Special Exposure Cohort Petition US. Department of Health and Human Services
under the Energy Employees Occupational Centers for Disease Control and Prevention
iness Compensation Act National Institule for Occupational Safety and Health

OMB Number: 0920-0639 Expires: 05/31/2007
Pp 7

cons aac E EINES HORNER tHE avis}

Special Exposure Cohort Petition — Form B
LE: -cxsRrposed Definitions Se

E1 Name of DOE or AWE Facility: “Eareekhaven Natianal Lahoratory
E.2 Locations at the Facility relevant to this petition:

E.3 Lisi 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:

o ema] Os} 28. a a a

E.4 Employment Dates relevant to this petition:

Stat $947 0 End PS

Start _ . End Le

Start End 2

E.6 Is the petition based on one or more unmonitored, unrecorded, ar inadequately monitored ar
recorded exposure incidents?: © Yes No

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

Go fo Part F.

Name or Social Security Number of First Petitioner: __ ~ ae


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

under the Energy Employees Occupational Centers for Disease Control and Prevention
Hiness Compensation Act National Institute for Occupational Safety and Health
instructions for Completing Special Exposure OMB Number: 0920-0639 Expires: 06/34/2007
Cohort Petition — Form B ; Page 5 of 10

C.7 —-Employment Information Related to Petition: Enter the following employment information about

this petition:
red i

imployee Nurmber: Enter the employee number, If you know it Not all employers assi

Oo? ae

employee numbers.

6.76 — Dates of Employment: Enter the dates of employment at the facility (or approximate dates, if
employment records are unavailable), from start date to end date.

—- Emgluyer Narie: Enter the name of the employer.

facility location (e.g., [daho National Engineering Laboratory).

C.7e — Supervisors Name; Enter the Supervisor's name, if known.
ernment nani ve — - ~ —
Go to Part E.
Part 9 a -

Petitioner faformation: Complete Part D if you are a‘labor organization.

— Home cinNe

This section is to be completed only by labor organizations submitting a petition on behalf of employees they
represent or represented. If you are not such a tabor organization, you should skip this part.

0.1 —- Labor Organization Information: Enter the name of the labor organization and the position of the
person who will serve as the principal contact with HHS for this petition.

D.2 — Name of Petition Representative: Enter the name of the official who will serve as the principal
contact for HHS communications and inquiries regarding this petition.

0.3-D.5 —~ Gontact Information: Enter the address, telephone number, and e-mail address of the tabor
official who will serve as the principal contact for HHS.

D.6 —- Period during which jabor organization represented employees covered by this petition: Enter
dates as indicated. For active facilities at which your labor organization continues to represent employees,
enter the date of the petition for the “end date.” Please attach related documentation (e.g, relevant pages of
labor-management contracts or NLRB certification).

D.7 — Identity of other labor organizations that may represent or have represented this class of
Employees: Enter the names of any other labor organizations wno may currently represent some members
of the ciass of employees or have represented members of this class in the past, if you are aware of any.
This information may assist HHS in contacting members of the petitioning class for information or to notify

them, should HHS add their class to the Cohort. |

Go to Part E.



a

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 | tealth
Instructions for Completing Special Exposure OMB Number: 0920-0639 Expires: 05/31/2007
Cohort Petition — Form B Page 10 of 10

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 iriformation,
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 insiructions..
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. § 552a), you are hereby notified of the
following:

The Energy Employees Occupational iiness Compensation Program 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.

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 compelied 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, ather 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.

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 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 Gohort Petition Us. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Contro! and Prevention
\iness Compensation Act National institute for Occupational Safety and Health
Instructions for Completing Special Exposure OMB Number: 0920-0639 Expires: 05/31/2007
Cohort Petition -- Form B ; Page 7 of 10

E.5 — Is the petition based on one of more unmonitored, unrecorded, or inadequately monitored or
recorded exposure incidents?; If the petition is based on one or more radiation exposure incidents for
which exposures were unmonitored (unplanned events that resulted in radiation exposures, versus routine
operations which may also result in radiation exposures), provide the date when the incident(s) began and
ended and describe the incident(s) in as much detail as possible.

