O~'N.s..~

c

Cfarmant 10 #:

and HUman Services

Centers for Disease Control and Pf9VentJon

NatJonailnstitute for Occupational Safety and Health

OMS Number; 09~ expires: 05/31/2007

~~ '!f2

I SpecIal Exposure Cohort Petition DOL D~o.' #'

under the Energy Employees Occupational NIOC

IJ1I1es$ Compensation Act ~

Special Ex~sure Coh~_rt Petition - Form B

Use of this-form-and disclosure-of Social Security Number are voluntary. Failure to-use this fonn or-~isclose

this number will not result in the denial of any right, benefit, or privilege to which ¥ou may be en~itIGd.

-

GenerallnstrucUons on Completing this Form (complete .instructions are available in a separate packet):

Except for signatwes, please PRINT alllnfo~tion 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 m_ore

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

to them. Addttionai copies of the first two pages of this foml are provided at the end of the foml for this purpose. A maximum of three petitioners is aJlowed. .

If YOu need more scace to orovlde additional infom1atlon. use the continuation page provided at the end of

I 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 nu'!'ber and ! request to speak to someone in the Office of Compensation Analysis and Support about an SEC petition:

1-800..356-4674.

!tJ A labor Organization. Start at D on Page 3

on Page 2

on Page 2

on Page 1

Q An Energy Employee (current or former). Start at C If you

are: - A Survivor (of a fanner Energy Employee). Start at B

i 0 A Representative (of a cun-ent or former Energy Employee), Start at A

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

Organization Information:

d No (Go to A3)

A.2

Name of Organization

A.3

Position of Contact Person

Name of Petition Representative:

Mr./MrsJMs

Address:

First Name Middle Initial Last Name

1A.4

Street Apt # P.o. Box

State Zip Code

IA.S

1A.6

A.7

City

Telephone Number:

Ernail Address:

a Check the b.ox at left to indicate you have aUad1ed to the b~ of this form written authorization to

petition by the survivor(s) or employee(s) indicated in Parts B or C of this fom1. An authorization

fom1 for this purpose Is provided.

If you are representing a Survivor. go to Part B; if you are representing an Employee, go to Part C.

-- - ---

Name or SocIal Security Number of First Petitioner:
U.S. Department of Health and Human ServIces

Centers for Diae88e Control and p~

Nationallnstftute for OcaJpetional Safety end Health

OMS Number: 0920-0639 Expi/'8S: 05/31flOO1

~2of71

I Special Exposure Cohol1 Petition

under the Enervy Employees Ocx:upallonal

i IU~ CompensatIOn Act

I Special ExDOSure Cohort Petition - Form B

~B.1

B.2

IB,3

I

,8.4

18.5

,8.6

Name of Survfvor: ,.- ~ - - -'~ -

M s. Am Name Middle Initial L.aat Name

Social Security Number of SUrvivor: -

Address of Survivor: '. \ " .

~ t \ ~.. . tS"-~ --' ~:.~-;~ . - ~. P.O.Box- - 

~t ArR. # . P.O. Box .,w~ \ 1\. . . -

City-- o State - Zip- cori8

,~

Telephone Number of Survivor: - I~ ~ - ', .~ r

EmaJl Address ofSurvfvor: I -- -- i

Relationship to Employee: Spouse

Grandparent

~

Son/Daughter

Grandchild

\ Parent

Go to Part C.

:C.1 Name of Employ..: -- - ~ 6'

First Name Mkidle Initial Last

lope (8 g. mAlliAnn~~eaegal namA m.nf:!AlnthAc)!; :! c'-",,-,

Last Name

- -

Middle Initial

:C.3

~.4

- ---

Mr ./Mrs./Ms. Rrst Name

Social Security Number of Employee:

Address of Employee (if living):

City - sta ;-c- ~-ZIp ~ -

Telephone Number of Employee: ( ) - ,-

. -..

