02-15-05PO2:36 RCVD

~ - --' .

-u.s. Department of Health and Human Services j

Cent8f8 for DI8ea8e Control and Prewntion

Nab18 In81bJ8 for OcC!Jp8Oon81 safetY and HeaIh

QM6 NLlmb4r: D9~e expb..:. QSi3jJ2.QO1-

P8Q81 ~71

I S~iaJ Exposure Cohort Petition

under Ule Energy Employees Occupational

IIDI\ess ~Ion ~

I S~1aI EXpoaure Cono~ Petition ~ F~ ~

- - -- - - - --' - ---

j General Instructions on Completing this Form (complete instructIons are BvaUab/e In a separate packet):

on Page 3

on Page 2

---

on Page 2

on Page 1

Start ~ D

Start at C

Start at B

Start at A

I Q A Labor Organization.

I a An Energy Employee (current or former), If you

are: ;~~ Su~~d afo;tMr ~;gy'-EmpkJye;~

:-a A ~-;en~tive (ot; ro~ ~rtO~r Energy Employee),

C No (Go to A3) ~

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

I~ Organization Information:

Name of Organization

Position of Contact Person

1A.3 Name of Petition Representative:

!A-4

City -" ~ - "J -- ~ ---. Zip Code

Telephone Number: , _'_i -, -" -- - -- -- .-

State

IA.5

'Ai

1A.7

EmaifAddress:

a Check the box at left to indIcate you have attached to the back of this form written authorization to

petition by the surviwr(s) or employee(s) indicated in .Parts B or C' of this tonn. An authorization

Name or Social Security Number of FIrst Petitioner: -~"" rJw

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

I Please read each of 'parts A - G In this form and complete the parts appropriate to you. ~ th~re Is more:

:than one Detitioner. then each petitk)ner should complete those sections of parts A - C of the fomt that apply

to them. AdditlonaJ copies of the first two pages of this form are provided at the end of the form for this purpose. A maximum of Ulree peUtioners is allowed.

If ~u need more scace to crovide additloni( infonna1J~n. use the continuation page provided at the end of

! the fonn and attach the completed continuation page(s) to Fonn B.

Ilf you have questions about the use of this form, please can the foRowing NIOSH toll-free phone num~r and

, request to speak to someone in the Office of Compensation Analysis and Support about an SEC petition:

'1-800-356-4674. --
~ --- - u.s. Department of Health and Human Service. I

Cd8I8 for ~-~ ConVcI ~

National Institute for~ &paIon8I S.rett and Hedt\

OMB Number: 0920-0639 Expirea:.05i31f2.007 "' ..,

~f~e;~~ Cohort Pettti~n

I under the Energy ~Ioyee' O~patlonal I UInes8 Ccxnpena8tion Act

I Special Exposure Coh~?atItIon - Lorm ~

Nama of Sur~or: . I . -1 "- - - ~- ~ :.- ~-- '

Mr j~ ~irst Nsne Middle Initial . ~ Name .

Social Security Number of Survivor:

Ad,- -- L_-

IB.1

18.2

B.3

-

-~;~.". ~~, ,,-,;,;~~:~.~ . . - - . . . P 0 Box

- - ~ ~;- ",

. ZIp_Code

s~

-- - -

City ~tat8

Telephone Number o! Survivor:

Emall Address of Survivor:

Relationship to Employee:

18.4 8.5

I

IB.6 I

,- ~

- . - -

a Son/Daughter Q Pa~nt a . Gtandthrtd

- --

g."'Spouse

0 Grandparent

,/') IC.1 Name of Employ~e: 1-

Mr lMrslMs. Arst Name ~ Middle Initial Last Name

- C.2 Fonner Name ~f Employee (~g" maJden name/legaJ name change/other):

0-. - --

Mr JMrs./Ms. Rr8t Name

Social Security Number of Employee:

Address of Employee (If living):

!C.3

jC.4

-- - -- -- City State ~. ZIp Code

i C.5 Telephone Number of Employ..: (, . . -

- D II I ?C~- _~I": -~

, "".g ~I'." ~U'" v~ "I ~mployee: ~ -~

I C.7 Employment InformatIon Related to Pettion: . C

,C.7. Employee Number (If known): ~

,C.7b Dates of Employment /) _Sta~ - ..:J.- End .

, C.7c Employer Name: tk./.:1T

! C.7d .Work Site location: '.

f

,C.7eI . SuperviSOr's Name:':

Name or Social Security Number of First Petitioner:
- --

u.s. Department of Health and Human Service.

c.,..,. tx D8ea88 C<X1Uol ~ ~

NatIonal Institute for OCQJp8tk)nal S8f8ty and tMfth

9Me.Nuntber: 0920-0639 ExpI188: ~1/200:z --

!S~Ia8J~ ~ Cohort-P;ttti;;;;;

I under ~ Energy EmpkJyees Q=JpatlonaJ

IIk\eSS 'Campensation ~

. Special expOsure COhort Petition - Form 8

labor Organization Infol:mation:

.- Name of Organization

10.1

---

Position of Contact Person

10.2 Ham. of Petition Representative:

Address of Petition Representative: 10.3

ID.4

..0.5

I

iD.6

Street. - Apt - - , P.o. Box - - - 

City State ~ Code

Telephone Number of Petition Representative: I , -

Entail Address of Petition Representative:

Period during which labor organization repre.ented employe.. covered by this petition

(please attach documentation): start End

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

employee. (if known):