For example, you might describe the source of the radiation exposure or ernission, its cause, the response to
the incident, and ihe potential number of employees involved. You should report everything you know about
the incident. NIOSH will use this information to identify the event and obtain additional information from the
Department of Energy and other sources. If NIOSH finds it cannot confirm the occurrence of the event
through information from the Department of Energy or any other sources, it will require that you abiain and
provide medical evidence relating to the incident and/or one or more affidavits providing information about
the incident, as provided under section 83.9(c)(3) of the Special Exposure Cohort Rule (42 CFR Part 83).

: : Go to Part F.

Basis for Proposing that Records and Information are Inadequate for individual Dose
Reconsiructions

2 sorrento — ieee en

Complete at least one of the eniries under this part. You are not required to complete more than one entry,
although you should complete more than one entry when such additional information is available to you. This
additional information may assist HHS in evaluating your petition.

F.4: Complete this entry if you are petitioning on the basis that ceriain radiation exposures and doses to the
class were not monitored. By completing this entry, you do not need to establish (through documentation or
affidavit) that there was no monitoring whatsoever, of any radiation exposures and doses incurred by the
class of employees. You need only establish that some types of radiation exposures and doses incurred by
the class were not monitored, or that during certain periods of time, certain operational procedures, or certain
exposure incidents, the exposures and doses incurred by the class were not monitored.

For example, if the employees in the class were instructed to remove their radiation dosimetry badges for
certain operations involving radiation exposures, this might qualify as unmonitored exposures, despite the
fact that the employees might have routinely worn their radiation dosimetry badges during most operations.
Similarly, if there was a period of time during an operation when there was no monitoring of internal doses,
this might qualify as unmonitored exposures.



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 National Institute for Occupational Safety and Health
Instructions for Gompleting Special Exposure OMB Number: 0920-0639 Expires: 05/31/2007
Cohort Petition — Form B ; Page 6 of 10
Part E

Proposed Definition of Employee Class Covered by Petition

‘The information provided in this section will assist HHS in evaluating the petition. Petitioners should note that
it is possible that, as HHS conducts its evaluation of a class, it may revise the definition proposed by the
petitioner, making the class more expansive or more specific, and possibly cornbining the classes of several
petitions or dividing the class of a single petition into two or more classes. Ultimately, HHS must define
classes consistent with the criteria for determining whether or not the class should be added to the Cohort |

6.4 — Name of DOE or AW cility: Enier the name of the DOE or AWE facility where the class of
employees covered by this petition was employed.

NOTE; Although individual employees may have worked at more than one facility during their career, a
petition must be specific to a class of employees at a single facility, as specified by the Act. It is acceptable to
file petitions for more than one facility, however, you must file a separate petition for each facility.

£2 — Locations at the Facility relevant to this petition: Name or describe the location(s) at the facility
relevant to this petition; the locations where members of the class were exposed to radiation If the location
does not have a name, such as a building number or floor or room of a building, describe the location by its
more specific characteristics, such as the operation or process conducted there, or the equipment, fixtures,
or facilities in that location. Be as specific as possible.

£.3 — List job titles and/or job duties of employees included in the class: List the job titles and/or job
duties that characterize employees who you believe belong in the class, to the extent necessary to define the
class,

Examples:

2 If you can define the class by job duties alone, and you believe that anyone with such job duties should
be included in the class, listing the job duties would be sufficient

« {f you believe all employees in a location during a period of time should be included in the class,
regardless of job title or job duty, enter an “all” here instead of specifying job titles or job duties.

e However, if you believe that only persons with certain job duties involved in certain operations or
processes should be included in the class, you must specify this.

The point is to define the class carefully and specifically, so that it includes all employees for whom you
believe radiation doses cannot be estimated and whose health could have been endangered, and only such
employees. To be certain your definition covers all employees that you intend ta include, you may choose to
list by name individuals who should be included in the class and who have not already been identified among

the petitioners you have listed in this form.

E.4 — Employment Dates relevant to this petition: Enter the approximate or precise dates of the period of
employment that applies to the petition. For example, the potential exposures to radiation may have occurred
during a period of a certain operation, during a period when certain radiation protection policies were in
place, during a period when radiation monitoring was omitted, or during a period for which exposure and
monitoring records are lost.



