Form OCAS -1 OMB No. 0920-0530

May 2005 Exp. Date 03/31/2012

Statement by the Claimant Closing the Record on a NIOSH Dose Reconstruction under the 

Energy Employees Occupational Illness Compensation Program Act

I, _________________(NIOSH Tracking Number XXXXXX), a claimant under the Energy 

Employees Occupational Illness Compensation Program Act (EEOICPA), certify that in signing this 

form, I have read, understand, and affirm that the following statements are true: 

1) I am not in possession of any additional information that has not already been provided to NIOSH 

for completing a dose reconstruction to estimate the radiation doses incurred by the employee; and,

2) I understand that NIOSH will forward a final dose reconstruction report to the Department of 

Labor (DOL), so that DOL can continue adjudication of my claim and produce a recommended 

decision and then a final decision to accept or reject my claim; and, 

3) I understand that NIOSH can not forward the dose reconstruction report to DOL for adjudication 

without receipt of a properly signed OCAS-1 form within 60 days of my receipt of this form and 

NIOSH may administratively close the dose reconstruction and notify DOL of this action if I do 

not provide a properly signed OCAS-1 form within this 60-day period; and, 

4) I understand that my opportunity to seek a review of the NIOSH dose reconstruction occurs when 

my claim is with DOL and occurs only after DOL produces a recommended decision to deny my 

claim; and,

5) By signing this form, I do NOT certify or imply that I agree with NIOSH decisions indicated in the 

draft NIOSH dose reconstruction report concerning how NIOSH has used or not used information I 

have provided for the dose reconstruction; and, 

6) By signing this form, I do NOT certify or imply that I agree with the findings of the NIOSH dose 

reconstruction and I understand that I may seek review of this NIOSH dose reconstruction after 

DOL makes a recommended decision on my claim.

Notice: I affirm that the information provided on this form is accurate and true. 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. 

Signature__________________________________________ Date ______________________

Public Burden Statement

Public reporting burden for this collection of information is estimated to average 5 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-D-74, Atlanta, GA 30333; ATTN:PRA 0920-0530. Do not send the 

completed interview form to this address. Please complete and return this form using the enclosed pre-addressed, postage-paid 

envelope. Persons are not required to complete this form unless a currently valid OMB number is displayed.

(NIOSH Tracking Number XXXXXX)