e

Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention
Illness Compensation Act National Institute for Occupational Safety and Health

. OMB Number: 0920-0639 Expires: 09/20/2013
Special Exposure Cohort Petition — Form B Appendix — Petitioner 2

Use of this form and disclosure of Social Security Number are voluntary. Failure to use this form or disclose
this 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 him or her.

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

If you need more space to provide additional information, use the continuation 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.

LQ An Energy Employee (current or former), Start at C
If you are: |Q A Survivor (of a former Energy Employee), Start at B
QA Representative (of.a current or former Energy Employee), Start at A

Representative Information — Complete Section A if you are a
Survivor(s) to petition on behalf of a class.

rized by an Employee or

A.1_ Are you a contact person for an organization? QO Yes (Go to A.2) Q No (Goto A.3)
A.2 Organization Information:

Name of Organization

Position of Contact Person

A.3 Name of Petition Representative:

Mr./Mrs./Ms. First Name Middle Initial Last Name

A4 Address:
Street Apt # P.O. Box
City State Zip Code

A.5 Telephone Number: ( } -

A6 Email Address:

A.7 Q Check the box at left to indicate you have attached to the back of this form 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.

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:

{®



Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention
Iliness Compensation Act National Institute for Occupational Safety and Health
OMB Number: 0920-0639 Expires: 09/20/2013

Special Exposure Cohort Petition — Form B
Labor Organization Information — Complete Section D ONLY if you are a labor organi.

Page 3 of 7

D.1 Labor Organization Information:

Name of Organization

Position of Contact Person

D.2 Name of Petition Representative:

D3 Address of Petition Representative:

Street Apt # P.O. Box

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

D.5 Email Address 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 have represented this class of
employees (if known):

Go to Part E.

Name or Social Security Number of First Petitioner:

3



Special Exposure Cohort Petition U.S. Department of Health and Human Services
under the Energy Employees Occupational Centers for Disease Control and Prevention
lilness Compensation Act National Institute for Occupational Safety and Health

OMB Number: 0920-0639 Expires: 09/20/2013

e Special Exposure Cohort Petition — Form B Appendix — Continuation Page
Continuation Page — Photocopy complete as necessary.

Attach to Form 8 if necessary.

Name or Social! Security Number of First Petitioner:

4



Special Exposure Cohort Petition U.S. Department of Health and Human Services
under the Energy Employees Occupational Centers for Disease Control and Prevention

Illness Compensation Act National Institute for Occupational Safety and Health

Instructions for Completing Special Exposure OMB Number: 0920-0639 Expires: 09/20/2013
Cohort Petition — Form B Page 5 of 10

C.7 —Employment Information Related to Petition: Enter the following employment information about
this petition:

¢.7a — Employee Number: Enter the employee number, if you know it. Not all employers assigned
employee numbers.

C.7b — Dates of Employment: Enter the dates of employment at the facility (or approximate dates, if
employment records are unavailable), from start date to end date.

¢.7¢ — Employer Name: Enter the name of the employer.

C.7d — Work Site Location: Enter the location of the facility and work site relevant to the petition. Be as
specific as possible about the work site, naming the specific building or work area if possible, as well as the
facility location (e.g., Idaho National Engineering Laboratory).

C.7e — Supervisor’s Name: Enter the Supervisor's name, if known.

Go to Part E.

PartD

1

enter the date of the petition for the “end date.” Please
labor-management contracts or NLRB certification).

D.7 — Identity of other labor organizations that may repres®nt or have represented this class of
Employees: Enter the names of any other labor organizations wha may currently represent some members
of the class of employees or have represented members of this classNo the past, if you are aware of any.
This information may assist HHS in contacting members of the petitioning class for information or to notify
them, should HHS add their class to the Cohort.

Go to Part E.



Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention
Ulness Compensation Act National Institute for Occupational Safety and Health

; OMB Number: 0920-0639 Expires: 09/20/2013
Special Exposure Cohort Petition — Form B Appendix — Petitioner 2

Survivor Information — Complete Section B if you are a Survivor or representing a Survivor.