U.S. Department of Health and Human Services

Special Exposure Cohort Petition

under the Energy Employees Occupational Centers for Disease Control and Prevention

{ lliness Compensation Act National Institute for Occupational Safety and Health
Instructions for Completing Special Exposure OMB Number: 0920-0639 Expires: 05/31/2007
Cohort Petition — Form B Page 9 of 10
Part G

Signature of Person(s) Submitting this Petition

Each petitioner should sign and date the petition as indicated. A maximum of three petitioners may sign the
petition.

Summary at Form Requirements

To ensure that you have completed the required sections of the petition, please refer to the table below:

LAL Part | Part | PartD | Parte | Parte ) PartG
< . S caaeeinememaan’ = 1 si
Employee x x X xX
nee woe [an .
Survivor Xx xX x xX x

Authorized
Representative (if
cee applicable) fd a .
Labor x x x x

Appendix — Petitioner 2

if there is an additional petitioner (not a labor organization), he or she must complete the Appendix —
Petitioner 2 and sign Section: G of the original petition. Please refer back to pages 2 — 5 of this instruction
set for more information on completing the appendix.

~ ee

Appendix —- Petitioner 3

If there is a third petitioner (not a labor organization), he or she must complete the Appendix — Petitioner 3
and sign Section G of the original petition. Please refer back to pages 2 — 5 of this instruction set for more
information on completing the appendix.

Appendix — Continuation Page

The Continuation Page is provided for you if you reed more space to provide additional information. Please
photocopy as needed, and attach to the petition.



May 1, 2008

National Lnstitute for Occupational
Safety aud Lcalth

4676 Columbia Parkway, MS/C/46

Cincinnati, OH 45226-1998

RE: claim #
AYN: Laurie Breyer,

My>
Laboratory in Upton, NY from

05~09-08A09:35 R CVD

was an employee at Brookhaven National

Lam filing a request to be added to the Special Exposure Cohort class for

Brookbaven National Laboratory
97 pages of data from the DOE.

profile was finished in August, 2007 and there are

To the best of my knowledge, there was no internal monitoring for some
individuals at Brookhaven National Laboratory and insufficient internal monitoring for

the class in the carly 1980’s. My

was involved in an incident during that time.

came home one day to tell me that a person inspecting the badges wanted to know

where tad been because his badge was overexposed,
maintained,

of the experiments on the equipment

mentioned that during one

the warning light system indicating a radioactive area had not been activated and’? was

in the area repairing some malfunction.

also tacntioned that the equipment that

Sincerely,

7) 8 Nowars Paktic af

Viet

repairing was still “hot”.

Ty Carina

page lO K I ne.

ali ST aioe—
suid Conner and Sie o hereby ccrtify

nally appeared belgre we

ogy yy tus Way ana genom theta
. es ios of he foragome insrumens, easCE was AyD
~ s

Sty
Fg fs

hy “Oy

4
Sy

Os
Cys?
Metin

itp bi at of Sea, ete 6
erage Be... wt

ured er Putin



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

MrJMirs is. FirstName

B.2 Social Security Number of Survivor:
8.3 Address of Survivor:

Street

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

Name of Ernployee:
wee :

‘Middle Initial

a spouse

) Grandparent

Go to Part C.

U.S. Department of Health and Human Services
Centers for Dissase Control and Prevention
National Institute for Occupational Safely and Health

Expires: 05/31/2007
Page 2 of 7

OMB Number: 0920-0639

LastName ‘

Apt #

P.O. Box”

Zip Code ~

Ct Son/Daughter Q Parent

Q Grandchild

onl
Mr/Mrs/Ms. FirstName —~—=~~S*«Middie initial —=—S=*~CS~i ast Namen —
G.2 Former Name of Employee (e.g., maiden name/legal name change/other):
La ee
Mr/Mrs./Ms, First Name Middle Initial “LastName
C.3  Secial Security Number of Employee: _ ee oo
C4 Address of Employee (if living): :
Street ~ Apt # P.O. Box
City State Zip Code
C.5 Telephone Number of Employee: ( eee oe
C.6 Email Address of Employee: NSA
C.7 Employment Information Related to Petition:
C.7a_ Employee Number (if known): — _
WC.7b Dates of Employment: Start ‘ pnt End _ ‘ _
‘ . a /
C.7e EmployerName: “Beook haven _Aatianal Labs a
C.7d Work Site Location. ok. —_ —
we ren, wy _ .
. iS visors Name: - ——
C.7e uperviso Bo rege

Go to Part E.

