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

under the Energy Employees Occupational Centers for Disease Control and Prevention
lIness Compensation Act i | National Institute for Occupational Safety and Health

OMB Number: 0920-0639 Expires: 07/31/2010
I Page 5 of 7

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 requjred to complete more than one entry.

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F.1 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.
emonstrated by the attgebhed z2tidzwt,
there war 710 rnontoring for smiternal Ot
Cxrternel badiztin CXpocule and thre Was
his nrotectinmn (24 OF tithing Evra tment
tor _L26ed, Z
EXEL LYLE. !

F.2 Q 1/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. i

(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.

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
lilness Compensation Act National Institute for Occupational Safety and Health
OMB Number: 0920-0639 Expires; 05/31/2007

|

Petitioner Authorization Form —e L . . Page 1 of 2
Use of this form is voluntary, Fallure to use this form will not rasult in the denial of any right, benefit,
Instructions;

If you wish to petition HHS to consider adding a class of 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 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 Office of Compensation Analysis and
Support about an SEC petition: 1-800-366-4874,

dc

P.O, Box

Wily, DIAS BG Sip woUe OF PeuuUTET i

to petition the Department of Health and Human Services on behaif of a class of empioyees
that includes:

Name of Clase

for the addition of the class to the Special Exposure Cohort, under the Energy Employee’s
Occupational liness Compensation Program Act (42 U.8,G. §§ 7564-7385),

foo ened a eth edenteee fee

. | an ‘
fen that she satitioner named above will have ail the rights



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

under the Energy Employees Occupational Centers for Disease Control and Prevention
lilness Compensation Act , National Institute for Occupational Safety and Health

OMB Number: 0920-0639 Expires: 07/31/2010
Special Exposure Cohort Petition — Form B i Page 7 of 7

Public Burden Statement

Public reporting burden for this collection of information is estimated to average 300 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 gn this form unless it displays a currently
valid OMB number. j

Privacy Act Advisement

In accordance with the Privacy Act of 1974, as amended (5 U.S. G. § 552a), you are hereby notified of the
following:

The Energy Employees Occupational Illness Compensation Progham 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. H

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.
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 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.

1
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 B) is voluntary but your pi vision 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.

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
{llness Compensation Act ! | National Institute for Occupational Safety and Health

ome Number: 0920-0639 Expires: 07/31/2010
Special Exposure Cohort Petition — Form B | Page 6 of 7

F.3 Q 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  Q IMWe 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
employees covered by the petition.

(Attach report to the back of the petition form.)

All P. iximum of three persons may sign the petition.
GLB LAO
' Date
Signature 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
Office of Compensation Analysis and Support
NIOSH
4676 Columbia Parkway, MS- C-47,
Cincinnati, OH 45226

Name or Social Security Number of First Petitione


State of California

County of San Francisco '
Subscribed and sworn to (or affirmed) before me on this 3rd day of June 2010, by proved

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to me on the basis of satisfactory evidence to be the person who appeared before me.

(Seal) Signature_ Z DrecenK,

Dawn Lyons, Nofary Public

DAWN LYONS
COMM. #1851086 z
Notary Public - Califorma 3
San Francisco County =
Comm. Expires Jun. 14, 2013

i

Document Description: Affidavit of



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06-09-10A11:06 RcvD

Special Exposure Cohort Petition
under the Energy Employees Occupational
lliness Compensation Act

U.S. Department of Health and Human Services
: Centers for Disease Control and Prevention
National Institute for Occupational Safety and Health

OMB) Number: 0920-0639
|

Expires: 07/31/2010

Page 1 of 7

Special Exposure Col
f ofthis, form an

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. !

I
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 Office of Compensation Analysis and Support about an SEC petition:
1-877-222-8570. i

Q A Labor Organization, ' StartatD on Page3

Ifyou O An Energy Employee (current or former), A StartatC on Page 2
are: QA Survivor (of a former Energy Employee), StartatB on Page2
aA Representative (of a current or former Energy Employee), StartatA on Page 1

Representative Information — Complete Section A if you are aut ized by an Employee or

Survivor(s) to petition on behalf of a class.