10.7

Name or Social Security Number of First Petitioner:-
Special Exposure Cohort PettUon U.S. Department of HeaHh and Human ServlcM

under 1h. e..rgy Empioywea 0ccupatI0n8I Cec'd8ra b" Di8.-. ~ and P,,'Ientior\

JUnes. Compensation Act N8tioI'I8IInstt&D for ~.!p8tionaI Safet{ aM Huftf\

I OMS Number: 0920..0639 expires: 05/31/2007

S~ Ex~sur. Cohort Petition - Fom'\ B P8Q8 4 of 7

!E.1

IE.2

IE.3

Name of DOE or AWE Faci'~

Locations at the FacUlty relevant to thJs petition:

Uat Job titl.. and/or Job dutie8 of ~pIoyeM Included In the cia In addition. you can lIat by

name any Individual. otl\er than peti1Ioners Identified on this fonn who you believe should be

Included In this cia..: _~l)Lf., .-

IE.4

5

Employment Dat88 relevant to this petition:

Start - End

Start. End

Start End

I. tile petition based on one or more unmonttored. unrecorded, or inadequately monitored or

recorded exposure Incidents?: a Yes ~o

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

as necessary):

~~~ .,:--

Name or Social Security Number of First Petitioner. v
-0 - - -

u.s. Department of Health and Human Services . Cent8r8 for Di888se CCX1tlQI ar¥1 Pr ntion

National In88tL/18 for ~~I Saf8t18nd Hedh

OMS Number: 0920-0639 expires: !JS/3.tl2007

- P8Qe!~7

I SpeCial Exposure Cohort Petition

under u,e EI1ergy Employees Occupatbnal

IIIk1es8 Compet188tion Act

I S~laJ Ex~ure Cohort Petition - Fonn B

rJ'

I~p'ete ~'t i;.;t on~~;~ ng en~ ~ ~n by ~~gutt;;; appropriate box and providing the required Information related to the selectk>n. You are not required to complete more U1an one entry.

F.1 W"""WJe have ~ttached either documents or statements provided by affidavit that indicate that

radiation exposures and radiation doses potentially incurred by members of the proposed class, I that relate to this petition. were not monitored, either through personal monitoring or through area

\ monitoring.

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

\ . I Describe as completely as possible, to the extent it might be unclear, how the attached

documentation and/or affldavit(s) Indicate that potential radiation exposures ~ not monibred.

'//I.,e

!

r.e ~ /-=

! . rA- ~ 7lJ

\ / r ~e. ~.eJi~ ~ ",M:a~~,/j ~- aIP-at> .4l:IlL:

3~~.; OW ~ llJ tra.J~ ~m. TUE.e# ~ ~./JI;J/LG£.~~~:2S' ~

~~~ /tI.e /}.E(!e~ ..{) &J£.t£. I /1E/J1.er1'J1~~ _/~./).e/N~

~ & ...(1l<itJ

/&011 "'" ~ ~. ~ I . F.2 0 e have ~8d either ocu enfi p by affidavit that Indicate that

radiation monitoring records for members of the proposed dass 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.

I (Attach documents and/or affidavits to the. back of the petltk>n form.)

Describe as completely as possible. to the extent it might be unclear, how the attached

documentation and/or affidavft(s) Indicate that radiation monitoring records for members of1he .

proposed class have been lost. altered Illegally, or destroyed.

Name or Social Security Numbor of First Petitioner t1
U.S. Department of Health and Human ServiGes centers for Disease Con1roI and ~

Na~llnstitute for Occupational Safety and Health ,

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

Page 6 of7

SpeCial Exposure Cohort Petition

under the Energy Emplo~ OCC\lpationai

Inness Compensation Act

Special Exposure Cohort Petition - Fonn B

'F.3

,F.4

Q Il\Ne have attached a report from a heal1h physicist or other individual with expertise in

radiation dose ~struction documenting the rsmitations 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

guidelines. members of the class under 42 CFR Part 82 and related NIOSH technicaJ Implementation .

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

[J l/VVe have attached a scientific or technical report, issued by a government agency of the

Executive Branch of Government or the General Accounting otrlCe, the Nuclear Regulatory

CommissIon, or the Defense Nuclear FacirrtJes Safety Board, or pubUshed in a peer-reviewed

journal, that identifies dosimetry and related infonnation 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 fonn.)

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

Signature Date

Signature Date

Notice:

Signature Date

Any person who knOV!lngly makes any false statement. misrepresentation, concealment of

fact or any other act of fraud to obtain compensation as provided under EEOICP A 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 affinT1 that the information provided on this form is accurate and true. .

Send this form to: SEC Petition

Office of Compensation Analysis and Support

NIOSH

r ",,;:,,: CinCInnati, OH 45226 "'~~""'C,.c .c

Name or Social Security Number of First Petitioner:
I 

- - . ISpecial Exposure Cohort Petition

Iunder 1he Energy Employees Occupational 

I IUness Compensation Act 

U.S. Department of Health and Human Services 

cent~forDlSeaseConWIandPreventlcn 

NationallnstibJte for Occupafloilal Safety and Health 

I Spec_i~1 ~r?Osu-~ Cohort Petition ~ fo~ ~ OMS Number; 0920-0639 expires: 05/3112007 

Pa~7~7 

Public Burden Statement 

pubrlC reporting burden for this coltection of info~ation is estimated to average 300 minuteS' 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 CHfton 

I Road, MS-E-11, At1anta GA, 30333; A TTN: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 In"stl'Uctions. 

Persons are not requred 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 V.S.C. § 552a), you are hereby notified of the 

following: 

The Energy Employees Occupationalil/ness 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 ~ure Cohort (SEC). EEOICPA authorizes HHS to implement its responsibilities with the 

I assistance of the Nattonallnstitute 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. 

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

below. 