Ema" Addres8 of Employee: Employment -- Infonnation Related to ~n:

En1pJoyee Number (If known):

Dates of Employment:

Employer Name: -

Work Site Locatk)n:

,

,c.s IC.6

~

IC.7 ,C.7a

IC.7b I

-.7c

1~7d I"'"

- ~k (1 -.;t~ ~ ~ .rJ1~ ~-'!~~Z:i 1\.I;.s1 ~ =: ;~l - 'c

t"

-- _Ai 1o---Ll--- - - .~

~

r~.7. Supervisor's Nam

~

Go to Part E.

Name or SocIal Security Number of Arst Petitioner:
U.s. Department of HNJth and Human SeIVlces

Cents,. for Disease Control and Preventbn

National Institute for OCCUpational Safety and Hea/tl

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

P8£ae3of7

I Special Exposure Cohort Petition

urder the Energy Employees Occupational

IBness Compensa1iCXt Act

I S~clal Ex~sure Cohort Petition - Fonn B

10.1 Labor Organization Information:

Name of Organization

" ,- ,i ,-

Position of Contact Person

Ic.2 Name of P8tltlon Representatiw:

Address of Petition Representative: 10.3

10.4

10.5

D.e

City State ZIp Code

Telephone Number of Petition Representative: (\ . .

Ernail Address of Petition Representative:

Period during which labor organization represented employees covel'8d by th. petition

(please attach documentation): Start End

Identity of other labor organizations that may repreSent or have represented this class ot

employees (if known):

10.7

Go to Part E.

Name or Sodal Security Number of FIrst Petitioner:
~

Name or Social Security Number of FIrst Petitioner:
..

.- - . .,., -

-- - - --

u.s. Department of Health and Human Services

Cent8Cs for DJSe888 Control and Prev~

Natlonal1nsdtute for Occupational Safety and He8Jth

OMB Number. 0920-0639 Expires: 05/3112.007

~5of7~

. Special Exposure Cohort Petition

, wider the En.-gy Empbyees Ocx:upa1k)n81

~ Illness Compensation.Act

I So8c1aJ ~~Ur8 Cohort_Petition - Form B

.- - -

", , _r-,"".-, PartFJs.c:ontlnU8ci"oriffte.fo1loW1n g'-'pa-~'.' ::'::";'" ".::..\ 1

':r'~- . -~ '- - ,-. - - ,. y-. ..

Name or Social Security Number of First Petl1ioner.

~ from ~ site where 1he employees won<ed.

I (Attach documents and/or affidavits to the back of the petition fonn.) ~

monltonng.

(Attach docUmenb and/or affidavits to the back of the petition fonn.)
.

Special Exposure Cohort Petition

under the E~ Employees OccupatiOnal

Dln88aCompen88tionAct

U.s. Department of Health and Human ServiC88

C8nI8I5 b' DIse888 Controf and PI8V8ntIon

NatlonallnstlbJte for Occupational Safety and Hea~

OMB Number: 0920-0639 Expires: 05/31/2001

SpeciBI Exposure Cohort Petition - Form B Page 4c1T

Name of DOE or AWE Facility:

. :.2 LocatJons at the Facility relevant to this petftJon:

~tJLl._/J1plilr4 (1.Ah ~JA/,). -- - -: """'7

LIst job titles and/or Job duties of emplo ees Included In the class. In addition, you can lIst by

n who you believe should be In .. . .f"'- . ~ 

~

:,-, Ij,~

+'-~~flftl'UA

.3

"fill

~. E.4 ~mployment Dates relevant to this petition:

Start - _'1so End

Start End

Start End . - ~

Is the petition based on one or more unmonltored, unrecorded, or Inadequately monitored or

recorded exposure incidents?: ~Yes Q No

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

as necessary): . .

~

- I::'~~.') c ..

_.tJJ~

,1 ~ fp

. 0-:.5

aN

~kS~e

1:( °7a.

-"'~~ f,--i

_." . ;.~ .;!.j,.,.~' . , ~. ! "t",: # ~ Bf/~-!- Jr I!-" ./,"\ --~-c:x.' L8..~ ...; ..Ii-Jk., ,-",'1,,"- ~ ~. - ..ill" ~ ~~r- J

, J A- ;~.~~~ '~t.~fg ~.4- 6:;';~\~~'¥~

.1

Name or Soda! Security Number of First Petitioner:
..