Name or Sociai Security Number of First Petitioner:



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

under the Energy Cmployees Occupational Centers for Disease Control and Prevention

4 illness Componsation Act National Institute for Occupational Safety and Health
_ OMB Number: 0920-0639 Expires: 05/31/2007

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 an Completing this Farm (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
{han 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 Office of Compensation Analysis and Support about an SEC petition:

1-800-356-4674,

jua Labor Organization,

Start atD on Page 3

{i} An Energ playee (current or former), StartatG on Page 2

you =
ares A Survivor (of a former Energy Employee), StartatB on Page 2

1A Representative (of a current or former Energy Employee), StartatA on Pago 1

~

Survivor(s) to petition‘on behalf, ofaiciass;

At Are you a contact person for an organization? 0 Yes (Go to A.2) y No (Go to. A3)

A.2 Organization Information:

Name of Organization

Position of Cantacl Person

A.3 Name of Petition Representative:

MriNirs/Ms. FirstName ~~ Middle initial ~~ Last Name
A4 Address:
Street ~~ Vapt# —”:*«éi SB
city State “ZipCode tt—CSsS
Ad ‘Telephone Number: (___)

A.6 Email Address: - en

AZ OQ 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.

Naine or Social Security Number of First Petitioner. . me



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

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

Instructions for Completing Special Exposure OMB Number: 0920-0639 Expires: 05/31/2007
Cohort Petition — Form B Page 8 of 10

F.2:; Complete this entry if you are petitioning on the basis that radiation monitoring records for members of
the proposed class have been lost, falsified, or destroyed. Documentation or affidavits demonstrating that
monitoring records are missing for a class of workers might be sufficient to indicate that the records have
been lost or destroyed, Documentation or affidavits demonstrating differences between exposures or
monitoring results and the current official records of these exposures or monitoring results might be sufficient
fo indicate that records might have been falsified. You should note, however, that records can be changed ta

reflect corrections te faulty monitoring results.

Also complete this entry if there is no inforrnation regarding monitoring, source, source term, or process from
the site where the members of the proposed class worked.

By completing this entry, you do not need to establish (through documentation or affidavit) that there are no
monitoring records whatsoever, for personal or area monitoring that was conducted for the class of
employees, or that all the relevant records have been falsified. You need only indicate that the records
relating to same types of radiation exposures and doses incurred by the class, or relating to certain periods
of time, certain operations, or certain exposure incidents involving the class, have been lost, falsified, or
destroyed, or that there is no such information.

F.3: Complete this entry if you are petitioning on the basis of an unpublished expert report addressing record
limitations for the class of employees proposed in your petition. You are not required to use this approach to
support your petition, Most petitioners are unlikely to be in a position to employ an expert to evaluate the
limitations of DOE records on exposures to a particular class of employees. However, this is an option that
might be used by some petitioners, particularly organizations. lf you are considering this option, we suggest
the expert you employ contact NIOSH before completing such an evaluation. NIOSH will ensure that the
expert is aware of the availability of relevant information concerning the procedures by which NIOSH
estimates radiation doses for cancer claims under the Act, including the HHS regulations on dose
reconstruction methods (42 CFR Part 82) and related implementation guidelines.

F.4: Complete this entry if you are petitioning on the basis of a scientific or technical report that was
published in a peer-reviewed journal or issued by a government agency of the Executive Branch of
Government, or the General Accounting Office, the Nuctear Regulatory Commission, or the Defense Nuclear
Facilities Safety Board. Federal agencies most likely to have funded or to fund such studies are DOE and
NIOSH. itis possible that state environmental protection agencies might have funded such studies related to
AWE facilities. Such reports are likely to have been issued either as scientific or technical reports available
directly by request from government agencies or as research reports published in scientific journals,

Go to Part G.



