Special Exposure Cohort Petition 

under the Enrgy Envloyeer Ocwpattonal Illness Canqensatm Act 

U.S. Department of Health and Human Services 

Cmtar br Direase Cnnkd and PRvenbon 

Natmal lndhlls br 0capatlone.l Safery and Health 

OMB Number. 092C4839 Wires: 05/3112007 

Special Exposure Cohort Pstltlon -Form B ~aga 1017 

Use of this tom snd disclosure of Sodal Suurity Numbor am voluntaq. Fallurn to use mls fom or dluloeo I thls numbor wlll no( mult In tha denlal of any right, . . . ben.fn, or p~I~Iloge to whlsh you my bo entilied. I 

General Instructions on Completing this Form (complete insfructmns ere aveilable in a separate packet): 

I Except for signatures, please PRINT all information clearly and neaUy on he form. I 

Please read each of Pam A - G in this form and complete the parts appropriate to you. Y there . . is rnoe 

than one Dehtloner, then each petitioner should complete those sections of parts A - C of the form that apply 

to them. Addiiional 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. 

I Jf vou need more mace to provide additional informatiw, use the continuation page prodded at the end of 

Me form and attach the completed continuation page(s) to Fm 0. 

I If you have questions about Me use of this form, please call the following NlOSH toll-free phone number and 

request to speak to someone in the Offm of Compensation Analysis and Support about an SEC petition: 

1-800-3564874. 

I 10 A Representative (of a current or former Enemy Employee), Start at A on Page 1 I 

nyw 

are: 

Are you a contact person for an organization? 0 Yes (Go to A.2) 0 No (Go to A.3) 

Organization Information: 

0 A Labor Organization, Start at D on Page 3 

8 An Energy Employee (current or former). Start at C on Page 2 

0 A Suwiwr (of a former Energl Employee). Start at 0 on Page 2 

Name of Organization 

Position of Contact Person 

Name of Petition RepresentaUw: 

Mr.IMrs.1Ms. First Name Middle Initial Last Name 

Address: 

Street Apt # P.O. Box 

city State Zip Code 

Telephone Number: 1 

Email Addreee: 

I A7 0 Check the box at left to ~ndicale you have attached to the back ofthii fm mitten authorizatbn to 

pelition by tJm surviwr(s) or employee(s) indicated in Parts B or C of this form. An authorization 

If you am mpresentlng a Survivor, go to Part B; if you am represenUng an Employee, go to Part C. 

,. - .- - Name or Social Securlty Number of First Petffier: 
Special Exposure Cohort Petition 

under me Energy Employees Ormpat~onal 

Ilm- CunpenrDbon Ad 

U.S. Depaltment of Health and Human Services 

Men fof D18sasa Conma and Rsvsntbn 

NaUonal Ins- for OrmpabOnal Ssmy aM Hcarm 

Name of Survivor: I I Mr.lMrs.lMs. First Name Middle Initial Last Name I 

B.2 Soclal Security Number of Survivoc 

B.3 Address of Survivor: 

I stmt Apt # P.O. Box I 

City State Zip Code 

8.4 Telephone Number of Sunlwr: r 1 

B.5 Email Address of Survivor. 

B.6 Relatlonshlp to Employee: 0 Spouse 0 SonlDaughter 0 Parent 

0 Grandparent 13 Grandchild 

I GO to Part C. I 

Name of Employee: . 

. . ~. -- Mr.lMrs.lMs. First Name Middle Initial Last Name 

Former Name of Employee (e.g., maiden name/legal name changelother): - -- 

Mr.lMrs.lMs. First Name Middle Initial Last Name 

Soclal Security Number of Employee: 

Address of Employee (if living): 

- 

Street Apt # P.O. Box 

City State Bp Code 

Telephone Number of Employee: J - . . 

Email Address of Employee: .-----... -- . 

Employment Information Related to Petition: - 

Employee Number (i known): 

Dates of Employment: Start \46< End mi 

Employer Name: ~MIQJJ[), EG'G f~ ~fl! ek 

Work Site Location: \I)OUFIO SITE ~~\~MI\~D\LQG,oH 

Supervids Name: ! - 

I GO to Part E. I n- - . -. - . 