B.1_ Name of Survivor:

Mr/Mrs./Ms. First Name Middle Initial Last Name
B.2 Social Security Number of Survivor:

B.3. Address of Survivor:

Street Apt # P.O. Box
City State Zip Code
B.4 Telephone Number of Survivor:  ¢ L

B.5 Email Address of Survivor:

B.6 Relationship to Employee: Q Spouse Q Son/Daughter QO Parent
Q Grandparent Q Grandchild
. Go to Part C.
c Employee Information — Complete Section C.
C.1 Name af Emnlauaa 1
Mr/Mrs./Ms. First Name Middle Initia? Last Name

C.2. Former Name of Employee (e.g., maiden name/legal name change/other): AY

Mr./Mrs./Ms. First Name Middle Initial Last Name
C.3 Social Security Number of Employee:

C.4 Address of Emolovee (if livina):

T re
C.5 Telephone Number of Employee:
C.6 Email Address of Employee:
C.7 Employment Information Related to retrtron:
C.7a Employee Number (if known): |
C.7b Dates of Employment: - ane - 7. .
C.7c Employer Name: .
C.7d Work Site Location: .
C.7e Supervisor's and

‘Sign Patt G of the original petition... . meee

Name or Social Security Number of First Petitioner:

“



Special Exposure Cohort Petition U.S. Department of Health and Human Services
under the Energy Employees Occupational Centers for Disease Control and Prevention
illness Compensation Act National institute for Occupational Safety and Health

Special Exposure Cohort Petition — Form B

OMB Number: 0920-0639 Expires: 09/20/2013
Appendix itioner 3

rvivor Informati

— Complete Section B if you are a Survivor or representing a

Name of Survivor:

Mr/Mrs./Ms. First Name Middle tnitiat Last Name

C.2

C.3
C4

C.5
C6

C7

C.7a
C.7b
C.7¢

C.7d

C.7e

B.2. Social Security Number of Survivor:
B.3 Address of Survivor:
Street Apt # P.O. Box
City State Zip Code
B.4_ Telephone Number of Survivor: )
B.5 Email Address of Survivor:
B.6 Relationship to Employee: Q Spouse Q Son/Daughter Q Parent
Q Grandparent QO Grandchild
Go to Part C,

Employee Information — Complete Section C.
Name of Employee:

Mr./Mrs./Ms. First Name Middle Initial Last Name

Former Name of Employee (e.g., maiden name/legal name change/other):

Mr./Mrs./Ms. First Name Middle Initial Last 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 Address of Employee:

Employment Information Related to Petition:
Employee Number (if known):

Dates of Employment: Start End
Employer Name:
Work Site Location:

Supervisor's Name:

Sign Part’G of the original petition.

Name or Social Security Number of First Petitioner:

13



Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention
Illness Compensation Act National Institute for Occupational Safety and Health

: OMB Number: 0920-0639 Expires: 09/20/2013
Special Exposure Cohort Petition — Form B Page 7 of 7

Public Burden Statement

Public reporting burden for this collection of information is estimated to average 5 hours 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-E-11, Atlanta GA, 30333; ATTN:PRA 0920-0639. 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 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:

The Energy Employees Occupational !llness Compensation Program Act (42 U.S.C. §§ 7384-7385)
(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.

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/CDC/NIOSH.” These records are treated in a confidential manner, unless otherwise compelled by law.
Disclosures that NIOSH may need to make for the processing of your 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 local agencies for taw enforcement purposes; and (f) a Member of Congress or a
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.

Name or Social Security Number of First Petitioner:

8



[Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention
lIIness Compensation Act National Institute for Occupational Safety and Health
instructions for Completing Special Exposure OMB Number: 0920-0639 Expires: 09/20/2013
Cohort Petition — Form B Page 10 of 10

Public Burden Statement

Public reporting burden for this collection of information is estimated to average 5 hours 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-E-11, Atlanta GA, 30333; ATTN:PRA 0920-0639. 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 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:

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

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/CDC/NIOSH.” These records are treated in a confidential manner, unless otherwise compelled by law.
Disclosures that NIOSH may need to make for the processing of your 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 local agencies for law enforcement purposes; and (f) a Member of Congress or a
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.



Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention
Illness Compensation Act National Institute for Occupational Safety and Health
Instructions for Completing Special Exposure OMB Number: 0920-0639 Expires: 09/20/2013
Cohort Petition — Form B Page 7 of 10
E.5 — ls the petition based on one or more unmonitored, unrecorded, or inadequately monitored or

recorded exposure incidents?: If the petition is based on one or more radiation exposure incidents for
which exposures were unmonitored (unplanned events that resulted in radiation exposures, versus routine
operations which may also result in radiation exposures), provide the date when the incident(s) began and
ended and describe the incident(s) in as much detail as possible.