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
Instructions for Completing Special Exposure OMB Number: 0920-0639 Expires: 05/34/2007
Cohort Petition — Form B . . Paye 4 of 10
Part Cc

Petitioner Information: Camplete Part C if you are an Energy Employee or a Survivor. Also complete this
Part if you are an individual or entity (other than a labor organization) authorized by an employes or survivor
to petition on behalf of a class of employees.

This section is to be completed by petitioners who are employees of DOE/AWE facilities or their survivors, or
by petitioners authorized by employees or thoir survivors This section does not have to be completed by
labor organizations submitting a petition (labor organizations should complete Part 2).

Please complete all the entries in this section, as applicable, The form allows for as many as three
petitioners {o provide this complete information if they so desire, but this is not necessary. We only require
that a single petitioner provide complete information for this section.

GA — Name of Employes: Enter the full legal name of the energy employee.

6.2 — Former Name of Employee: If the employee had a different name at the time of employment at the
DOE ar Atomic Weapons Employer facility (for example, a maiden name), enter that name.

6.3 — Social Security Number: (Optional) Providing a Social Security Number is voluntary. Failure fo
disclose this number will not result in the denial of any right, benefit, or privilege to which you may be
entitled. Personal information, like your social security number, will be protected under the Privacy Act.

Enter the Social Security Number of the energy employee. If you are an authorized representative, make
sure you have permission to enter the employee’s Sacial Security Number.

G.4— Address: Enter the current mailing address of the energy employee.

{f you are authorized te petition by an employee or a survivor under Part A of this form, you do not need to
comipiete this entry.

C.§ — Telephone Number: Enter the telephone number at which the employee can be reached from 8:00
am to 5:30 pm Eastern Standard Time on weekdays. Please specify more limited hours of availability, If

necessary.

If you are authorized to petition by an employee or a survivor under Part A of this form, you do not need to
complete this eniry.

C.6 — Email Address: (Optional) Enter the employee's email address at work or home.

If you are authorized to petition by an employee or a survivor under Part A of this form, you do not need to
complete this entry. :



Special Exposure Cohort Petition ws S. Department of Health and Human Services
under the Energy Employees Occupational Centers for Disease Control and Prevention
.| finess, Compensation Act National Institute for Occupational Safety and Health

OMB Number: 0920-0639 Expires: 05/31/2007

Special Exposure Cohort Petition — Form B seuneiparmepemens Pago 5 of 7

WBasis for Propos

: fepiitnettehedsantnien A
Complete at least one of the following ¢ entries in this section by checking the appropriate box and providing
the requited information related to the selection. You are not required to complete more ihan one entry.

FA We have attached cither documents or staternents 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 WW 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.

Ast tcttnachscd og haat —— — Oe

Part F is continued on the following page.

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
|tiness Compensation Act National Institute for Occupational Safety and Health

Instructions for Completing Special Exposure OMB Number: 0920-0639 Expires: 05/31/2007
Cohort Petition — Form B Page 3 of 10
Part B

Petitioner Information: Complete Part B if you are a Survivor of a former Energy Employee. Also complete
this Part if you are an individual or entity (other than a labor organization) authorized by an employes or

survivor to petition on behalf of a class of employees,

Survivor: Enter the full legal name of the survivor.

(Optional) Providing a Social Security Numbor is voluntary, Failure to
It in the denial of any right, benefit, or privilege to which you may be
entitled. Personal information, like your social security number, will be protected under the Privacy Act.
Enter the Social Security Number of the survivor. {f you are an authorized representative, make sure you
have permission to enter the survivor's Social Security Number.

B.3 -— Address: Enter the survivor's current mailing address.
If you are authorized to petition by an employee or a survivor under Part A of this forrn, you do not need to
complete this entry.

BA lephone Number: Enter the telephone number at which the survivor can be reached from 8:00 am
to 5:30 pm Eastern Standard Time on weekdays. Please specify more limited hours of availability, if

necessary.

Kf you are authorized to petition by an employee or a sutvivor under Part A of this form, you do not need to
complete this entry.
Address: (Cptional) Enter the survivor's email address at work or home.

B.5 Er
If you are authorized to petition by an employee or a survivor under Part A of this farm, you do not need to
complete this entry.