Name or Social Security Number of First Petiiner. .. .. . , 
Special Exposure Cohort Petition U.S. DeDaItfnent or nealtn ana numan aervlces I 

under me Eneqy Employees Ompational 

Illness Compemation Act 

Centers for D~sease Conbol an0 Prwenhon 

hahonal Instlhte for Oc~pallona Safety an0 Healm 

OMB Number: 09200639 Expires: 051311200 

I D.l Labor Organization Information: r/ I 

Name of Organization 

Position of Contact Person I D.2 Name of Petition Representative: I 

D.3 Addm of Petition Repreaentaiw: I 

I Street Apt # P.O. Box I 

State Zip Code I D.4 Telephone Number of Petition Representative: ( 1 

1 D.5 Emall Add- of Petition Representative: 

D.6 Period during which labor organization represented employees covered by this petition 

(please attach documentation): Start End 

D.7 Identity of other labor organizations that may represent or haw represented thie clasa of 

employees (f known): 

I GO to Part E. I 

A 

Name or Social Security Number of First Petitioner. 
1 Smial Exwsure .~ Cohort Petition ~ - ~~~ - ~ ~ 

~ ~~ 

u&rh Energy Employees patt tonal 

Illness Cornpensahon Act 

U.S. Department of Health and Human Services 

Canter8 br Dlssaw Conbul and RNenbon 

Nm'M InsOluB for Ocapbmel Safety and Health 

E.l Name of DOE or AWE Facility: W\Odn .>W n - 

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

< k%\*\~O1d1;5 ~~~ki L S I'+?W6(/tcc\GiT\t 113 fltt 

E.3 List job titles andlor job dutles of employees included in the class. In addition, you can list by 

name any indin'duals other than petitionen identified on this form who you believe should be 

included in this class: 

hi I GWwW& , \blLm,idG hkK&& M G_@ iCt M m~ W,-U@ 

\', .a/ 

E.4 Employment Dates relevant to this petition: 

~tart&ba'%* i344 End &ES~ .- Start End 

Start End 

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

recorded exposure incidents2 $Yes No 

the date@) of the incident(*) and a complete description (attach addiional pages 

m A C~L~LG OF LrnZM?. kG)mu.lmmz\l& 

~Q~G~~NOCL!K~+& ~LL.-4 gm GO& 

~KSYEX mOc 1 h\okf{.ld~q mm Id rSoNACsh w SMM mo smmd, 

K,AG i~ NDA - &m;4 PUG- -2 

W&& wCiw\rQc: 

Go to Part F. 1 

Name or Social Security Number of First Petitioner. 

r a, tqy, l,;Ly 

Special Exposure Cohort Petition 

under the Enegy Employees Occupational 

Illness Compensation Act 

U.S. Department of Health and Human Services 

Centers for Disease Contml and Prevention 

National Institute for Occupational Safety and Health 

OM6 Number: 0820-0639 Expires: 05/31/2007 

Special Exposure Cohort Petition - Form B Page 6 of 7 

F.3 0 IMle 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 

I believing th&e documented limitations might prevent the completioin of dose reconstructions for 

members of the class under 42 CFR Part 82 and related NlOSH technical implementation I I guidelines. I I (Attach report to the back of the petition form.) I 

F.4 IMle 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 Faciliies Safety Board, or published in a peer-reviewed 

journal. that identifies dosimeby and related information that are unavailable (due to either a lack 

of monbring 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. 

l~ll Petitioners should siwd date the petition. A maximum of three persons may sign the petition. I 

I Signature Date I I Signature Date I 

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 cornpensation to which that person is not entitled is subject to civil or 

administrative remedies as well as felony criminal prosecution and may, under appmpriate 

criminal provisions, be punished by a fine or imprisonment or both. I affirm that the information 

provided on this form is accurate and true. 

Send this form to: SEC Petition 

Office of Compensation Analysis and Support 

NlOSH 

4676 Columbia Parkway, MS-C47 

Cincinnati, OH 45226 

If Ulere are additional petitioners, they must complete the Appendix Forms for additional petitioners. 

The Appendix forms are located at the end of this document. 

Name or Social Security Number of First Petitioner: 
Speclal Exposure Cohort Petition 

under lhe Energy Employees Ocapational 

Illnag Compensation Ad 

U.S. Department of Health and 

antan 101 OiseaBC Conbd #and Pmbn 

NaUonal lnaauls for OaupmDnal Safety and Health 

OM0 Number: 09204839 hires: OY3112W' 

Special Exposure Cohort Petttlon - Form B ~lpe7ot' 

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 Clion 

Road, MS-E-11, Atianta GA. 30333; ArrN:PRA 0920-0639. Do not send the completed petitlon form to this 

address. Completed petitions are to be submitted to NlOSH 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 OM0 number. 

I Privacy Act Advisement 

I In accordance wiM the Privacy Act of 1974, as amended (5 U.S.C. 5 552a). you are hereby notified of the 

following: 

I The Energy Employees Occupational Illness Compensation Program Act (42 U.S.C. 55 7384-7385) 

(EEOICPA) authorizes the President to designate additional classes of employees to be included in the 

Special Exposure Cohoct (SEC). EEOICPA authorizes HHS to implement its responsibilities with the 

assistance of the National lnstiaute for Occupational Safety (NIOSH), an Insme of the Centers for Disease 

Conhul and Prevention. Information obtained by NlOSH in connection wiM 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 NlOSH system of records under the 

Privacy Act. 0%2G147 'Occupational Health Epidemiological Studies and EEOICPA Program Reards. 