For example, you might describe the source of the radiation exposure or emission, its cause, the response to
the incident, and the potential number of employees involved. You should report everything you know about
the incident. NIOSH will use this information to identify the event and obtain additional information from the
Department of Energy and other sources. If NIOSH finds it cannot confirm the occurrence of the event
through information from the Department of Energy or any other sources, it will require that you obtain and
provide medical evidence relating to the incident and/or one or more affidavits providing information about
the incident, as provided under section 83.9(c)(3) of the Special Exposure Cohort Rule (42 CFR Part 83).

Go to Part F.

Part F

Basis for Proposing that Records and Information are Inadequate for Individual Dose
Reconstructions

Complete at least one of the entries under this part. You are not required to complete more than one entry,
although you should complete more than one entry when such additional information is available to you. This
additional information may assist HHS in evaluating your petition.

F.1: Complete this entry if you are petitioning on the basis that certain radiation exposures and doses to the
class were not monitored. By completing this entry, you do not need to establish (through documentation or
affidavit) that there was no monitoring whatsoever, of any radiation exposures and doses incurred by the
class of employees. You need only establish that some types of radiation exposures and doses incurred by
the class were not monitored, or that during certain periods of time, certain operational procedures, or certain
exposure incidents, the exposures and doses incurred by the class were not monitored.

For example, if the employees in the class were instructed to remove their radiation dosimetry badges for
certain operations involving radiation exposures, this might qualify as unmonitored exposures, despite the
fact that the employees might have routinely worn their radiation dosimetry badges during most operations.
Similarly, if there was a period of time during an operation when there was no monitoring of internal doses,
this might qualify as unmonitored exposures.



Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention
Illness Compensation Act National Institute for Occupational Safety and Health
Instructions for Completing Special Exposure OMB Number: 0920-0639 Expires: 09/20/2013
Cohort Petition — Form B Page 6 of 10
Part E

Proposed Definition of Employee Class Covered by Petition

The information provided in this section will assist HHS in evaluating the petition. Petitioners should note that
it is possible that, as HHS conducts its evaluation of a class, it may revise the definition proposed by the
petitioner, making the class more expansive or more specific, and possibly combining the classes of several
petitions or dividing the class of a single petition into two or more classes. Ultimately, HHS must define
classes consistent with the criteria for determining whether or not the class shoutd be added to the Cohort.

£.1 — Name of DOE or AWE Facility: Enter the name of the DOE or AWE facility where the class of
employees covered by this petition was employed.

NOTE: Although individual employees may have worked at more than one facility during their career, a
petition must be specific to a class of employees at a single facility, as specified by the Act. It is acceptable to
file petitions for more than one facility; however, you must file a separate petition for each facility.

E.2 — Locations at the Facility relevant to this petition: Name or describe the location(s) at the facility
relevant to this petition; the locations where members of the class were exposed to radiation. If the location
does not have a name, such as a building number or floor or room of a building, describe the location by its
more specific characteristics, such as the operation or process conducted there, or the equipment, fixtures,
or facilities in that location. Be as specific as possible.

E.3 — List job titles and/or job duties of employees included in the class: List the job titles and/or job
duties that characterize employees who you believe belong in the class, to the extent necessary to define the
class.

Examples:

«If you can define the class by job duties alone, and you believe that anyone with such job duties should
be included in the class, listing the job duties would be sufficient.

e If you believe all employees in a location during a period of time should be included in the class,
regardless of job title or job duty, enter an “ail” here instead of specifying job titles or job duties.

» However, if you believe that only persons with certain job duties involved in certain operations or
processes should be included in the class, you must specify this.

The point is to define the class carefully and specifically, so that it includes all employees for whom you
believe radiation doses cannot be estimated and whose health could have been endangered, and only such
employees. To be certain your definition covers all employees that you intend to include, you may choose to
list by name individuals who should be included in the class and who have not already been identified among
the petitioners you have listed in this form.

E.4 — Employment Dates relevant to this petition; Enter the approximate or precise dates of the period of
employment that applies to the petition. For example, the potential exposures to radiation may have occurred
during a period of a certain operation, during a period when certain radiation protection policies were in
place, during a period when radiation monitoring was omitted, or during a period for which exposure and
monitoring records are lost.



This page intentionally left blank.



| Special Exposure Cohort Petition U.S. Department of Health and Human Services
under the Energy Employees Occupational Centers for Disease Control and Prevention
Illness Compensation Act National Institute for Occupational Safety and Health

Instructions for Completing Special Exposure OMB Number: 0920-0639 Expires: 09/20/2013
Cohort Petition — Form B Page 9 of 10
Part G

Signature of Person(s) Submitting this Petition

Each petitioner should sign and date the petition as indicated. A maximum of three petitioners may sign the
petition.

