitio:



5

Special Exposure Cohort Petition
under the Energy Empleyees Occupational
Nness Compensation Act

U.S. Department of Health and Human Services
Centers for Disease Controt and Prevention
Nationat institute for Occupational Safety and Health

OMB Number: 0920-0639 Expires: 05/31/2007
Special Exposure Cohort Petition — Form 8 Appendix — Petitioner 3

Survivor information — Complete Section B if you are a Survivor or representing a Survivor.
B.1 Name of Survivor:

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

B.2 Social Security Number of Survivor:

B.3 Address of Survivor:
Street Apt # P.O. Box
City State Zip Code

B4 Telephone Number of Survivor: ¢ ) =

BS Email Address of Survivor:

B6 Relationship to Employee: Q Spouse  Son/Daughter Q Parent

O Grandchild

Q Grandparent

Employee Information — Complete Section C.

Name of Erm

«rst Name Middie Initiat Last Name

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

Mr/Mrs/Ms. First Name Micleite Initial Tact Nama
€.3 Social Security Number of Empfoyee: |
fox
P.0.Box
City State” Zip Code
C5 Telephone Number of Employee!
C6 Email Address of Employee:
C.7 Employment Information Related to Petition:
C.7a_ Empioyee Number (if known):
C.7b Dates of Employment: Start /0.54 End
C.7c¢ Employer Name:
C.7d_ Work Site Location: ZAAP
C.7e Supervisor's Name: Pl Ht aw

Sign Part G of the oriainat petition.

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
illness Compensation Act National institute for Occupational Safety and Heaith

OMB Number: 0920-0639 Expires: 05/31/2007
Special Exposure Cohort Petition — Form B

Proposed De’ ion of Employee Class Covered by P.

E.1 Name of DOE or AWE Facility:

E2 Lb ions at the Facility rel nt to this tition:
sy Y x ity Bhexants e

G ) Yaud G amd Yard | “Fieiag Site Acea , Stornapisites. oe Ribs seceges
includcne. BI 3 was vebees bed badepd
E.3 _List job titfes andor 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 jn this class:
Aw. :

iort — Complete Section E.

i we iw PVoKivnt its onleten
gadteactive mate aQs ahha. leuk act excluscue to tee, Fa lewing St thes
abo soy Aedanicion Hea. Technicians, tee Pods Viveeug
EY Empigymentt Dates rolevant to Fae Fecariiy, maiwlenance anch ReSors

Stat IA46 End _ 14S"

Stat End

_ Stat End

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

recorded exposure incidents?: 4 Yes Q No —

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

The Pray oord ea | of the ecgnseck work fee usas neh povtivels

Porten woekeus 5 STADE
on wrod Dork g an OS ds ee.
iucwuoante ex Sosave tevees se ‘othe
THAAD Dani 'G2- £F oS com
o@ RE ACES we Spear to
Name or Social Security Number of First Petitior

pe pessibre a
qe. Cange ond yon @
expos ees The 5s BL Mere



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

under the Energy Employees Occupational Centers for Disease Control and Prevention.
{liness Compensation Act Nationa) institute for Occupational Safety and Health

OMB Number. 0920-0639 Expires: 05/31/2007
Special Exposure Cohort Petition -— Form B Page 6 of 7

F.3  Q WWehave 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
guidetines.
(Attach report to the back of the petition form.)

Fa x WWe have attached a scientific or technical report, issued by a goverment agency of the
Executive Branch of Government or the General Accounting Office, the Nuciear Regulatory
Commission, or the Defense Nuclear Facilities Safety Board, or published in a peer-reviewed
journal, that identifies dosimetry and relate information that are unavailable (due fo either a fack
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.)

Complete Section G,

~- -* tnree persons may sign the petition.

a-AI OS
Date
ELBLOY.
Date
ESF fae
Date

Notice: Any person who knowingly makes any false statement, misrepresentation, conceaiment 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
criminat 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
Office of Compensation Analysis and Support
NIOSH

4676 Columbia Parkway, MS-C-47
Cincinnati, OH 45226

fal petitioners, they inust ec
on The Appendix forms are located-at the end of this docu

Name or Social Security Number of First P



eS

Special Exposure Cohort Petition
under the Energy Employees Occupational

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

illness Compensation Act National Institute for Occupational Safety and Health

OMB Number: 0920-0639 Expires: 05/31/2007
Page 1 of 7

Special Exposure Cohort

Generaf 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. 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 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 8.

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 Office of Compensation Analysis and Support about an SEC petition:
1-800-356-4674.

