3 Imputed Interests Under 18 U.S.C. § 208: 

Are you aware of any particular matter in which NIOSH/DCAS is involved, in which any of the following 

persons or entities would have a financial interest? 

Your spouse  YES ~ NO 

Your minor child  YES @ NO 

Your general partner  YES I&'.] NO 

An organization in which you serve  YES I&] NO 

Any person or organization with whom you are negotiating for prospective employment or have an 

arrangement concerning prospective employment DYES ~ NO 

If you answered "yes" to any of the questions above, please provide additional details: 

Person/Entity Details 

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1 Do you work, or have you ever worked, at or for a DOE or AWE facility?  YES 5'J:'NO 

If "yes," please provide details below (length/type of employment, location(s), etc.), and proceed to Question 

2. If "no," proceed to Question 3: 

Facility Employment Details 

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2 If you answered Question l in the affirmative: 

Did your length of employment total 250 days or more?  YES ONO 

During the course of your employment, did any discrete incidents likely to have involved exceptionally high 

levels of rad iation exposure occur?  YES ONO 

If you answered "yes" to either of the questions above, please provide additional details: 

Facility Details 

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NIOSH AOB DISCLOSURE FORM 
4 Covered Relationships Under 5 C.F.R. § 2635.502: 

Are you aware of any particular matter involving specific parties, in which NIOSH/DCAS is involved, that is 

likely to have a direct and predictable effect on the financial interest of a member of your household? 

0YES f NO 

Are you aware of any particular matter involving . pecific parties in which NIOSH/DCAS is involved, where a 

person with whom you have a covered relationship is or represents a party to such matter? This includes: 

Anyone with whom you have or are seeking a business or financial relationship (other than a routine 

consumer transaction): 

 YES KJNO 

A member of your household (including roommates, domestic partners, etc.): 

 YES ,Kj NO 

A relative with whom you have a close personal relationship: 

 YES R) NO 

Anyone with whom your spouse, parent, or dependent child is serving or seeking to serve as an officer, 

director, trustee, general partner, agent, attorney, consultant, contractor, or employee: 

 YES g}NO 

Any person with whom you have served as an officer, director, trustee, general partner, agent, 

attorney, consultant, contactor, or employee within the past year: 

 YES ~NO 

Any organization in which you are an active participant: 

 YES jKI NO 

If you answered "yes" to any of the questions above, please provide additional details: 

Person/Entity Details 

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5 Do you fall within any of the "appearance of bias" categories below (as set forth in the NIOSH AOB 

Policy): 

Status as a covered employee under EEOICPA based on employment at the DOE or AWE facility: 

 YES J8'.INO 

Employment for any duration in the design, development, or management of radiation safety or 

dosimetry records management operations of the DOE or AWE facility:  YES (Z1No 

Covered employment at the DOE or AWE facility for any duration with possible exposure to an acute 

radiation exposure incident potentially covered under the definition of a "discrete incident" under 42 

C.F.R. § 83.3(c)(i): 

 YES ~ NO 

Where a spouse, parent, or non-dependent child has the status of either a claimant under the Act or a 

covered employee under EEOICPA based on employment at the DOE or AWE facility: 

 YES JKINO 

Participation as one of the following: (1) an authorized representative for a claim under EEOICPA; (2) 

an SEC petitioner; or (3) an advocate for a clain:,ant or an SEC petition at a specific DOE or AWE facility: 

 YES ~NO 
Membership in a union which serves as a petitioner for an SEC petition: 

O YES ~ NO 

Participation as an expert witness in litigation involving safety or health conditions at the DOE or AWE 

facility, when such participation is not deemed a financial conflict of interest under 18 U.S.C. § 208 or 

an appearance of conflict under 5 C.F.R. § 2635.502: 

O YES [gi NO 

Authorship of a report or the delivery of a public statement (including testimony) indicating that you 

have taken a position on a particular matter involving specific parties at a DOE or AWE facility, 

independent of your position with NIOSH, the Board, or a contractor providing technical support to 

NIOSH or the Board, when such particular matter is now at issue in the program: 

OYES 15{] NO 

If the answer to any of these questions is "yes," please identify the categories that apply and provide 

additional details: 

Category Details 

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