Summary of Form Requirements

To ensure that you have completed the required sections of the petition, please refer to the table below:

PartA PartB Part C PartD PartE Part F PartG
Employee xX xX X x
Survivor xX x Xx x x
Authorized x x Xx x x xX
Representative (if
applicable)
Labor x x x x

Appendix — Petitioner 2

If there is an additional petitioner (not a labor organization), he or she must complete the Appendix —
Petitioner 2 and sign Section G of the original petition. Please refer back to pages 2 — 5 of this instruction
set for more information on completing the appendix.

Appendix — Petitioner 3

If there is a third petitioner (not a labor organization), he or she must complete the Appendix — Petitioner 3

and sign Section G of the original petition. Please refer back to pages 2 — 5 of this instruction set for more
information on completing the appendix.

Appendix — Continuation Page

The Continuation Page is provided for you if you need more space to provide additional information. Please
photocopy as needed, and attach to the petition.



Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention
lilness Compensation Act National Institute for Occupational Safety and Health
Instructions for Completing Special Exposure OMB Number: 0920-0639 Expires: 09/20/2013
Cohort Petition — Form B Page 1 of 10

Use of Form B and disclosure of Social Security Number are voluntary. Failure to use Form B or disclose this
Number will not result in the denial of any right, benefit, or privilege to which you may be entitled.

Instructions on Completing Special Exposure Cohort Petition — Form B
Introduction

The Energy Employees Occupational Illness Compensation Program Act (the Act) authorizes the U.S.
Secretary of Health and Human Services (HHS) to consider petitions by classes of current and/or former
employees at facilities of either the Department of Energy (DOE) or Atomic Weapons Employers (AWEs)
requesting to be added to the Special Exposure Cohort. HHS has issued procedures that explain how such
employees, their survivors, or individuals or organizations authorized in writing to represent them, can submit
a petition and how the outcome of the petition will be decided. The procedures, titled: “Procedures for
Designating Classes of Employees as Members of the Special Exposure Cohort” (federal regulations at 42
CFR Part 83), are available from HHS at the address provided below. 93 ae?

ae por*
SEC Petition nae)
Division of Compensation Analysis and Support 0~ ~
NIOSH
4676 Columbia Parkway, MS-C-47
Cincinnati, OH 45226

Use this form unless NIOSH has reported to you in writing that it cannot complete the dose reconstruction
needed for your cancer claim. If so, use Special Exposure Cohort Petition -- Form A. You do not have to
use either form to submit a petition. The forms are intended to assist petitioners in providing the complete
information required by HHS as efficiently as possible.

Hardcopy Submissions: Submit completed forms to the following address:

SEC Petition

Division of Compensation Analysis and Support
NIOSH

4676 Columbia Parkway, MS-C-47

Cincinnati, OH 45226

For Further Information: !f you have questions about these instructions, please call the following NIOSH
toll-free phone number and request to speak to someone in the Division of Compensation Analysis and
Support about an SEC petition: 1-877-222-8570.



Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention
\iness Compensation Act Nationai Institute for Occupational Safety and Health

. OMB Number: 0920-0639 Expires: 09/20/2013
Special Exposure Cohort Petition — Form B Page 1 of 7

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

General instructions on Completing this Form (complete instructions are available in a separate packet):
Except for signatures, please PRINT all information 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 more
than one petitioner, then each petitioner should complete those sections of parts A — C of the form that apply
to them. Additional copies of the first two pages of this form are provided at the end of the form for this pur-
pose. A maximum of three petitioners is allowed.

If you need more space to provide additional information, use the continuation page provided at the end of
the form and attach the completed continuation page(s) to Form B.

{f you have questions about the use of this form, please call the following NIOSH toll-free phone number and
request to speak to someone in the Division of Compensation Analysis and Support about an SEC petition:
1-877-222-8570.

Q A Labor Organization, StartatD on Page 3
If you An Energy Employee (current or former), StartatC on Page 2
are: QA Survivor (of a former Energy Employee), StartatB on Page 2
OA Representative (of a current or former Energy Employee), StartatA on Page 1

A Representative Information — Complete Section A if you are authorized by an Employee or

Survivor(s) to petition on behalf of a class.