-. .. . _. - .. ., --

~ ---

U.S. Deparbnent of Health and Human Services

Cent.-. for D18e88e ~ 8M Prevention

N.oon8l1n8tft1Jte for 0=zpaU0na1 Saf8ty 8t'd H_!h

OMS NumbW: 0920-0639 ExpIres: 05/31fJ.OO7

P8g85of7

- -- - -

I Special Exposure Cohort Petition

!.mer1he Ener;y Employ.- Oa:l!p&tlonal

. 1Un8$S CQm~nsatk)n"Act

! Special Exposure Cohort Petition - Form B

I Comple1a at least qne d the foU0wt-n9 ~~ tI:.i's~ -;. ~ d)~i thesppropr1818 box and providing

i the required InformatIon related to the selection. You are not required to complete more. than one entry.

:.1 Q!/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 dass,

that relate to this petition, were not monitOred. either throogh personal monitoring or through area

monltoling.

(Attad1 documents and/or affidavits to the back of the petition fom1.)

Desaibe as completely as possible, to the extent It might be undear, how the attad1ed

" '.' . 'dbaJrf\entation and/or affldavlt(~) indicate th"at potential i"ad1atlon eXpOsures Were nOt it\Onltof6d:

II..

-

I radiatiOn monitoring records for members of the proposed dass have been lost, fafsffied, or

j desb'oyed; 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.) ~

1 ~escribe as completely es posslble,°to the extent it might be unclear, how the attached )' dOaJmentation and/or aftidavit(s) Indicate 1hat radiation monitoring records for members of th,e

. proposed QaSS have been lost, alter&d Illegally, or destroyed.

- C:e5'~ i I ' .

J - IOS~ Is, (.A.~'~

! I -~~~ - '

, ~- _O':o~..- - . \Of) 0 ."-'

. .

.lO~

--

I~I~

1~~-4- .(I\l

,

:"~'~.,.-.:~::: " . '. ~art FI.'cOnUnUed~on:i,e.fojloWfrig" :pa"et...~~:.~-,-~~ ~.-:;~ ':::'-..1 ::" 1.

-' "--~.,. .,' ..".' -". ,.). ~

e~.tA~~ \"'~Ai ~ V'\

~~~~.. C ~ \

.&..LAo

Name or Social Securfty Num~r of Arst Petitioner:
U.s. Oepar1ment of Health and Human ServiCM

CenI8r8 for DI888ee CcxtroI a,.s Preventkx1

National Institute for Qcx:upational Safety and H88at1

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

- ADO8ndIx - Contl~~ Page

I Special Exposure Cohort Petition

: under the Energy Employees Occupational

Illness COO1pensatioo Act

I Special Expos~re Cohort ~~n - Form B

~

~

it-

~ . '

~~~ ~..-:> ~ ~ J' n 1 1 r"--:A- ~_I'~'~~~ Pc £fu =~ ~ ~~ . - ~ R IAJ '.Q4&~~ ~ ~ ~ r nA..l 0, ;~\~...I~~~ (. Y'o.Lfi &." ~ l.-'..Q(t

A~.~~" \J-\'L.\.\~{ ~ I~~.~ .~~U.~--

Attach to Form B If n8C8~ry.

Name or Social Security Number of First Petitioner:
-U:S. Department of Health and H~ an Services Centers for D/8e88e Control and PrevenOOn

Na1X)nai1r811tut8 for Occupetk)nal Safety and ~

OMB Number: 0920-0639 Expires: 05/31~OO7

- Pege~7

I Special Exposure Cohort Petition

I under the Energy Employees Occupational

Illness Compensation Act

I Special ~re ~rt P.~_n - F~ B

.3

:.4

[J lJWe have attached a report from a heatfh physicist or other in~uaI with expertise In

radiation dose reconstruction documenting the limitations of existing DOE or AWE records on

radiation exposures at the fadJity, as relevant to the petition. The report specifies the bas1s for

beiieving ti)ese documented limitations might prevent the completion of dose reconstructions for

members of the class under 42 CFR Part 82 and related NIOSH ted'\nlcal imP'ementation

guidelines.