NIOSH may need to discbse personal identifying information to: (a) the Department of Energy, other federal 

agencies, other government or private entities and to private sector employers to pennit these entities to I retrieve records required by NJOSH; (b) identified witnesses as designated by NIOSH so that Ulese 

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

(e) Federal, state and local agencies for Jaw enforcement purposes; and (f) a Member of Congress or a 

Congressional staff member in response to a verified Inquiry. 

This notk:e 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 infonnation required by these 

forms is mandatory for the consideration of a petition, as specified under 42 CFR Part 83. Petitions that fajf to 

provide required infomtation may not be considered by HHS. 

Name or Social Security Number of First Petitioner: 
This page left intentionally blank.
~- -

U.s. Depamnent of Health and Human Servfces

Cent8r8 b' DIsease ~ and p, "tlon

NationallnstitlJf8 for 0ccup81f0naJ Safety end Health

OMS Number; 0920-0639 Expites: ~1/2.007

I speCial Exposure Cohort Petition

I under the Enetgy ~ Ocx:upatlonai

! I aness ~fk)n Ad

I SpectaI Exposure Cohort Petition - Fonn B

r -- Use this Appendix for Petitioner 2.

This appendix fonn Is to be used as needed. Petitioner 2, or his or her representative, should complete the

'.parts applicable to him or her.

I Refer to the Generai In.str~ns on completing petitk)ner inforrTI~n for Parts' A. B, or C.

i If YOU need more ~ to orovide addjtjQnallnfom1~n. use the continuation page provided at the end of

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

I Except for signatures, please PRINT aH infom\ation clearly and neatly on the fomt. -

Start at C

-

Start at B

Start etA

lOAn Energy Empk)yee (current or fcm1ef).

I H you are: rfii'ASU~ (~f a tonnIr En8fgYempk>yee~. ---

(0 A Representative (of a current or former Energy Employee),

Q No (Go to A.3) -- ---

Are you a contact person for an organization? a Yes (Go to A2)

1A.1 A.2 Organization Information:

Nam~ of Organiza~n

Position of Contact Person

'A3 Name of Petition Representative:

Mr JMrs./Ms. FIrst Name) Middle Initial last Name--

IA4 Address:

City St8te ZJp Code--

A.5 T818 hone Number: - -- A.6 Em." Address: .

A. 7 a Check the box at left to Indicate you have attached to the back of this fOn1\ wriUen authorizatbn to

petition by the sulVivor(s) or employee(s) indicated in Parts B orC of this form. An authomaUon

form for this purpose Is provided. .

Name or SclCiaI Security Number of First Petitioner:
"Speclal Exposure Cohort Petition

lInder Ute Energy Employees Occupational

RJness ~tion Ad.

U.S. Deparbnent of Health and Human Services

CenteIS for Disease Control and Prevention

National Institute for OCQJpational Safety and Health

OM~ Nu:mber: 0920-0639 ~l~: m11'1..QO7 Spe~ial Exposure Cohort Petiti~ -=- ~~ ~ ~ndIx - P9U~ 2

8.1 Name-of Surviv,

B.2

6.3

Sb'eet

City State

Telephone Number of Survivor:

EmaJl Address of Survivor:

Relationship to Employee:

~¥-

8.4

8.5

!B.6 ~ 0 n/D !Y9!1!g r

a Grandchild

a Spouse 0 Parent

a Grandparent

1~.1 Name of Em

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

~.2 Former Name of EmnlnVM (e.g., maiden name/iegal name change/other):

Middle Initial I ~st Name

.

~.3 ~,

~.4

Mr./MrsJMs. r'I~\ '~QJI""

Social Security Number of Employee:

Address of EmpJoyee (if living):

City State Zip Code

, ~.5 Telephone Number of Employee: r } eo ,-

. ~~~

-C-:6 t:.mall Aaaress Of Employee: .;

C.7 Employment Information Related to Petition:

",.7&' Employee Number {if known}: ~

I ~.7b Dates of Employment Start.

, ,

~ C.7c ~plov~r Name:

End - ~/J1.M~

:i4-~~ !C.7d Work Site Location:

IC.1e Supervisors Name: fJ./

Name or Social Securi,ty Number of First Petitioner:- v
,-..

-- -- ~-- - - -

U.s. Deparbn..,t of Health and Human Services

C81t8fI frx Disease Ccx1VoI W Pr8Wf1tbt

~ 1n8811.8 1« ~ 5aty - Hedh

OMe Number: 0920-0639 expif8S: Q~1f};OQ7 ~~QCIJ - ~ s

[Special Exposure Cohort Petition

I.NIder the Energy Empjoyeea Occupational

IBness ~ Act

I Special ~ure Cohort PeUtion - Form B

-- ~ --- - .. . UN this Appendix for Petitioner 3.

. This appendix tom is to be used 8S needed. Petitioner 3, or his or her representative, should complete the

parts applk:abie to him or her.

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

)fvou need more &Dace to Dfovlde additi2!!i! i1fQ!~n: use the continuation page provided at the end of

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

i ." .

: Except for signatures, please PRINT aU infom1ation clearly and neatly on the form.

Start at C -

StartatB- -

Stal1 at A

I tJ An Ef1ergy Employee (current or fonner).

I If you are: 11:1 ASu~r (of a fanner ~ Employee),

r 0 A R~n1atIve ~ a current or fonner Energy eme~1

a . No (Go to A.3) -- ---

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

Organization Information:

"A.1

JrA2

Name of Organization

Position of Contact Person .