A.1 Are you a contact person for an organization? O Yes (Go to A.2) QO No (Go to A.3)
A.2 Organization Information:

Name of Organization

Position of Contact Person

A.3 Name of Petition Representative:

Mr./Mrs/Ms. First Name Middle Initial Last Name

A4 Address:
Street Apt # P.O. Box
City State Zip Code

A5 Telephone Number: ( d

A6 Email Address:

A.7 Check the box at left to indicate you have attached to the back of this form written authorization to
petition by the survivor(s) or employee(s) indicated in Parts B or C of this form. An authorization

Ifyou are representing a Survivor, go to Part B; if you are represetiting an Employee, go to Part,

Name or Social Security Number of First Petitioner:

I



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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
Illness Compensation Act National Institute for Occupational Safety and Health
Instructions for Completing Special Exposure OMB Number: 0920-0639 Expires: 09/20/2013
Cohort Petition — Form B Page 8 of 10

F.2: Complete this entry if you are petitioning on the basis that radiation monitoring records for members of
the proposed class have been lost, falsified, or destroyed. Documentation or affidavits demonstrating that
monitoring records are missing for a class of workers might be sufficient to indicate that the records have
been lost or destroyed. Documentation or affidavits demonstrating differences between exposures or
Monitoring results and the current official records of these exposures or monitoring results might be sufficient
to indicate that records might have been falsified. You should note, however, that records can be changed to
reflect corrections to faulty monitoring results.

Also complete this entry if there is no information regarding monitoring, source, source term, or process from
the site where the members of the proposed class worked.

By completing this entry, you do not need to establish (through documentation or affidavit) that there are no
monitoring records whatsoever, for personal or area monitoring that was conducted for the class of
employees, or that all the relevant records have been falsified. You need only indicate that the records
relating to some types of radiation exposures and doses incurred by the class, or relating to certain periods
of time, certain operations, or certain exposure incidents involving the class, have been lost, falsified, or
destroyed, or that there is no such information.

F.3: Complete this entry if you are petitioning on the basis of an unpublished expert report addressing record
limitations for the class of employees proposed in your petition. You are not required to use this approach to
support your petition. Most petitioners are unlikely to be in a position to employ an expert to evaluate the
limitations of DOE records on exposures to a particular class of employees. However, this is an option that
might be used by some petitioners, particularly organizations. If you are considering this option, we suggest
the expert you employ contact NIOSH before completing such an evaluation. NIOSH will ensure that the
expert is aware of the availability of relevant information concerning the procedures by which NIOSH
estimates radiation doses for cancer claims under the Act, including the HHS regulations on dose
reconstruction methods (42 CFR Part 82) and related implementation guidelines.

F.4: Complete this entry if you are petitioning on the basis of a scientific or technical report that was
published in a peer-reviewed journal or issued by a government agency of the Executive Branch of
Government, or the General Accounting Office, the Nuclear Regulatory Commission, or the Defense Nuclear
Facilities Safety Board. Federal agencies most likely to have funded or to fund such studies are DOE and
NIOSH. It is possible that state environmental protection agencies might have funded such studies related to
AWE facilities. Such reports are likely to have been issued either as scientific or technical reports available
directly by request from government agencies or as research reports published in scientific journals.

Go to Part G.



Special Exposure Cohort Petition
under the Energy Employees Occupational
illness Compensation Act

U.S. Department of Health and Human Services
Centers for Disease Control and Prevention
National Institute for Occupational Safety and Health

OMB Number: 0920-0639 Expires: 09/20/2013

Special Exposure Cohort Petition — Form B Appendix — Petitioner 3

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

Use this Appendix for Petitioner 3.

This appendix form is to be used as needed. Petitioner 3, or his or her representative, should complete the
parts applicable to him or her.

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

If you need more space to provide additional information, use the continuation page provided at the end of
the form and attach the completed continuation page(s) to Form B.

Except for signatures, please PRINT ail information clearly and neatly on the form.

Q An Energy Employee (current or former), Start at C
If you are: |Q A Survivor (of a former Energy Employee), Start at B
OQ A Representative (of a current or former Energy Employee), Start at A

Representative Information — Complete Section A if you are authorized by an Employee or

Survivor(s) to petition on behalf of a class.

A.1_ Are you a contact person for an organization? O Yes (Go to A.2) Q No (Goto A.3)

A.2 Organization Information:

Name of Organization

Position of Contact Person

A.3 Name of Petition Representative:
Mr./Mrs./Ms. First Name Middle Initial Last Name

A4 Address:
Street Apt # P.O. Box
City State Zip Code

A.5 Telephone Number: ( ) =

A. Email Address:

A.7 Q Check the box at left to indicate you have attached to the back of this form 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.

