Special Exposure Cohort Petition 

under the Energy Employees Occupational 

Illness Compensation Program Act 

Special Exposure Cohort Petition ­ Form B 

U.S. Department of Health and Human Services 

Centers for Disease Control and Prevention 

National Institute for Occupational Safety and Health 

0MB Number: 0920-0639 Expires: 07/31/2016 

Pa e 1 of7 

Use of this form is voluntary. Failure to use this form 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 sections 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 

purpose. 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. 


For Further Information: If 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. 

Labor Organization, 	 Start at D 

If you 1 Energy Employee {current or former), 	 Start at C 

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


Representative (of a current or former Energy Employee); Start at A 


A. 	 Representative Information - Complete Part A if you are authorized by an Energy Employee or 

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

A.1 	 Are you a contact person for an organization? 

I A.2 Organization Information: 

I 

I 

Name of Organization 

Position of Contact Person 

A.3 	 Name of Petition Representative: 

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

A.4 Address of Petition Representative: 

Street 	 Apt# P.O. Box 

City 	 State Zip Coele 

A.5 	 Telephone Number of Petition Representative: ,_____ -----------~ 

A.6 	 Email Address of Petition Representative: 

09-01-16A09:14 RCVD 


A.7 
Special Exposure Cohort Petition 

under the Energy Employees Occupational 

Illness Compensation Program Act 

U.S. Department of Health and Human Services 

Centers for Disease Control and Prevention 

National Institute for Occupational Safety and Health 

0MB Number: 0920-0639 

8.1 Name of Survivor: 

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

B.2 Address of Survivor: 

Street Apt# 

City State Zip Code 

8.3 Telephone Number of Survivor: (.____.)____________ 

8.4 Email Address of Survivor: · 

B.5 Relationship to Energy Employee: D Spouse 

DGrandparent 

Goto Part C. 

DSon/Daughter 

DGrandchild 

P.O. Box 

DParent 

C. Energy Employee Information - Complete Part C UNLESS you are a labor organization. 

C.1 Name of Energy Employee: 

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

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

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

C.3 Address of Energy Employee {if living): 

Street Aot# P.O. Box 

City State Zip Code 

C.4 Telephone Number of Energy Employee: (.____J)_-~---------­

C.5 Email Address of Energy Employee: 

C.6 Employment Information Related to Petition: 


C.6a Energy Employee Number (if known): 


C.6b Dates of Employment: Start t 9C 9 End 2.otJ6 


C.6c Employer Name: Mt U Is ~ Gn fro (s (!ex.r;.S "J:1-r&ft-t,l~,,,:6;, ,//11.d c._) 


C.6d Work Site Location: 3 f Ft!J re5, t Sfr-ec. t-


A ft It:. h.:,ro. 1-1.A O 2 ;z 03 

C.6e Supervisor's Name: _ 

Goto Part E. 
Special Exposure Cohort Petition 

under the Energy Employees Occupational 

Illness Compensation Program Act 

0.1 Labor Organization Information: 

U.S. Department of Health and Human Services 

Centers for Disease Control and Prevention 

National Institute for Occupational Safety and Health 

0MB Number: 0920-0639 

Name of Organization 

Position of Contact Person 

0.2 Name of Petition Representative: 

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

0.3 	 Address of Petition Representative: 

Street 	 Apt# P.O. Box 

City 	 State · Zip Code 

0.4 	 Telephone Number of Petition Representative: (----~------------­

0.5 	 Email Address of Petition Representative: 

0.6 	 Period during which labor organization represented energy employees covered by this petition 

(please attach documentation): 


Start End 


0.7 	 Identity of other labor organizations that may represent or have represented this class 

of energy employees (if known): 

Go to Part E. 
Special Exposure Cohort Petition U.S. Deparbnent of Health and Human Services 

under the Energy Employees Occupational · Centers for Disease Control and Prevention 

Illness Compensation Program Act National Institute for Occupational Safety and Health 

0MB Number: 0920-0639 

E.1 Name of DOE or AWE Faclllty: /vl e.. f cJ. 5 & &,o1.. +rb (S (-rr /1'1-~ c.) t4ff/t-£.,,-o 

~c·te.. E.2. 	 Locations at the Facility relevant to this petition: 

E.3 	 List job titles and/or job duties of energy 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 Included in this class: 

E.4 	 Employment Dates relevant to this petition: 

Start End 


Start End 


Start End 


E.5 	 Is the petition based on one or more unmonitored. unr.ecorded, or inadequately monitored or 

recorded exposure incidents?: 

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

necessary): 

Go to Part F. 
Special Exposure Cohort Petition 

under the Energy Employees Occupational 

Illness Compensation Program Act 

U.S. Department of Health and Human Services 

Centers for Disease Control and Prevention 

National Institute for Occupational Safety and Health 

0MB Number: 0920-0639 

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 morethan one entry. 

F.1 I/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 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. 

F.2 	 D 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 energy 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. 

Part F Is continued on the followin 
Special Exposure Cohort Petition 

under the Energy Employees Occupational 

Illness Compensation Program Act 

U.S. Department of Health and Human Services 

Centers for Disease Control and Prevention 

National Institute for Occupational Safety and Health 

Special Exposure Cohort Petition ­ Form B 

0MB Number: 0920-0639 Expires: 07/31/2016 

Pa e 6 of7 

F.3 I/We have 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 82and related NIOSH technical imolementation 

guidelines. 

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

F.4 I/We have 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) f9r estirnatirJQ the radiation doses of energy 

employees covered by the petition. 