1A.3 Name of Petition Representative: I

iA.4

I -- I City -'.J ZIp Code I . ! AS Emall Address: ~5 TeleDhone Number: ( \ - - - -- ~ 

r"'- 7 0 Check the box at left to indicate you have attached to the back of this form written authorization to

petition by the survlvor(s) or employee(s) indicated In Parts B or C of this form. An authorization

form for this purpose is provided: '

State

_I

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

-~ -~-

U.S. Department of Health and Human Services,

c.n. for DiI88I8 ConV'oI am Prewnfi<X\

Nation8II~ for ~~ Safety n~

OMB Number: C)920.0e39 ~Ire§: Q$'3;1~QO7

~dIx-P.utIoIW3

I'Speclal Exposure Cohort Petition

under tI:Ie Energy EmpI~ ~patIonaJ

, nInes8 CompenaaOOn Act

I Special Exposure Cohort Petition - Form B

B.1 Name of Survivor:

- . - - . ~

Ur JMrsJMs. rlf$t Name Middle Initial last N8ne

Social Security Number of SurvIvor:

Address of Survivor:

18.2

18.3

Sb'eet .' a . - ft" n_~ . Apt ,P.O. Box

Zip Code ---

City State

Telephone Number of Survivor:

Email Address of SUNivor:

Relationship to Employee:

8.4

'8.5 [

;8.6

, ,. --

0 Son/Daughter

0 Grandchild-

(J Spouse a Parent

t3 Grandparent

Name 'of Employee: 1~I v. 1

Mr JMrsJMs. First Name Middle Initial , Last Name . . 

Fonner Name of Employ.. (e.g., maiden namel1egal name change/other): I

,C.2

--~-

Mr lMrsJMs. First Name Middle Initial LaSt Name

Social Security Number of Employee:

Address of Employee (if living): iC.3

c.~

---

city - State - - - - - ZIp Code .

. C.5 Telephone Number of Employee: (- - -' .' J~~

I . 0 po ea. -

C.7 Employment Information Related to Petition:

I C.7a Employee Number Of known):

C.7b Dates of Employment Start

,

.C.7c Empiover Name:

End

- --

.~.7d Work Site location:

I,..

1..,.7e Supervisor's Name:

