I Special Exposure Cohort Petition U.S. Department of Healtil and Human Services I under the Energy Empb~ OcaJpational Centers for Dis888e Control aOO Prevention

I IDness ~on Ad: National \nstin& for ~~tia1aI safely arK! HeaIU\

OMB Number: 0920-0639 expires: 05/31/2007 Special Exposure Cohort Petition - Form A Page 1 of 2

-..~.1'.-.:;r."t;~"~-~""~'~ .

. ~. - ...' . .. .

:~~.~~.."~: :

Instructions on Completing this Form:

I You should use this petition form only If NIOSH has reported to you in writing that it cannot complete the

dose reconstnx:tion needed for your cancer claim.

I All other petitioners should use Petition Form B to submit a petition to NIOSH.

! For Further Information: If you have questions about these instrudions, please call the following NIOSH

toll-free phone number and request to speak to someone In the OffIce of Compensation Analysis and

I Support about an SEC petition: 1-800-356-4674.

!A.1 NIOSH Tracking Number (indicated on all NIOSH oon'e8pondence):

IA.2 Print Name of Energy Employee for whom this claim was filed:

1A.3

~/Mrs.IMs. First Name Middle Initial Last Name

Social Sec~rity N~ber of Ene~ Employee for whom this claim was filed:

Print and sign your name below to Indicate that You are petitioning for HHS to consider adding a class

of employees to the Special ExPOsure Cohort that would Include the employee Indicated by the

b'ackir\g number or name under entry 1 above.

Print your'name below: . - . ~- ':, . .

First Name Middle Initial Last Nam6 First Name Middle Initial LaSt Name

Once NIOSH receives this form, the U.S. Department of HeaJth and Human Services will consider adding a

class of employees to the Special Exposure Cohort. Your contad at NIOSH will be available to infoml you of

the progress of your petition.

Send tt1is fonn to: SEC Petition

Office of Compensation Analysis and Support

NIOSH

4676 COlumbia Parkway. MS-C47

Cincinnati. OH 45226

Name or Social Security Number cI First Petitioner
Special Exposure Cohort Petition I u" u. Ensvy ~ ~~

Illness ~on Ad;

u.s. Deparbnent 

. Cen8r8 of Health b' Di888M and Coi1U'd Human end Services ~ '

Nationalinelu. b ~patkX\8I Safety 8I1d HeeIh

OMS Number: 092~ ExpIr8l: 05/31f1.007

I S~eclal Ex~O8Ure_Cohort ~etition -:: Fonn A Paaa2of2

Public Burden Statement

I Public reporting burden for this conection of informaUon Is estimated to average 3 minutes per response,

i Including time for reviewing Instructions. gathering the information needed, and completing the fonn. If you

. nave any comments regarding the burden estimate or any other aspect of this collection of infocmatlon.

I including suggestions for reducing this burden, send them to CDC Reports CIearan~ Officer, 1600 Clifton

Road. MS-E-11 , Atlanta GA, 30333: A TTN:PRA 0920-0639. Do not send the completed petition fonn to this

address. Completed petitions are to be submitted to NIOSH at the addrss provided in these Instructions.

I Persons are not required to respond to the Information collected on this form unless It displays a currently

I 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:

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

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

I Speaal 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

I ctasses of employees In the SEC will be used to evaluate tie petition and report findings to the Advisory

Board on Radiation and Worker Health and HHS.

I Records containing identifiable information become part of an existing NIOSH system of records under the

PrIvacy Ad,'O9-2Q-147 80caJpationai Health Eprdemlological StOOies at1d EEOICPA Program Records.

I HHS/CDC/NIOSH,8 These records are treated In a confidential manner, unless otherwise OOfnpeiled by law.

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

lbebw.

',NIOSH may need to disclose personal identifying infonT1ation to: (a) the Deparbnent of Energy, other federal

I agencies, other government or private entities and to private sector employers to penT1it these entities to 'retrieve r8c:0"i"ds i'eqUtied by NIOSR;' (b) identified WIttIesties 88 designated by NIOS~ so.that these .

I jndlviduals can provide infonnation 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

I Congressional staff member in response to a verified Inquiry.

I 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 fonns (A and B) is voluntary but your provision of infonnation required by these forms Is maooatory for the consideration of a petition. as specified under 42 CFR Part 83. .

i provide required information may not be considered by HHS.

Name or Sodal Security Number of First Petitioner:

~="-~.:::', ~,:~, :'::.:.j~:-"