GNo (Go to A.3)

Are you a contact person for an organization? O Yes (Go to A.2)

A.2. Organization Information:

Name of Organization

Position of Contact Person i
A23 Name of Petitinn Ranracantative: :

First Name Middle Initial: Last Name ~

A4 Address:

Street O. Box

City —_ State” Zip Code
A.5 Telephone Number —

i

A6 Email Address: —!
AZ  @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

— es ee ae ee ——
Vor; go'to-ParPREt vai areViftosantiMtian EMbiovedsei

Name or Social Security Number of First Petitione


[Special Exposure Cohort Petition + ~~_U,, Department of Health and Human Services
under the Energy Employees Occupational H Centers for Disease Control and Prevention
lilness Compensation Act National Institute for Occupational Safety and Health

OMB Number: 0920-0639 Expires: 06/31/2007
Petitioner Authorization Form eee . Page 2 of 2
Public Burden Statement

|

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 respand to the information collected on this form unless it displays a currently
valid OMB number. '

Use of this form is voluntary. Fallure to use this form will not result in the denial of any right, benefit, or
privilege to which you may be entitled, f

oe — en saeemneee seaamamaninaaes - cere

Name or Social Security Number of First Petitioner:



AFFIDAVIT OF

state: fl

worked at Wah Chang from 1951 1979, without

being monitored and without proper protection. 1
1
i

To the best of my knowledge, no documents exist showing internal or external exposure. (See draft

Dose Reconstruction Report of March 24, 2010.)

'

worked at the Wah Chang site during my senior year in high scho and during the
summers while attending college, checking for radioactive materials with a Geiger counter without

protective gear every day and went in and out of his building without monitoring.

I declare under penalty of perjury that the foregoing is true and correct.

Executed in San Francisco, California, on June 3, 2010, :


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
i .

OMB Number: 0920-0639 Expires: 07/31/2010

Special Exposure Cohort Petition — Form B
Proposed Defi on of Employee Class Covered by Pe' n — Complete Section E.

E.1 Name of DOE or AWE Facility: fy OL ZAG
E.2 Locations at the Facility relevant to this petition: & ‘]

Page 4 of 7

E.3 List job titles and/or job duties of employees includediin the class. In addition, you can list by
name any individuals other than petitioners identified on this form who you believe should be

luded in this class:
include: i ALL

1
E.4 Employment Dates relevant to this petition:

Start OLAS GE End LEBEL GIR
Start OS LOf L LGU? End OW, LLL LF ZO

Start End
E.65 Is the petition based on one based on one or more unmonitored, unrecorded, or inadequately monitored or
recorded exposure incidents?: Q Yes lO,

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

Name or Social Security Number of First Petitio


under the Energy Employees Occupational
Illness Compensation Act | National Institute for O

OME Number: 0920-083

Special Exposure Cohort Petition — Form B

Labor Organization Information:

Name of Organization

Position of Contact Person

D.2 Name of Petition Representative:

Special Exposure Cohort Petition U.S. Department of Health and
! Centers for Disease

Zontrol and Prevention

ational Safety and Health
Expires: 07/31/2010

Page 3 of 7

D.3. Address of Petition Representative;

i
Street | Apt #

P.O. Box
i
City State "Zip Code
D.4 Telephone Number of Petition Representative: ( ) -
D5 ition Representative:
D.6
D7

Name or Social Security Number of First Petitioner: __



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

under the Energy Employees Occupational Centers for Disease Control and Prevention
iIness Compensation Act iNational Institute for Occupational Safety and Health
ome Number: 0920-0639 Expires: 07/31/2010

Special Exposure Cohort Petition — Form B i Page 2 of 7
Survivor Information — Complete Section B if you are a Survivor or representing a Survivor.

B.1 Name ~* Sr -oo -

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

Street

City —
B.4 Telephone Number of Survivor:
B.5 Email Address of Survivor:
B.6 _ Relationship to Employee:

C.1 Name of En-~ ">>> ~~ '

Mr./Mrs./MS, rirativanic wruwie nnuar j hasta

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

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

C.3 Social Security Number of Employee: = __ _
C.4 Address of Employee ((f living):

Street Apt # P.O, Box

City State Zip Code
C.5 Telephone Number of Employee: ( ) 2 h

C.6 Email Address of Employee:

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

C.7b Dates of Employment: Start 4G SE End ; PG: 9
C.7¢ Employer Name: LitZh Chzag |
C.7d Work Site Location: ALBCAW! OREGO NM

C.7e Supervisor's Name: _ _

Name or Social Security Number of First Petitioner: __ __