B.6 —— Relationship to Ernployee: Check the relationship of the survivor to the energy employee.

Go to Part ©.



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

under the Energy Employees Occupational Centers for Disease Controt and Prevention
Ines Compensation Act Ooty Cer vide RC National Institute for Occupational Safety and Health

Instructions for Completing Special Exposure OMB Number: 0920-0639 Expires: 05/31/2007
Gohort Petition — Form B Page 2 of 10

IMPORTANT: Petitions DO.NO

Please read each of parts A — G in the form and complete only those parts appropriate to you, according to
these instructions. A checklist has been provided on the last page of these instructions to help ensure that
you have properly completed all of the sections applicable to you. Except for signatures, please PRINT all
information clearly and neatly on the form.

If there, is more than ong petitioner, then each petitioner should complete those sections of paris 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 purpose. A maximum of three petitioners is allowed, but only one petitioner is required. Limiting
the number of petitioners to three for each petition does not limit the number of members of the class

covered by a petition, but will enable HHS to consider and decide petitions more efficiently.

If you need more space to provide additional information, use the continuation page provided at the end of

the form and attach the continuation page(s) to Form B.

ff

Part A

Petitioner Information: Complete Part A if you" are an individual or entity authorized by an employee or a
survivor to petition on behalf of a class of employees, as provided for under 42 CFR Part 83.7(c).

A.1— Are you a contact person for an organization (other than a labor union): If you are a contact
person for an organization, other than a labor organization, check Yes and go to A.2; if you are not a contact

person, check No and go to A.3.

A.2-— Organization Information: If you are a contact person for a legally constituted organization, a firm, or
another type of entity, enter the name of the organization and your position as the person who will serve as
the principal contact with HHS for this petition. If you are NOT a contact person, leave this entry blank.

A3 — Name oj Petition Representative: Enter your full legal name (applies to both a contact person and
an authorized representative of an energy employee or survivor).

A.4— Address: Enter your current mailing address.

A.5 —- Teleghone Number: Enter the telephone number at which you can be reached from 8:00 am to 5:30
pm Eastern Standard Time on weekdays. Please specify more limited hours when you are available, if

necessary.

A,6 — Email Address: (Optional) Enter your email address at work or home.

A.7 — Authorization: Check the box and attach the written authorization, as indicated A separate
authorization form, “Petitioner Authorization Form”, is available for this purpose.

eset” EUPIA a AT OE EH CEES

exorcist? RIMMER A SESSA DIETS RES EATS!

If you are representing a survivor, go to Part B; if you are representing an employee, go to Part C,
Lo ~ eee ee



D.2

D3

D4
D5
D6

D7

Special Exposure Cohort Petition
under the Energy Employees Occupational
{ Illness Compensation Act

Dt

OMB Number: 0920-0639

Expires: 05/31/20
Pp;

Labor Organization Information:

Name of Organization

Position of Contact Person Vv

Name of Petition Representative: “4

Address of Petition Representative:

Street : - Apt# ~~ ~P.O.Box
Ciy “ZipCode t—CSstsSCS~S~*S
Telephone Number of M | en

(please aitach documentation): Stat End _

identity afOther labor organizations that ray represent or have represented this class of
amployees (if known):

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

07
fF

Name or Social Security Number of First Petitioner: _ _ oe _.



Special Exposure Cohort Petition U.S. Department of Health and Human Services |
under the Energy Employees Occupational Centers for Disease Control and Prevention

_ | tiness Compensation Act National Institute for Occupational Safety and Health
. OMB Number: 0920-0639 Expires: 05/34/2007
Special Exposure Cohort Petition —— Form B Page 6 of 7

F3  ( IMWehave attached a report from a health physicist or other individucl 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 reco istructions 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 © 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 identifies dosimetry and related information that are unavailable (due to either a Jack
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.)
Go to Part G.

Signature &f ~~~ Date
Signature  ss—SsSSSS “Date
Signature == —“‘i=‘“—~S*~*~*~*~S~<“<Ss~s~s‘“s=<C=<CS;STO 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
Cinginnati, OH 45226

lf there are additional petitioners, they must complete the Appendix Forms for additional petitioners.
The Appendix forms are located at the end of this document.

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