May O3 2010 11:55AM

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. Special Exposure Cohort Petition us. Department of Health and Human Services

under the Eneray Employees Occupational | Centers for Disease Control and Prevention

Iliness Compensation Act drunee Institute for Occupational Safety and Health
OM!

Number: 0920-0639 Expires: 07/31/2010
| Page 1 of 2

Special Ex ure Cohort Petition — Form A

Instructions on Completing this Form:

You should use this petition form only if NIOSH has teported to you in writing that it cannot complete the
dose reconstruction needed for your cancer claim. |

Alt other petitioners should use Petition Form B to submit a petition fo NIOSH.

For Further Information: if you have questions about these instructions, please call the following NIOSH
toll-free phone number and request to speak ta someone in the Office af Compensation Anafysis and

‘Support about an SEC petition: 1-877-222-8570. |
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NIOSH Claim Information — Complete as much information as you can in Section A.

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A‘ NIOSH Tracking Number (indicated on all NIOSH correpponaence):

wl

wenn ede

A2 Print Name

FirstName Middie Initial Last Name

Social Security Number of Energy Employee for whom this claim was file

Signature of Person Subm

atitioning for HHS to consider adding a class

Print and sign your name below to indicate that you are ip
include the employee indicated by the

of employees to the Special Exposure Cohort that woul
tracking number or name under entry 1 above.

Print vonr name below:

Middle Initial Last Name

First Name

First Name‘ Middle Initial Last Name

Please send this form to NIOSH at the address below.

and Human Services wil) consider adding a

Once NIOSH receives this form, the U.S. Department of Healt!
ct at NIOSH will be available to inform you of

class of employees to the Special Exposure Cohort. Your cat
the progress of your petition. |

Send this form to: SEC Petition |
Office of Compensation Analysis and Support
NIOSH. |
4676 Columbia Parkway, MS-C-AT
Cincinnati, OH 45226 |

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Name or Social Security Number of First Petitioner:


May 03 2010 11:55AM p.3

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Special Exposure Cohort Petition U.S. Department of Health and Human Services
under the Energy Employees Occupational | Centers for Disease Control and Prevention
ltiness Gompensation Act | National Institute for Occupational Safety and Health
OMB Number: 0920-0639 Expires; 07/31/2010
Special Exposure Cohort Petition — Form A | Page 20f2

Public Burden Statompnt
Public reporting burden for this collection of information is estimated toe average 3 minutes per response,
including time for reviewing instructions, gathering the information needed, and completing the form. If you
have any comments regarding ihe burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, send them to GDG Reports Clearance Officer, 1600 Clifton
Road, MS-E-11, Atlanta GA, 30333; ATTN:PRA 0920-0639. Do not send the completed petition form io 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 OMB number. |

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

(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.

The Energy Employees Occupational Illness Compensation cosben Act (42 U.S.C. §§ 7384-7385)

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/CDCINIOSH." These records are treated in a confidential manner, unless otherwise compelled by law.
. [Disclosures that NIOSH may need to make for the processing ofjyour 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 focal agencies for law enforcement purposes; and (f) a Member of Congress ora
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.

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Name or Social Security Number of First Petitioner.



May 03 2010 11:55AM

Fax Cover Sheet

~  LOurie Breyer

OF:

wx 5/3-933-08/7

PHONE

FROM: ———
PAGES: : , including this fover sheet

DATE: SBM

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‘This facsimile may contain privileged or company private information that is intended solely for
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