Name or Social Sealriy Number of Arst Petitioner:
~

..~

~--

U.S. Department of Health and Human Services . cenl8rsb'tMHueControl~~

National t1\SUtute for Occupetionat S.c.ty and Health

OMB: Number: 0920-0639 - ExPICM:.05f31/2007

,

I Special Exposure Cohort Petition

under 1he EnefgY Employees Q<:c:upatlonal

i Illness Cc;.T~-.aatk)n .Act

: SpeCial Exposure Cohort Petition - Fonn B I

~

- . ~

~~~~ "-

-, . ,-

-- ~-- - - -'.

,

Name or Sodal Security Number of Fk'st Petitioner:
J &RJd8r u.. Energy ~.~ Ocx:uP8tb18l c.-. for ~~ Ccx1Iro/ end ~

II~ ~8tion Ad N.aon81I~ foi' 0Ccupati0nI1 Safety 8nd Hea81

OMS Number: 0920:00639 ExpJr'es: 05/31/2007

Special Exposure Cohort Petition - Form B P8Qe'1of7

- -- - - - - - -

Generallnstructlona on Completing this Form (complete instnJctkx1s are sV86able in s sepSl8te 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 paf1s appropriate to you. If Sb!re Is mOfB

th~n ohe Detitloner. then each petitioner should complete those sections of parts A - C of the fom\ that apply

to them. Additional copies of the first two pages of this fonn are provided at the end of the form for this purpose. A maximum of three petftk>ners Is allowed. '

If vou need more sDace to orovide additional informatjgn. use the continuation page provided at the end of

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

If you have questions about the use of ~Is fonn, please cal( the following NIOSH toU-free phone number and

I request to speak to someone fn the Offk:e of Compensation Analysis and Support about an SEC petition: 11-800-356-4674. .

on Page 3

on Page 2

on Page 2

on Page 1

Start at D

.

Start at C

I a A Labor Organization.

I c~n-;;:gy E~Pbyee (~~nt;- former), If you

are: r ~ SuNtVor (ole ~r Energy Employee), Start at B

I a A Representative (of a current or fonner Energy Employee), Start at A

Are you, a contact person for an organization? a y~ (Go to A.2) 0 No (Go to A.3)

Organization Information:

A.1

1A2

Name of Organization

iA3

Position-of Contact Pe-rson

Name of Petition Representative:

1A.4

I Ciy at.-. Zip COde --

; A.5 Telephone Number: ( )-

!~~- :in~~~~:~~- - --: . I A.7 Q Check the box at le~ to indicate you have attached to the back of this tonn written authorization to . -: . -- . . -- . 

i petition by the suNivor(s) or employee(a) indicated In .Parts B or C of this form. An authorization .

Name or Social Security Number of Arst Petitioner:
I - . 	 - ­ Special Exposure Cohort Peuaon 	 U.S. Department of Health and Human Service. I a81der0. Energy En1)IO)18es o=Jpatb8 	 c.-- for Di88888 Control and PrewntiOn 

~~ nsaIon Ad. NatJon8Ilns8ute for 0ccupaG0naJ Safety n Health 

OMSNumber:0920-0639 Expires:O~1/2007 ISpecial ~ure Cohort Petition - Fonn B 	 -- PaGe2.of 7 

IB.1 Nam 

IB.2 8.3 

Str'	 Ant. P.O. Box

l,1~Y 	 ~LCt~~ 

Telephone Number o! SurvIvor: 

18.4 

!8.5 Email Address of Survivor:	 ­ (6.6	 Relationship to Employee: a spouse '»""Son/D a ugh t e r Q Parent 

Q GtWtdparent a ~dthild 

Name or Social Security Number of Flm Petitioner: 
r Special Exposure Cohort Petition U.S. Department of Health' and Human Services

, und.- .,. en.vy ~ o=Jpatk)n8i c.-. b DI88a8e ~ ~ ~Y'v.~

~ 'Cc-..,~ -li8tki., Aa Ndon8IlnsUtIM f« 0CQIP8tI0n81 Sar8I)' and HeeIh

\ OMS Number; 0920-0639 expires: 05/31/2007 Special Exposure Cohort Petition - Form Bi paqeJof7

Labor Organization Info~ation: jO.1 ,

Name of Organ IzatIon

Position of Contact Person

10.2 Name of Petition Representative:

10,3 Address of Petition Representative:

Street .' Apt' P.o. ~-

'0.4

.10.5

iO.6

City State ZIp Code

Telephone Number of Petition Representatfve: ( \ .

Emall Address of Petition Representative:

Period during which labor organization represented employe.. cov.rad by this petition

(please attach documentation): Start End

Identity of other labor organizations that may represent or have represented this cia.. of

employees (If known):

10.7

~

Name or Social Security Number of FIrst Petitioner:
--~ -

u.s. Department of Health and Human ServlcM CenteIB for C Control am Preve*" I

Nationallnstit1Jt8 for OcaIpationaf Safett and HeaIh I

OMS Number: 0920-0639 Expire$: 05/31f1.007'

\ Special exposure Cohort Petition

under the Energy Employees Ocx:tlp8t1on81

II~ Compensation Ad

I Sp~cfal ~.ur. Cohort Petition ~ F~ ~

fE.1

,";;.2

Nam. of DOE or AWE Facility: J - . LocatIon. at the Facility reJeYant to Uti. petition: It! /2 iiD.ur ~;l;1;~ llL. . - .

UstJob 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 fonn who you believe should be

Included in this class:

'.3

'p.iJ:.-:~ , -,.

1~.4

:E.5

Employment Oat.. relevant to this petition:

Start - - End

Start End

Start . - End

Is 'tt\e petition based on one or more unmonitored, unrecorded, or Inadequately monitored or

recorded exposure Incidents?: 0 Yes ~o I

IfYN, provide the date(s) of the Incldent(s) and a complete description (attach additional pages

as necessary):

-, r

,,- - -

~

- -~ ~- ---

-- ,- . 

Name or Social Security Number of Arst Petitioner:
--' --

u.s. Department of Health and Human Servicel r

Cen_forC*e88eConbolerd~

NEonaI Institute ftI' 0CQIpaIXIr\W Safety.~ Healh

OMB Number: 0920-0639 . Expires: 05/31f1.001

",,'_1,

- I

! SpeCial Exposure Cohort Petition

under the ~ Employees Occupational

l&\ess CCX1IpenIa1ion Ad,

I Sp.ecIaJ ~8ure Cohort Petition - Form B

! complete at 'east one of u,e following entries in this section by checldng the appropriate box and provkflng

,the required Informatl°':1 related to the selection. You are not required to complete more than one entry.

IF. ~ ~lIWe have attached either documehts or statements provided by affidavit that i1dfcaie that

radiation exposures and radiation doses potentially incurred by members of the proposed class,

that relate to this petitk>n, were not monitored, either through personal monitoring or through area

monitoring.

(Attacl1 documents and/or affidavits to the back of the petitk)n form.)

Describe 88 completely 88 possible, to the extent it might be unclear, how the attached

documentation and/or afI'Idavit(s) Indicate that potential radiation exposures were n~ monJkxed.

~ 1to'.:1

.I: - ~ . .

;.2 Q V We have attached either documents or statements provided by affidavit that Inddie that