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:

Ie



Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention
illness Compensation Act National Institute for Occupational Safety and Health
Instructions for Completing Special Exposure OMB Number: 0920-0639 Expires: 09/20/2013
Cohort Petition — Form B Page 4 of 10
Part

Petitioner Information: Complete Part C if you are an Energy Employee or a Survivor. Also complete this
Part if you are an individual or entity (other than a labor organization) authorized by an employee or survivor
to petition on behalf of a class of employees.

This section is to be completed by petitioners who are employees of DOE/AWE facilities or their survivors, or
by petitioners authorized by employees or their survivors. This section does not have to be completed by
labor organizations submitting a petition (labor organizations should complete Part D).

Please complete all the entries in this section, as applicable. The form allows for as many as three
petitioners to provide this complete information if they so desire, but this is not necessary. We only require
that a single petitioner provide complete information for this section.

C.1— Name of Employee: Enter the full legal name of the energy employee.

C.2 — Former Name of Employee: If the employee had a different name at the time of employment at the
DOE or Atomic Weapons Employer facility (for example, a maiden name), enter that name.

C.3 — Social Security Number: (Optional) Providing a Social Security Number is voluntary. Failure to
disclose this number will not result in the denial of any right, benefit, or privilege to which you may be
entitled. Persona! information, like your social security number, will be protected under the Privacy Act.

Enter the Social Security Number of the energy employee. If you are an authorized representative, make
sure you have permission to enter the employee's Social Security Number.

C.4 — Address: Enter the current mailing address of the energy employee.

If you are authorized to petition by an employee or a survivor under Part A of this form, you do not need to
complete this entry.

C.5 — Telephone Number: Enter the telephone number at which the employee can be reached from 8:00
am to 5:30 pm Eastern Standard Time on weekdays. Please specify more limited hours of availability, if
necessary.

If you are authorized to petition by an employee or a survivor under Part A of this form, you do not need to
complete this entry.

C.6 — Email Address: (Optional) Enter the employee’s email address at work or home.

If you are authorized to petition by an employee or a survivor under Part A of this form, you do not need to
complete this entry.



E

Special Exposure Cohort Petition U.S. Department of Health and Human Services
under the Energy Employees Occupationat Centers for Disease Control and Prevention
lliness Compensation Act National Institute for Occupational Safety and Health

Special Exposure Cohort Petition — Form B Page 4 of 7

OMB Number: 0920-0639 Expires: 09/20/2013

roposed Definition of Employee Class Covered by Petition mplete Section E.

E.1 Name of DOE or AWE Facility: NUCLEAR HerAus, INC -

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

West CoPcotd , HA - Buwys A A,c De F Bureet Bed6.

E.3 List job titles and/or job duties of employees included in the class. In addition, you can list by
name any individuals other than petitioners identified on this form who you believe should be
incl i is class:
included in this class: AL lo- Theee WAS Be gestections on

(CEAP2YEE ACCESS To PAS Y, o2 HosT, OURANIYH PREcEsS AREKS
Dues rue pine PraiedS oF 1472 ~- (783
E.4 Emplovment Dates relevant to this petition:
Start - (#70 End 1483
Start End
Start End

E.5 Is the petition based on one or more unmonitored, unrecorded, or inadequately monitored or
recorded exposure incidents?: Xl Yes Q No
If yes, provide the date(s) of the incident(s) and a complete description (attach additional pages
as necessary):

hETAICED IS FORMATION OF WUMERoVS  VNHoWITILED ExP0SURES
ARE Provided, 1 THe umPaRT AG  AFFADAVITS Auld A PRedices
Peovided BY Add orvees,
bet — — eT _
Go to Part F.

Name or Social Security Number of First Petitioner:

4



Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention
illness Compensation Act National Institute for Occupational Safety and Health

. OMB Number: 0920-0639 Expires: 09/20/2013
Special Exposure Cohort Petition — Form B Page 6 of 7

F.3 O IMWehave 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
believing these documented limitations might prevent the completion of dose reconstructions for
members of the class under 42 CFR Part 82 and related NIOSH technical implementation
guidelines.

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

F.4. Q iMWehave 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 Facilities Safety Board, or published in a peer-reviewed
journal, that identifies dosimetry and related information that are unavailable (due to either a lack _
of monitoring 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.

ature of Person(s) Sub

ion — Complete Section G.