HHSICDCMIOSH.' These krds are treated in a confidential manner, unless othemise compelled by law. 

Disclosures that NlOSH may need to make for the processing of your petition or other purposes are listed 

below. 

NlOSH 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 

relrieve records required by NIOSH; (b) identified witnesses as designated by NlOSH so that these 

individuals can provide information to assist with the evaluation of SEC petitlons; (c) contractors assisting 

NIOSH; (d) collaborating researchers, under certain limited circumstances to conduct further investigations; 

(e) Federal, state and bcal agencies for law enfomment purposes; and (f) a Member of Congress or a 

Congressional staff member in response to a vemed inquiry. 

This notice applies to all fonns and informational requests that you may receive from NlOSH in connection 

with the evaluation of an SEC petition. 

Use of the NlOSH petition forms (Aand 0) is voluntary but your provision of information required by these 

forms is mandatory for the consideraton of a petition, as specified under 42 CFR Part 83. Petitions that fail h 

provlde required information may not be considered by HHS. 

Name or Social Security Number of First Petitioner. 
May 15,2007 

u. s. Lkprtment of Labor 

Fi Adjudication Branch 

1001 Lakeside Avenue, Suite 390 

Clevelan4 OH 44114 

Re: File Number: - 

Objection to NIOSH Dose Recombxction Methodoloev and 42 U.S.C 73841(9) (B) and 42 

U.S.C 738411 ib) 

I am appealing the Denial of mv claim based on the followiag reasonfsk 

A. Causation of mv documented Cancers: Current research das na eliminate 

HodMs Lwahoma and Basal Cell Caccinoma hm causation by the wcposure factors that 

were udent at the Mound Plant Site. (NIOSH - Sauford Cohen Audit of Mound) 

B. Monitorine and Health Records of Mound Lab Plant Em~lovees: 

1. Monitoring of potentially radioactive materials and Mound Plant Employees was done in a 

hap- way, with changing criteria almost daily. Monitoring of personnel via dosimeter, 

urinalysis, etc. was even more sporadic and eventually administratively denied to all except thosc 

employees chosen by 'Rad Control". In place Administrative Controls prohibited the collection 

of Radiological data for most all Mound employees. -. 2. ~ound Plant E~D~OYCC Health Records are not available. These records were mnoved 

from the Mound Plant site in 2005 and buried in the Los Alamos, N.M. desert without the 

knowledge and permission of the Dept. of Labor (Energy Compensation Program) due to 

radioactive contamhation. 

3. Mound Plant Emolovee Health Records were removed hm their storage site at Mound and 

kept in Building61 prior to their shipment to the desert site. I was the Supervisor over the cnws 

that were involved with the removal and shipment of these records (materials). These materials 

sat in Buildii 61 for a period of time prior to their shipment to Nevada 

I am requesting that the U. S. Department of Labor place the Mound Plant Site in the 

Suecia1 Emsure Cohort Stam, so that Mound wkers who were exposed to radiation have the 

opportunity that has been given to other nuclear and radioactive plant workers to receive 

assistance and compensation benefits. I will be submitting a Petition for Special Exposure 

Cohoa Status with the U.S. Dept. of Health and Human Services. 

Cc: Senators George Voinovich and Sherrod Brown and Representative David Hobson 

Copy - submittedto U.S. Dept. of Labor at EEOICPA Hearing on May 15,2007 

Fie 
Report says ill 

Mound workers 

treated unfairly 

An independent auditor faults the site 

profile being used to evaluate and often 

reject compensation claims. 

By Tom Beyeijein tifically reconshuct worker 

Staff Writer exwsures. Mound add 

q& for "special expoA newly released inde- sure cohort" status that 

pendent auditor's reoort would allow sick workers 

punches holes in the to automahdy receive source document that the lumpsum payments and 

federal memment has medical benehts if thev 

been Gng to evaluate - have certain cancers. . and, in man cases, reject Atomic workers who don't 

- compensation daims have the status can soend 

fmm &mtriken for 

mer workers at the Miam. 

isburg Mound Plant. 