radiatbn monitoring records for member$ of the proposed class have been lost, falsified, or

destroyed; or that there Is no Informatbn regarding monItoring, source, source term, or process from the site where the employees worked. .

(Attach documents and/or affidavits to ~8: back of the petition form.)

Describe as completely 8S possible, to the extent it might be undear, how the attached

documentation and/or affldavit(s) indicate that radiation monitoring records for mem~rs of the .

proposed cJass have been lost, altered illegally, or destroyed.

Name or Social Security Number of First Petitioner:
".

u.s. Department of Health and Human ServIces

Cent8f8 for Disease Cootlol and Prevention

National ~ for Occupational Safety and Health

OMS Number: 0920-0639 expires: 05/31/2007 '

Page 6 of7

Special Exposure Cohort Petition

under the EnelgY Emplo~ occupational

IUness Compensation Ad

Special Exposure ~hort Petition - Form B

F

F.4c

Q !/We have attached a report from a healU1 physicist or oUter 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 Utese documented limitations might prevent the competion of dose reconstructiOns for

members of the class under 42 CFR Part 82 and related NfOSH technical implementation guidelines. .

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

Q l/tNe have atta~ed a scientific or technical report, issued by a government agency of the

executive Branch of Government or the General Accounting ~, the Nuclear Regulatory

Commission, or th'e Defense Nucfear Facilities Safety Board. or published in a peer-revfewed

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.)

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

Signature Date

Signature Date

Notice:

Signature Date

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 weD as felony criminal prosecution and may. under appropriate

criminal provisions, be punished by a fine or imprisonment or both. I affirm that the infom1ation provided on this form Is accurate and true. .

Send this form to: SEC Petition

Office of Compensation Analysis and Support

NIOSH ~~~ "IV r v A~70 "'..1 _'-1- D_~.- &A~"" vvIYl1-tWla-r-GtftYVay,-I_-~"- A"7 --- ~,,--,-,---

Cincinnati. OH 45226

-.- -..

A

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 arKI Prevetrtion 

1Ik'l9S$Compensation~ National Institute for ~oMI Safety and Health 

OMB Number: 0920-0639 expIres: 05/31/2001 Special Exposure Cohort Petition - Form B Page? of7 

Public Burden Statement - J burden for this collectIon of information is estimated to average 300 minutes per response, Iincluding time for reviewing instructions, gathering the information needed, and completing the fom\. If you 

I have any comments regarding the burden estimate or any other aspect of this collection of information. 

I 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 

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

Persons are not required to respond to the infonnatlon collected on this tom unless it displays a currently 

number. 

Privacy Act Advisement 

accordance with the PriVacy Act of 1974, as amended (5 U.S.C. § 5528), you are hereby notified offue
 

I 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 

I assistance of the National institute for Occupational Safety (NIOSH), an Institute of the Centers for Disease 

I Control and Prevention. Information obtained by NIOSH in connection with petitions for including addftional 

classes of employees in the SEC W\11 be used to evaluate the petitiOn and report findings to 'the AdvisOlY on Radiation and Worker Health and HHS. . 

Identifiable iIlformation become part of an existing N/OSH system of r,ecords under the 

Privacy Act, 09-20-147 .Occupatlonal Health Epidemiological Studies and EEOICPA Program Records. 

are-treated ill a confidential manner, unless otherwise compeUed by law. 

. Disclosures that NIOSH may need to make for the processing of your pen"tion 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 

indMduais can provide infonnatJon to assist with the evaluation of SEC petitions; (c) contractors asslsfilg

~}:J.;..(.d).coJlabotatiQg..r.eseal:Cbel:s,JJDde[.cedainJimited..ciccumstaIL~s to CO"_tjl]ctfudber inv~c:fj~ . .

(e) Federal, state and local agencies for law enforcement purposes; and (1) a Member of Congress or a
 

Congressional staff member in response to a verified inquiry.
 

-. This notk::e applies to all forms and informational ~equests that you may receive from NIOSH in connection 

with the evaluation of an SEC petition. 

Use of the N/OSH petition forms (A and B) Is voluntary but your provision of information required by these ~- - ---'"

is mandatory for the considelation of a petition, as specified under 42 CFR Pari 83. Petitions that faU to , 

~ provide required infonnation may not be considered by HHS. 

Name or Social Security Number of FIrSt Petitioner: 
"

This page left intentionany blank.
-- --- -

U.s. Department of Health and Human Services

CeIUr8 frx DiIeaI8 CuItroI BOO Prevention

National h'Istitut8 fCK ~~ ~ WId HeaIb

OMS Number. 0920.0639 expires: 05/31/2007 . ~-~2.

special Exposure Cohort Petition , under the Energy Employe. oCQlpationai

': "bless Compef1s8Iion Act

i S~I.I ~ure Cohort Petition - FOrnI B

I . -- - - ~ - ~ - Use this Appendix for Petitioner 2-

I

I This appendix fonn Is to be used as needed. Petitioner 2, or his or her representative, should complete the

parts appl~bIe to him or her.

Refer to the Generaf Instructions on completing petitk>nef.information fr Parts A. B, or C.

If YOU need more mace to Drovide add!IiQnll mtonna~. use the continuation page provkled at the end of

the fonn and attach the ~pleted continuation page(s) to Form B.

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

I ~ An Energy Employee (C\B'rent or -- -- former). - ~~ ~ g - -

~Survivor (of a former Energy Employee), Start at B I" you are:

Start at A ~ ---' --- ---

q A'Representative (of a current 0( fOfTner Energy Employee),

a No (Go to A.3) Are you a contact person for an organization? a Yes (Go to A.2) -- 

Organization Information:

Nam~ of Organization

- -

Position of Contact Person

.3 Name of Petition Representative:

I - - -

Sb'eet ~. P.9. Box

c~- ~~ I A.8 emili Address: I -j Telephone Number: ( , ~- '

"7 Q Check the box at left to indicate you have attached to the beck ci UtI. fonn wriIen authorlzatk)n to

petition by the survivor(s) or ernpfoyee(s) indicated In Parts B or C of this tonn. An auU1orization

form for this purpose is provided. .

State

Name or Social Security Number of First Petitioner
~ , .

I 'speclal Exposure Cohort Petftlon U.S. Oepartnent of Heafth and Human Services ... Ute EI*gy EmpbyMs o=,patbnal Cec-. go Oilea8e ~ R Pre~ IIk'IesS Ca1\penaation ~ Natlonall~uta for OcaIpai!onaI Safety and Heafth

. OMS Numbef: 0920..0639 ExpIm: 05J31flOO7 I~~~- ~~hort Petition -Fonn_~ ~-~~ ~ 21

IB.1 Name.of Survivn...

- -

Last Name

1 8.2

8.3

. . - P.O. Box--

Sfre;

~r.lVle --~-~- ---

City State

Telephone Number of Survivor:

Emall Address of Survivor:

Relationship to Employee:

I S.4 85

8.6

j,..

a Son/Daughter

ID-GrandchUd

Q Parent

-

a spouse

a Grandparent

Name of ElnploveA~

~JM~w~ I lI~t J~dlIIU -Middle Tnifiar- - Last Name

Former Name ~ Employee (e.g., mak1en name/legal name change/other):

")~~E - - ---

MrJMrs./Ma. First Name fIltttflo InIfi~1 l.ast Name

Social Security Number of Employee:

Address of Employee (if living):

City -- - ~ Code

i C.5 Telephone Number of Employee: ( ; . 1C:6 -effii"~aari8-sorEffiproyii:---:::-=-::-- - , C.1. Employment Infonnatlon Related to P.ua~: I C.1a Employee Number (w known): -

IC.1b Dates of Employment - Start

. C.1c_- §~p/oyer Name: ,

State

End ~

..-

IC.7d WOft Site Location:

IC. Supervisor's Name: L.I..ti,.J{l/I1U/A/ .

Name or Social Security Number of First Petitioner:

.7.
u.s. Deparanent of Health and Human ServIces

Cen-. b' DiIe8se Con~ aid PrewmIcn ,

National Ins6I1M f« ~ Sarety and He8ah

. OMB Number: 0920-0639 expires: 0513112007 APP8ncIx - P.aa ~ 3

Special Expoaure Cohort Petition

I LN1der the ErIeIg)' E"1Jbyees QCQJpational

'~s CQ'npen8atk)n }.I;t

i ,

I Special Ex~ur. Cohort Petition - Form B

-~ --- -- . . . Us. this Appendix for Petitioner 3.

This appendix form Is to be used as needed. Petitioner 3, or his or her representative, should complete the

pans applicable to him or her.

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

. !{ YOU need more SDSce to Drovide additbna! informat!O!J_' use the continuation page provided at the end of

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

I Except for signatures, please PRINT aU Infonnation clearly and neatly on the fonn.

10 ~~~E~pIo~ (current or former), StartatC

Start at B

Start at A

; If you ale: I OASu~ (of a former Energy EmpkJ~.

I a A ~R-;P~~ (of 8 cun-ent. or former Ene.rgy Emp~).

a . No (Go to A.3)

0- --- ---

Are you a contact person for an organization? a Yes (Go to A2)

Organization Information: 1A.1

1A.2

Name of Organization

Position of Contact Person

1A.3 Name of Petition Representative: I

~A.4

--- -- I City - --- ) ZIp Code

J I' A.6 emall Address: ~§ -0 Tel.phon! Number: ( 1 - - --- - - - -- .

I A 7 0 Check the box at left to indlc8te )011 have attad1ed to U1e back of tf1js form written authorization tc

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

form for this purpose is provided. ' I .

State

Name or Social Security Number of Rrst Petitioner:
~~

. . . - -- -. -

I's~al Exposure Cohort Petition U.s. Oeparbnent of Health and Human servfce&

I und.f' h Enecgy ~ ~ C8\t.. for Dis Contrd and Pme~

I ~ Cut ~~Ion Act N8tIon8Ilndbb b' ~ ~ Safety arwJ HeaIh

OMB Number: 092000039 Expires: 05/3112007 Special Exposure Cohort Petition - Form B) App8ndIx - P~.. a

Name of Survivor. IB.1

Mr JMrs./Ms. First Name Middle Initial last Name

Social Security Number of Survtvor:

Address of Survivor:

B.2

I

18.3

--- --- Street Apt' P.O. Box

City State Zip Code

Telephone Number of Survivor:

Emall Address of Survivor:

Relationship to Employee:

1,8.4

jB.~

IB.e

t' .

Q Son/Daughter a Parent

(] GrandchildQ Spouse

Q -Grandparent

:C.1 Name of Employee:

- - - - ..~-

Mr ./MrsJMs. First Name Middle Initial Last Name

Former Name of Employee (e.g., maiden namenegal name change/gUlar): {C.2 . .. . - -

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

Social Security Number of Employ..:

Address of Employee (If living):

C.3 I

I,C.4

--- - - - - Street' Apt' P.O. b

CitY -co State -- --~~ -

i C.5 Telephone Number of Employee: 1\ .' - .:~ ~

~:8 i::miJrAaar-eiiOfErnPJ~- - - : .if

'C.7 Employment Infonnation Related to Petition:

I C.7a Employee Number (if known):

, C.7b Dates of Employment Start

. C.7c- _Employer Name:

End

Walk Site Location: :~.7d

1~.7e Supervisor's Name:

Name or Social Security Number of First Petitioner:
..

u.s. Department of Health and Human Services

cent.. b' ~ ~ and Pre~

NationaIlnsItute for ~l..~ S8fet)' BOO H88Ith

OMS Number: 0920-0638 . Expires: 05/31/2007

Special Exposure Cohort Petition

under ttle En8Igy Employees Occupational

Ihsa Compensation Ad

~ S~I.' ~u~ Cohort Petition - F~ B

Name or Social Security Number of First Petitioner:
AFFIDAVIT

State of T eDD~ County of ~~.#,~1E MAR 28-Rf!J 11 11

Due to the fact that DOE has DOt or cannot prod~ biological monitoring records for my

claim # . or - claim #

I feel that they were not monitored properly, and dosimeter badges were not being checked. -

. [~if'iOI'Ill)/of affiant]

j). .

1 nameUol-a.u;m 11:]

[addresa of qfflant} II

Subscribed and sworn to before me, this~--~I/ ~ ~ -- day of

1~ ~,20~

[Notary Seal:]

v ~ '.1<. C'\ ~ .I [si~~;~:~N~J ~u~~-

:'~'f; R It K 30 N e: ~ -

[1IQIIIe afNotary]

NOTARY PUBLIC

My commission expires:~~ ,~., ,20!£.
DEPARTMENT OF HEAL m &. HUMAN SERVICES Public H_1th ServIce

SEC Tracking Number Natk)nallnstilute for ~pation$1

Safety and Health

Robert A. Taft laboratories

4678 Columbia Parkway

Cincinnati, OH 45226-1 ~

Phone: 513-633-6825

Fax: 613-533-6826

April 29, 2005

Dear

The attachment to this letter summarizes the telephone conversations in which we

discussed with you your Special Exposure Cohort (SEC) submission, and provided

consultation to assist you in meeting the requirements of the SEC Rule. As you know

from the submission receipt letter sent to you previously, the National Jnstitute for