All Petitioners should sign and date the petition. A maximum of three persons may sign the petition.

s Date
a 6/20 / Q
ignature 7 Dafe
Signature Date
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 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. | affirm that the information
provided on this form is accurate and true.

Send this.form to: SEC Petition
Division of Compensation Analysis and Support
NIOSH
4676 Columbia Parkway, MS-C-47
Cincinnati, OH 45226

If there 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:



Special Exposure Cohort Petition U.S. Department of Health and Human Services
under the Energy Employees Occupational Centers for Disease Control and Prevention
Illness Compensation Act National Institute for Occupational Safety and Health

Instructions for Completing Special Exposure OMB Number: 0920-0639 Expires: 09/20/2013
Cohort Petition — Form B Page 3 of 10
Part B

Petitioner Information: Complete Part B if you are a Survivor of a former Energy Employee. Also complete
this Part if you are an individual or entity (other than a labor organization) authorized by an employee or
survivor to petition on behalf of a class of employees.

B.1— Name of Survivor: Enter the full legal name of the survivor.

B.2 — Social Security Number: (Optional) Providing a Social Security Number is voluntary. Failure to
disclose this number will not result in the denial of any right, benefit, or privilege to which you may be
entitled. Personal information, like your social security number, will be protected under the Privacy Act.

Enter the Social Security Number of the survivor. if you are an authorized representative, make sure you
have permission to enter the survivor's Social Security Number.

B.3 — Address: Enter the survivor's current mailing address.

If you are authorized to petition by an employee or a survivor under Part A of this form, you do not need to
complete this entry.

B.4 — Telephone Number: Enter the telephone number at which the survivor can be reached from 8:00 am
to 5:30 pm Eastern Standard Time on weekdays. Please specify more limited hours of availability, if
necessary.

If you are authorized to petition by an employee or a survivor under Part A of this form, you do not need to
complete this entry.

B.5 — Email Address: (Optional) Enter the survivor's email address at work or home.

If you are authorized to petition by an employee or a survivor under Part A of this form, you do not need to
complete this entry.

B.6 — Relationship to Employee: Check the relationship of the survivor to the energy employee.

Go to Part C.



Special Exposure Cohort Petition U.S. Department of Health and Human Services
under the Energy Employees Occupational Centers for Disease Control and Prevention
\lIness Compensation Act National Institute for Occupational Safety and Health

Instructions for Completing Special Exposure OMB Number: 0920-0639 Expires: 09/20/2013
Cohort Petition — Form B Page 2 of 10

IMPORTANT: Petitions DO NOT need to be submitted by all potential members of a class of employees
(“Class” has a very specific legal meaning under the HHS rule. Petitioners should consider “class” to mean
the group of employees who worked at the same DOE or AWE facility and who believe they, as a group,
should be added to the Special Exposure Cohort). A single member of a class of employees, the survivor of a
member. or an individual or entity authorized in writing by a member or survivor can petition on behalf of the
entire class. Petitioners are not required by HHS to contact other members of the class or obtain their
consent to submit a petition, although petitioners may wish to obtain information useful to the petition from
other members of the class

Instructions

Please read each of parts A — G in the form and complete only those parts appropriate to you, according to
these instructions. A checklist has been provided on the last page of these instructions to help ensure that

you have properly completed all of the sections applicable to you. Except for signatures, please PRINT all
information clearly and neatly on the form.

If there is more than one petitioner, then each petitioner should complete those sections of parts A - C of the
form that apply to them. Additional 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, but only one petitioner is required. Limiting
the number of petitioners to three for each petition does not limit the number of members of the class
covered by a petition, but will enable HHS to consider and decide petitions more efficiently.

If you need more space to provide additional information, use the continuation page provided at the end of
the form and attach the continuation page(s) to Form B.

PartA

Petitioner Information: Complete Part A if you are an individual or entity authorized by an employee or a
survivor to petition on behalf of a class of employees, as provided for under 42 CFR Part 83.7(c).

A.1— Are you a contact person for an organization (other than a labor union): If you are a contact
person for an organization, other than a labor organization, check Yes and go to A.2; if you are not a contact
person, check No and go to A.3.

A.2 — Organization Information: If you are a contact person for a legally constituted organization, a firm, or
another type of entity, enter the name of the organization and your position as the person who will serve as
the principal contact with HHS for this petition. If you are NOT a contact person, leave this entry blank.