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

[J UWe have attached a scientific or technicaJ report. issued by a government agency of the

Executive Branch of Government or the General ACXXJunting Otnce, the Nuclear Regulatory

Commission, or the Defense Nuclear FaclJltles Safety Board, or published in a peer-reviewed

journal, that identifies dosimetry and related informa1Jon that are unsvaRable (dua to either a lack

of monitoring or the destruction or Joss of records) for estimating the radiation doses of

employees covered by the petition.

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

~o tq Part G.

-.lXlmum of three persons may sign the petition.

_5 ' .z.,p~ -

~-- P '-n __-1 - Date

6'",z.-I!(;"

G:;; ;;::-::--~ ~~

- -

I1- ;;t==::l:~ ~ ~~-;~~;~~:~~~~-~~-

I ~t1:tre \ Date

:- ~ person who knowingly makes any faJee statement. misrepresentation. oonceaiment of

) fact or any other act of fraud to obtain compensation as provided under EEOICPA or who

knowingly accepts compensation to whim U1at peISon is not entitled Is subject to civil or

I administrative remedies as well as felony criminal prosecution and may. under appropriate

aimlnal prO'llisions, be punished by a fine or imprisonment or both. I affirm that the Information

provided on ~is fonn Is accurate and true.

Send this form to: SEC Petition - omce of Compensation Analysis and Support

NIOSH

4876 Columbia Par'Kway, MS-C-47

-.. -. - GnciMatio:o~u Ae."'~A-. - . , ~

I ,.Q~~ '--,

- -

I Notice:

. -

If there are additional p.etitloners. they must complete the Appendix Forms .for: additional petitioners.

. .., ...' .' . The AppenCiix forms are located'at the end of this' do:~Un:t'entr ",'.. . :.

- .. - -

Name or SoclaJ SeaJrity Number of First Petitioner:
Special Exposure Cohort Petition

under the Energy Employees Occupational

Inness Compensation Act

i u.s. Department of Health and Human Services

Centers for Disease Control and Prevention I

National Institute for Occupational Safety and Health

OMB Number: 0920-0639 Expires: 05/3112007

- Pag~ 7_of7

Special Exposure Co~ort Petition -Form 8

Public Burden Statement

I Public reporting burden for this collection of information is estimated to average 300 minutes Per response,

I including time for reviewing instructions, gathering the infonnation needed, and completing the form. If you

I have any comments regarding the burden estimate or any other aspect of this collection of infom1ation,

I incll1ding suggestions for reducing this burden, send them to CDC Reports Clearance Officer, 1600 Clifton

Road, MS-E-11 , Atlanta GA, 30333; A TTN:PRA 0920-XXXX 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 on this form unless it displays a currently

valid OMS number.

Privacy Act Advisement

In accordancewi1h the Privacy Act of 1974. as amended (5 U.S.C. § 552a). you are hereby notffled ofUle

following:

I The Energy Employees Occupatlonallllness Compensation Program Act (42 U.S.C. §§ 7384-7385)

(EEOICPA) authorizes the President to designate additional da$S of ~ployees 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 (N/OSH), an Institute of the Centers for DJsease

i Control and Prevention. Information obtained by N/O$H 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 i .

Board on Radiation and Worker Health and HHS.

,

Records containing identifiable information become part of an existing NIOSH system of /'8oords 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

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

I below.

NIOSH may need to disclose personal Identifying information to: (a) the Department of Energy. other federal

agencies, other govem~ent or private entitles 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

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

NIOSH; (d) coUaborating researchers. UC\der certain limited circumstances to conduct further investigations;

1e} Federal:State ana local agenCIes-tOr-laW enforceme-nrpQ"rPt)s-e-s; and"(f)-a-Memberoteongress-ora- -

Congressional staff member in response to a verified inquiry.