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

All Petitioners~ouJd sian :tnd date the netition. A maximum of three persons may sign the petition. 

Signature Date 

Signatuye 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. I 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. 
Special Exposure Cohort Petition 

under the Energy Employees Occupational 

Illness Compensation Program Act 

U.S. Department of Health and Human Services 

Centers for Disease Control and Prevention 

National Institute for Occupational Safety and Health 

Special Exposure Cohort Petition ­ Form B 

0MB Number: 0920-0639 Expires: 07/31/2016 

Paae 7 of7 

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 0MB 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 and 

WTC Health 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 8) 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. 
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 Program Act National Institute for Occupational Safety and Health 

0MB Number: 0920-0639 Expires: 07/31/2016 

Special Exposure Cohort Petition - Form B Aooendix - Petitioner 2 


Use of this form is voluntary. Failure to use this form will not result in 


the denial of anv 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 

sections applicable to him or her. 

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


If you need more s12ace to 12rovide 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. 


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

Ifyou A Survivor (of a former Energy Employee), 	 Start at B 

are: 

A Representative (of a current or former Energy Employee or Survivor); Start at A 

A. 	 Representative Information - Complete Part A if you are authorized by an Energy Employee or 

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

A.1 	 Are you a contact person for an organization? D Yes (Go to A.2) D 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 

A.4 	 Address of Petition Representative: 

Street 	 Apt# P.O. Box 

City 	 State Zip Code 

A.5 	 Telephone Number of Petition Representative: ,_____ ------------­

A.6 	 Email Address of Petition Representative: 

A.7 	 D 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 energy employee(s) indicated in Parts B or C of this form. An 

authorization form for this purpose is provided. 
""·---···------------------------------­

Special Exposure Cohort Petition 

under the Energy Employees Occupational 

Illness Compensation Program Act 

U.S. Department of Health and Human Services 

Centers for Disease Control and Prevention 

National Institute for Occupational Safety and Health 

0MB Number: 0920-0639 

8. 1 Name of Survivor: 

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

B.2 Address of Survivor: 

Street 

City State 

B.3 Telephone Number of Survivor: 

8.4 Email Address of Survivor: 

8.5 Relationship to Energy Employee: O Spouse 

D Grandparent 

Apt# 

Zip Code 

OSon/Daughter 

OGrandchild 

P.O. Box 

OParent 

Go to Part C. 

C. Energy Employee Information ­ Complete Part C. 

C.1 Name of Energy Employee: 

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

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

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

C.3 Address of Energy Employee (if living): 

Street Apt# P.O. Box 

City State Zip Code 

C.4 Telephone Number of Energy Employee: L _)____________ 

C.5 Email Address of Energy Employee: 

C.6 Employment Information Related to Petition: 

C.6a Energy Employee Number (if known): 

C.6b Dates of Employment: Start Ir~ 9 End 2&::>' 

C.6c Employer Name: Mefq(s t C,,, ·Ir~ /s ( 7<><"($ :Z.:.Sfru,..;n-f:.5 //'1d C-) 

C.6d Work Site Location: 3 f f:.tP/e. $ f: S1-rec & 

A ft Ie koro MA 02. l:o 3 

C.6e Supervisor's Name: 

Sign Part G of the original petition. 
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 Program Act National Institute for Occupational Safety and Health 

0MB Number: 0920-0639 Expires: 07/31/2016

Special Exposure Cohort Petition - Form B Accendix - Petitioner 3 


Use of this form is voluntary. Failure to use this form 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 

sections 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 8. 


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

,n Energy Employee (current or former), 	 Start at C 

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

are: , Representative (of a current or former Energy Employee); Start at A 

A. 	 Representative Information - Complete Part A if you are authorized by an Energy Employee or 

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

A.1 	 Are you a contact person for an organization? 

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 

A.4 	 Address of Petition Representative: 

Street 	 Apt# P.O. Box 

City 	 State Zip Code 

A.5 	 Telephone Number of Petition Representative: L .)________~ 

A.6 	 Email Address of Petition Representative: 

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 energy employee(s) indicated in Parts B or C of this form. An 

authorization form for this purpose is provided. 
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 Program Act National Institute for Occupational Safety and Health 

B.1 Name of Survivor: 

C. Energy Employee Information - Complete Part C. 

C.1 Name of Energy Employee: 

0MB Number: 0920-0639 

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

B.2 Address of Survivor: 

Street Apt# P.O. Box 

City State Zip Code 

8.3 Telephone Number of Survivor: (___-----------­

8.4 Email Address of Survivor: 

B.5 Relationship to Energy Employee: D Spouse DSon/Daughter OParent 

DGrandparent OGrandchild 

Go to Part C. 

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

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

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

C.3 Address of Energy Employee (if living): 

Street Apt# P.O. Box 

City ~tate Zio Code 

C.4 Telephone Number of Energy Employee: l J_ 

C.5 Email Address of Energy Employee: 

C.6 Employment Information Related to Petition: 


C.6a Energy Employee Number (if known): 


C.6b Dates of Employment: Start 19fu : End 4t0~ 

C.6c Employer Name: Me f4/s. J c;tr,:z(<; (re x<t.S L.sft~1:t's /111 d. (!,) 


C.6d Work Site Location: 3 'f Fore sf Sfree:f · 


All 1~ loo,.:,. MA CJ 2- ::Z o 3 

C.6e Supervisor's Name: 

Si n Part G of the ori