A.3 — Name of Petition Representative: Enter your full legal name (applies to both a contact person and
an authorized representative of an energy employee or survivor).

A.4— Address: Enter your current mailing address.

A.5 — Telephone Number: Enter the telephone number at which you can be reached from 8:00 am to 5:30
pm Eastern Standard Time on weekdays. Please specify more limited hours when you are available, if

necessary.
A.6 — Email Address: (Optional) Enter your email address at work or home.

A.7 — Authorization: Check the box and attach the written authorization, as indicated. A separate
authorization form, “Petitioner Authorization Form’, is available for this purpose.

If you are representing a survivor, go to Part B; if you are representing an employee, go to Part C.



Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention
\liness Compensation Act National Institute for Occupational Safety and Health
OMB Number: 0920-0639 Expires: 09/20/2013

Special Exposure Cohort Petition — Form B
Survivor Information — Complete Section B if you are a Survivor or representing a Survivor.

Page 2 of 7

B.1 Name of Survivor:

Mr/Mrs./Ms. First Name Middle Initial Last Name
B.2 Social Security Number of Survivor:

B.3 Address of Survivor:

Street Apt # P.O. Box

City State Zip Code
B.4 Telephone Number of Survivor:  ( ) -

B.5 Email Address of Survivor:

B.6 Relationship to Employee: Q Spouse Q Son/Daughter Q Parent
Q Grandparent Q Grandchild
Go to Part C.

Employee information — Complete Secti LESS you are a labor organization.
C.1__ Name of Emplovee:

Mr./Mrs./Ms. First Name Middle initial Last Name
C.2. Former Name of Employee (e.g., maiden name/legal name change/other):

Mr/Mrs./Ms. First Name Middle Initial Last Name

C.3 Social Security Number of Employee:

C4 Adabuane af Peantauan (if livina\:
Street Apt # P.O. Box
City State Zip Code

C.5 Telephone Number of Employee:
C.6 Email Address of Employee:

C.7._ Employment Information Related to Petition:
C.7a Employee Number (if known):

C.7b Dates of Employment: Start 1977 End - (943
C.7¢ Employer Name: NUCCEAR_ METALS, tC.
C.7d Work Site Location: WEST GConcokd, HA -

C.7e Supervisor's Name: M2,

Go to Part E.

Name or Social Security Number of First Petitioner:

Zz


Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention
Illness Compensation Act National Institute for Occupational Safety and Health

| OMB Number: 0920-0639 Expires: 09/20/2013
Special Exposure Cohort Petition — Form B Page 5 of 7

Basis for Proposing that Records and Information are Inadequate for Individual Dose —
Complete Section F.

Complete at least one of the following entries in this section by checking the appropriate box and providing
the required information related to the selection. You are not required to complete more than one entry.

Fi Me have attached either documents or statements provided by affidavit that indicate that
radiation exposures and radiation doses potentially incurred by members of the proposed class,
that relate to this petition, were not monitored, either through personal monitoring or through area
monitoring.

(Attach documents and/or affidavits to the back of the petition form.)

Describe as completely as possible, to the extent it might be unclear, how the attached
documentation and/or affidavit(s) indicate that potential radiation exposures were not monitored.

ATTACHED AFFADAVITS And SuPPenTIPh bocoHEsTS HEScRBES
MAY Uns Mow/TIZED URANIUM AIRBASE AND EXTERVAL EKPoSULES .

F.2 i I/ We have attached either documents or statements provided by affidavit that indicate that
radiation monitoring records for members of the proposed class have been lost, falsified, or
destroyed; or that there is no information regarding monitoring, source, source term, or process
from the site where the employees worked.

(Attach documents and/or affidavits to the back of the petition form.)

Describe as completely as possible, to the extent it might be unclear, how the attached
documentation and/or affidavit(s) indicate that radiation monitoring records for members of the
proposed class have been lost, altered illegally, or destroyed.

YAS war, WEST Cop CoLd HA CLA AYTS HAVE BEEN seBjecr To
Riosd bosé RécgasTaveTi aw, THESE Ceauls DEMONSTRATE A Lace
OF _IsTERMAL bose DATA Foo 1972 - (983 THAT HAY BE CaeTipy hue
To Hissi®G DATA, Rot poke eiheey Du To UsHoniT2RED
Enns pet. This ts AT EMT [Roe Fok
AND

— ees —e

Part F is continued on the following page.

Name or Social Security Number of First Petitioner:

x