{A Labor Organization, StartatD on Page3

Ityou hy An Energy Employee (current or former), StartatC on Page2
are: QA Survivor (of a former Energy Employee), StartatB on Page2
A Representative (of a current or former Energy Employee), StartatA on Page1

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

AA Are you a contact person for an organization? O Yes (Go to A.2)
A2 Organization Information:

BAECPE

Name af Oraanization

O No (Go toA3)

FORMER WoRKER PROGRAM
FrOUCS ORY BOARD

Position of Contact Person

Inn Daneneantatives

First Name Middte Initiat Last Name

[A4 Address

Street

City
A5 Telephone Number:
A6 Email Address:

AZ @ Check the box at lemomarcare you neve cuccncu 2 mevaex 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
form for this purpose is:provided.

‘If you are representing a Survivor, go to Part B; if you are representing an Employee; go to Part:

Name or Social Security Number of First Petition

06-15-04704:12 eyo Alo - UNCLASSIFIED Yon
Joh boa Gabe Marcijant
fer John Tr "op classified - DOR Bre e/o4

Date



* padietion .
has veverheen ok inctdant report in aves 2S years of,
operon imeles @ lack of reporting and insabyerent
RE Pos OMe erontor ng -

This usoek force gever used lead apuans whew near et

hand linge eits. Te Nios sit Prof fon ft, Portes
sit]e regorths ow Rage IS o® VF GRAY ~ TKBS~ S913-2,
not workers aore lead aprons becauser,

“~ O1Recct HANOLING OF ITS CAN RESVLT iN

MiG POSE RATES”

(nor bodiqe dake is avaiable is Suseeed goin
severed ceasons o¢ nofech above C lack 2Q Gy Veldation
eke, inconsistency wit PANTEX, iw consis’ our hwe, Vast
ayer hy exposed not monitored eked; in adiclitim ese
padegs were worn an ages at a quealer distanca
Prom He Qit Than tre csorkers abbdowens, Pelvis; Gums.

SimGowboy erheab neuivan close daket exists mor, hose boon

wunderes fi mati ve expasare clue to maniron Padua, Caso nr
moti monltx monitored a5 opposed Yo weetly A bireekty
Renaits of monitoring.

The site gmR Qe mas rely too sirengdy on +eo
Pers oes gondents, Awe fees and Rossii tee torong
juncdivicuads audfor Lob tasks menito (ai geassimbly

TRE isswke xf mela ddiva®” at ahe eld na, fs euseliways
Not alk gits were “cladTM (An Geng lhiaw and/or
Deleted Ovrawiam- Tr eddetion Aye. eegertect ey 4
aw mart Qing oy OITS SEESrenteYy ian aveck Pemor|ad
of te mote QOic WowmisChevres arian in eITS

in adelitien to fems ot, He Reyhtr Plestes

17 Leas  cor®nvas,


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

_ OMB Number: 0920-0639 Expires: 05/31/2007
Special Exposure Cohort Petition — Form A Page 1 of 2

Instructions on Completing this Form:

You should use this petition form only 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 B to submit a petition to NIOSH.

For Further information: If you have questions about these instructions, please call the following NIOSH
tol-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 Claim Information — Complete as much information as you can in Section A.

Al NIOSH Tracking Number (indicated on all NIOSH correspondence):

A2 Print -- ne ae ee
\
“irst Name Middie Initiat Last Name
AS Ca aieifs Mambhar af Eman Emniaues for whom this claim was filed:

Signature of Person Submitting this Petition — Complete Section B.

Print and sign your name below te 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.

FirstName Middle Initial. Last Name FirstName — Middle Initial Last Name

c Please send this form to NIOSH at the address below.

Once NIOSH receives this form, the U.S. Department of Health and Human Services will consider adding a
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:



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

under the Energy Employees Occupational Centers for Disease Contro] and Prevention
Miness Compensation Act National Institute for Gccupational Safety and Health
Z OMB Number: 0920-0639 Expires: 05/31/2007

Special Exposure Cohort Petitio!
Survivor Information —

B.1 Name of Survivor:

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

Mr/Mrs/Ms. First Name Middle Initial Tast Name
B.2 Social Security Number of Survivor:
B.3 Address of Survivor:

Street Apt# P.O. Box
City State Zip Code

B.4 Telephone Number of Survivor: ) =

B.5 Email Address of Survivor:

B& Relationship to Employee: Q Spouse Q Son/Daughter Q Parent

Q Grandparent Q Grandchild

Employee Information — Complete Section C UNLESS you are a labor organization.
C.1 Name of Emy”

lee Employee (e.g., maiden name/legal name change/other):

Mr/Mirs/Ms. First Name {
C.3 Social Security Number of Employee:
C4

), Box

ony ee ——

C.5 Telephone Number of Employee:
C.6 Email Address of Employee:

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

C.7b Dates of Employment steed 146é 8 nd LIPAF

C.7ce Employer Name: z __
C.7d Work Site Location: ZHAPC A HE CP Atte I eP )

C.7e Supervisors nana!

L.
. (Gq tree

Name or Social Security Number of First Pettey