The audit by contractor 

Sanford Cohen and Associates offers a stinging critique of Moundk program 

for monitaring workers 

years hghting an updill battk to pmve their illoesses 

were caused by on-thejob 

tmric expos^ 

Workers at the preMound Dayton Rvject, 

run by Monsanto Chemid Co., are dce to being 

for radioactive emosures soawed hn the d over the year. &d it sug- &us after a simihr audit 

Rests that poor monitoring found it wasn't possible 

and recodkepkg auld to amuately rewmhuct 

make it impodible br the their dares 

gwemmmt to ammate To date, the Labor 

h asses the daims of sick Demrtment has mid 197 

Mound workers of i.465 daim~ hied by 719 

federal wmpnsation. Mound workem with the 

SanIoni Cohen audited Enqgy Employees Occua technical 'site profile' pational Illness Compensaused by federal o~~ as tion Act. 

the basis for determinine One diem minted 

whether wm?m illnes&- out in the auditda:Supprt 

were caused by worblace staft- including adminis 

emmures. Wive. maintenance, ,wu. 

he National ~nstitute rity and janitorial wok 

far OcNpational Safety ers - were mhmindy 

and Health has used the ornosed to the same hszpmue lo p- 88 per- As as radiation workers, 

cent of the daims hled by but mt monitored. 

Mound wden - 70 pa- It is not dear," the 

cent of which have been audit said, 'bow dose 

rejected for coqmsation. esthmtion would be perNOSH a have to fanned for maiotamce 

reopen those claims if and slpport workers ... the site profile ultimate- whose actual jobs could 

ly is rwised by the federal have led to expcsures cmnAd&w Board M Radia- parable to cadiation worktion and Worker Health, ers." 

said NOSH swkesmunan 

Amanda ~ardey. >>Audit: Workers 

If the government deter. likely exposed to 
Exhumation would cost 

!-riillions, but they are key to 

workers' health claims. 

By Tom Beyerlein 

Staff Writer 

At least a dozen pallets of shrink 

wrnpped cardboard boxes, six 55gjllIon dm and 11 safes containing 

classified records from the Miamisburg Mound Plant are buried in undergmund shafts in Area G of a radie 

active waste landflu at Los Ahmcs 

National Laboratory in New Mexico. 

Nobody ham the condition of the 

help to determine if hundreds of omccrsbicken Mound workers qualify for 

federal compensation. 

Ve are open-minded as to whether 

(the records) should be exhumed," said 

Larry 3. Elliott, director of compnsntion analysis for the National Institute 

for Occup-atiml Safety and Health, or 

MSH. ?his is an intere6ting pmb 

lern, and we're doing the best wean to 

make sure that we have the documents 

we need to do our wok" 

EUiott's office oversees scientitc 

'dose reconstructions." a papemork 

method of estimating atomic workers' exposures to harmful radiation and 

atomic phta Federal conttadors working on a "site profile" olRlound hrds 

went to LosAlamostoviewtheclassi. 

fied records last year, only to learn the 

mrds had heen buried as radioactively 

mntaminntedwaste in 2005. Watt aaid 

it's the lagest dshuction of compensntiondated documents by Energy that 

he's ever S&IL 

"I hnd it amazing that the variety of 

records hem - 12 pallets full - muld 

aU be contaminated," Elliott said. 'How 

could it happen?" 

According to the Energy Department. Mound shipped 458 boxes of 

classif~ed ds to Los Alarnos in 

inated copies of the Mound records. 

and exploring ways to pment mm 

destruction of documents that could 

help ailing atomic workers to prove 

their compensation claima, aaid department apokcswoman Megan Barnett. 

'We are looking Into it,' she said. 

'We take this very seriously." 

Elliott said he hopes tmcontamEMted 

copies of the documents can be found 

It may be.oeeessary to exhume the 

records, he said, but that would require 

patentially exposing workers in spffial 

pmtedive gear to radioactive waste. 

EUiott said hell knmv in a few weeks 

whether exh~~mation will be necesaw. 

records, id the Enegy Department chemid-. If a reconshuction shows 1995 and later reclaimed 40 boxes for In a memo reIeased last.week, the 

san it would take uo tn 18 niunths and at least a 50 PeWt probability that a an early dobe reconstruction muid Euem Deoartment tald the led- & as much as $9 ;nillion to uneh ~hfs caner was caused by an on- Los Alamos officinls buried &e kmain- eral ~visdry Board on Radiation 

and decontaminate them theiob expawe, the worker rlualihes ing boxes, whlch contain logboola. and Worker Health it would take six 

But a leadinr! federal health ofhdal f01 ah and medical benehts under the Mfety anahis reports. Mound stud- months and cost $1.5 to $3 mlxoh to 

said %&y irmay be neeereay to dig Energy Emplopees huplltional Ihea ies of the $opertirs of toxic metab exhume tbe ~pfords and another year 

up the more than 400 boxes of remrds bmp~sation Rodram. used there, and desuiptions ofa 1989 and up to $6 don to scan them to 

from the 198b and 1990s in order to But NIOSH cant aceumtely estimate release of radiosdive tritium. create uncontaminated cooiee. 

get a clear picture of the hazards wolk- worker EWsures wthout lalowing the Energy off~cials are scouring their m, ,hir repme( IPn, 

ers faced at Mound The records muld hazards PRsent at edch of the nation's dives in hopes 01 hding uncontam or tbeprklmJLuytonoa~IyNms.mrn.