This notice applies to all forms and informational requests that you may receive from NJOSH In connection

I with the evaluation of an SEC petition.

Use of the NIOSH petttlon fonns (A and B) is Voluntary but YOiJr provision of Infom'lation required by these forms is mandatory for the qonsideration of a petition. as specified under 42 CFR Part 83. Petitions that fall toI'

provide requIred infonnation may not be considered by HHS. ,
This page left intentionally blank.

---~--~ ' ~--
Special Exposure Cohort Petition

under the Enel'QY EmpkJyees ~p8tional

Illness Compensation Act

U.S. Department of Health and Human Services

Centarsfcr Disease Control and Prevention

National Institute for ~onal Safety and Health

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

, Appendix - PetiUoner 2 Special Exposure C~h~~~~!tion ~ F~~ B - - -- --

Ose of this-form-and. disclosure. of Social Security Number are voluntary; Failure to use this form or disclosethis number will not result in the denial of any right, benefit, or privilege to which you may be entitled.

Use this Appendix for Petitioner 2.

ThiS; appendix: form is to be used as needed. Petitioner 2, or his or her representative, should complete the

parts applicable to hlm or her.

Refer to the General Instructions on completing petitioner Information for Parts A, B, or C.

If vou need more soace to orovide additional infonnation. use the continuatiol'\ page proVided at the end of

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

Except for signatures, please PRINT all Information clearly and neatly on the form.

a An E{1ergy Employee (current or former), Start at C

Start at B

--- -

Start at A

If you are: ~ASu_rv~~~~ ~rmer Ene~~!!1E!~~)'

Q A Representative (of a ~rrent or former Energy Employee).

Are you-S:-contact person1oiin organfiatiorf70 -Yes {(Soto-k2)

Organization Information:

A,1 cQ-Ne-{GotoA3)

A.2

Name of Organization

A.3

- -

Position of Contact Person

Name of Petition Representative:

~A.4 I

City '~ Zip Code

Telephone Number: ( \.

Q Check the box at left to indicate you have attached to the back of this tonn written authorization to

petition by the survivor(s) or employee(s} Indicated In Parts B or C of this form. An authorization

form for this purpose is provided.

State

'A.5

,

In

'A.7

If you are representing a Survivor, ~ to Part ~;ifyou arereprese'nting an Employee, go~~~ c:

Name or Social Security Number of First Petitioner: ~;;,-,.~~- ~~, 'V ~ . ~ ~ ~ 
Special Exposure Cohort Petition U.S. Department of Health and Human Services

urXier fie Energy Employees Occupalbnal Centers for DI8e8Se ConboI and Preventbn

Illness Compensation Ad. Nationallnstihrte fa' OCQJpa1iOnal Sfety and Health

OMS Number: 0920..0639 ExpIl8S: 05/31/2007 Special- Exposure Coh~.etltl°n - Fonn- ~ - ~- PetIUoner ~

IB.1 Name of Survivor

,-

Middle Initial Last Name

IB.2

! 8.3 Address of Survivor: r'I 1- .,

-

I\~' ,

street A ~# P.O. Box :..a. citY-- - - -0- State ' --- ZIp Code I "0

- _L. .

Telephone Number of Survh

Ema1J Address of Survivor:

Relationship to Employee:

1 8.4

8.5

!B.6

--,-- . --~---;-~~, A .1.,

!..:-~~.". -~ - ~l

Go to ParlC.

1~.1 Name of Employee:

Mr ./Mrs./Ms.- First Name - - Middle In~. - Last Name

i C.2 Former Name of employ" (e.g., maiden nama/tegaJ name cnan'ge7orner): - -

Middle Initial Last Name

~~

- ~--

Mr./Mrs./Ms. FIrst Name

Social Security Number of Employee

Address of Employee (if living):

City - ZIp Code

Telephone Number of Employee: ( , . -

Emau.. Addf8SS- of-&m p ! 0 yes :- -

Employment Information Related to Petition:

Employee Number (If known):

Dates of Employment Start.

Employer Name:

Wor'.( SIte Location:

State

~

I~~!.- C.7a

,C.7b

IC.1c

Ic.7d

End

~C.7e Supervisor's Name:

Sign Part G of the original petItIo~

Name or SocIal Security Number of First Petitioner:

3me

\.,../'

SodaJ Security Number of Survivor:
u~s. De-p.~ent of H;.m;-and Hum seTvi~

Centers for DI8eaae ContrcI and p~ I

NatkIn8J InstII.U fa" Ocx:upatlonal Safety and HeaIIt\

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

~:- Petilio~ 3

I SpeCIal Exposure Cohort Petition

under the Energy Employees OocupBftonaJ IHneas Compensation Act -

I

Special ~ure ~hort P~on - F~rm B

Use of this foma and'dis"CJosure of Social Security Number are voluntary. Fallur& to use this form or dlscloaethis number will not resuft In the denial of any right, benefit, or privilege to which you may be entIUed.

I Use this Appendix for Petitioner 3.

f This appendix fonn Is to be used as needed. Petitioner 3, or his or her represen1ative. should complete the

parts applicable to him or her.

Refer to the Generailnstrudior\S on completing petitioner infon-nation for Parts A. B, or C.

!f~u need more SDSce to Drovide addij!onaJ information. use the continuation page provided at the end of

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

I Except for signatures, please PRINT all Information clearly and neatly on the form.

a An Energy Employee (current or former), Start at C

If you are: A Survivor (of a former Energy Employee), Start at B

lOA Representative (of a current or former Energy Employee).

- - - -

Start at A

C No (Go to A3)

!~

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

Organization Information:

Name ofO,ganlzation

Position of Contact Person

1A.3 Name of Petition Representative:

---

Rrst Nlime Middle Initial Last Name

-

MrJMrsJMs

1A.4 Address:

City --- St8te -- ZIp Code

Te~phon8 Number: ( \ #

-E"ri18J1 Address:

Q Check the box at left to Indicate you have 8Uacj)8d to the badt of this form written authorization to

petit}on by the surviVor(s) or employee(s) Indicated in Parts B or C of this form. An authorization

. form for this purpose is provided.

'A5 I

1A6" A.7

- - - -- .

If you'are representing a SurviVor, go to Part B; If you are rapresantJng an Employee, go to Part c.

Name or Social Security Number of First Petitioner:
"'.

' Special Exp~':;Coho~.tltJon

under the Energy Employees Occupational

Illness Compensation Ad

u.s. Department of Health and Human Services

Centers for Disease Control and Prevention

National InStitute for ~~nal Safety and Health

OMB Number: 0920-0639 Expires: 05/3112007

- _~ix-= p~~

Special Exposure Cohort Petition - Form B - - --

B.1 Name of Survivor: /'

"

Middle Initial Last Name

8.2

8.3

C7 FirSt-Name U

Social Security Number of Survivo

Address of Survivor: \

Str~ Apt # P.O. Box

City State

Telephone Number of Survivor

Email Address of Survivor:

Relationship to Employee:

Zip Code

IB.4

!B.5

IB.6

GO. to. Part C.

:1 Name of Employee~

,-.

\.;;7"-"'--'.'-' . "~' Name Middle Initial ~[8itN8me-r'!~c~' ,j

C"Cc.':i,.~

~ --

Middle Initial Last Name

~.3

~.4

Mr ./Mrs./Ms. First Name

Social Security Number of Employee:

Address of Employee (If living):

Street Apt # P.O. Box

City State Zip Code

Telephone Number of Employee: (\ -!

"

Email ~~~~_C?:! Employee: -- ---

Employment Information Related to Petition:

Employee Number (if known):

Dates of Employment:

Employer Name:

Work Site Location:

'-

v.5

.C.6

C.'

,..

,..

i ..,.

T-/9t'!' Start "S""{) End ~~

- ~-~ ~

-~ ~ .

: :::.7e Supervisor's Name: , -

Sign p~ G of the original petition.

- --

.L-c:.--

Name or Social Security Number of First Petitioner:

7

78

7b

7c

7d