Occupational Safety and Health's (NIOSH) SEC Tracking Number for your submission

is:

SEC

As required in the SEC Rule (42 C.F.R. §§ 83.7 through 83.9) and outlined in the

"Instructions for Completing Special Exposure Cohort Submission - Form 8,. certain

elements are required to qualify a submission for evaluation. During the SEC

qualification phase, each submission IS carefully examined to verify that it meets the

requirements of the SEC Rule. We found that there were questions regarding your

submission that we needed to discuss with you for clarification.

A list of the issues we discussed with you is attached. For each of these items we have

included remarks to summarize our conversation. Please respond with any corrections,

if you believe such corrections are necessary, within the time frame for response on the

selected items. Any correspondence should be addressed to:

SEa l'

Office of Compensation Analysis and Support

NIOSH MS-C-47

4676 Columbia Parkway

Cincinnati, OH 45226

I

Based on the review of all of the documentation associated with your submission, we

want to inform you that the Nationa/lnstitute for Occupational Safety and Health's

(NIOSH) Office of Compensation Analysis and Support (OCAS) has completed the

qualification process for your submission, SEe" NIOSH has determined that your

submission qualifies for evaluation as a petition for inclusion into the SEC.
The evaluation process begins with this notification to you and the Advisory Board on 

Radiation and Worker Health (the Board). In addition. a summary of your petition will be 

posted on the OCAS web site (httD://www.cdc.oov/niosh/ocas). The evaluation process 

focuses on determining whether enough information is available to support dose 

reconstruction, if possible. through evaluation of existing records and documents 

currently in NIOSH's possession. In some cases, we will also request data from the 

Department of Energy I an Atomic Weapons Employer. or from other sources, balancing 

our need for information against the need for a timely consideration and evaluation of 

the petition. In cases in which we were to determine that there is not sufficient 

information to support dose reconstruction, we will also evaluate the degree of potential health endangerment. . 

When we have completed the evaluation, we will provide you and the Board with a copy 

of the evaluation report, which will be considered by the Board during its review. You 

will be invited to present to the Board during its review, should you so desire. {Your 

participation in the Board review is entirely voluntary, and does not have to be done in 

person.} After the Board makes a recommendation concerning your petition, the 

Director of NIOSH will propose a decision on whether or not to add one or more classes 

of employees to the SEC based upon your petition. The Secretary of Health and 

Human Services will make final determinations on these matters after you have had the 

opportunity to contest a proposed decision to deny adding a class to the SEC or 

concerning a health endangerment determination. If the Secretary of HHS designates a 

class to be added to the SEC, the class will' be added after 30 days, unless Congress 

acts beforehand either to reverse or expedite the decision. 

During the evaluation process, if you have any questions regarding your petition, please 

contact OCAS toll-free at 1-800-35-NIOSH (1-800-356-4674), directly at 513-533-6800, 

or by email at ocas@cdc.gov. You can also contact our contractor toll-free at 1-800­

322-0111. Additional information about OCAS and the SEC procedure can be found on 

the OCAS web site at httD:/Iwww.cdc.aov/niosh/ocas. 

SincerelyI 

~ ~1 ~~,.'i-:.

~I Larry J. Elliott, MSPH, CIH 

Director 

Office of Compensation Analysis and Support 

Attachment 

(43) Qualifies for Evaluation Letter 100 Consult (Final) -(04-29-2OOG) 
Qualification Phone Call Discussion and Aareements 

A qualification phone call was conducted by interviewer Pat K. Health Physicist Tim A., and Health and Human Services representative Rob M. on April 6. 2005 with ,. and - A detailed review of this phone cafl follows. The 

questions/statements made by the interviewer or Health Physicist are stated first and

the responses of the interviewer. Health Physicist. and the applicant are stated in italics. 

1. Clarification. You and your son have each provided separate submissions 

(separateForm 8's naming ; and ~ ~ ( as Energy 

Employees), that are identical except for your names on them. For 

simplification of our accounting and tracking purposes we intend to treat these 

as a single submission (SEC and would like to use a single Form B 

(listing both of you as applicants). 

You both agreed this was satisfactory and that will be the 

primaly point of contact for this submission. As discussed, you have 10 

days from the date on this letter to document any disagreement with 

this action or statement by writing to the address given on the second 

page of this letter. 

2. 	 Deficiency. In Section E, Item E. 1 is intended to identify the facility that you 

wish to have included in the class definition. In item E.1 you have identified 

the "Oak Ridge Laboratory" as the facility to include in the class definition. 

Based on other information included in Form B, it appears that you mean to 

identify the Y -12 Plant as the facility. 

You both agreed to change the facility designation to Y -12. As 

discussed, you have 10 days from the date on this letter to document 

any disagreement with this action or statement by writing to the 

address given on the second page of this Jetter. 

3. Clarification. 	 In Section E, Item E.2 and Item E.3, you have indicated facility 

locations and job titles/duties relevant to this submission as being "Y-12 Plant 

Oak Ridge, Tennessee" and "All," respectively. This description could be 

interpreted to mean your proposed class would include anyone who worked 

at any location at Y-12 during the time period you have included for this 

submission. 

You both agreed to list only the job titles/duties held by both 

" and The agreed upon job titles for this 

submission are Steamfitters, Pipefitters and Plumbers. As discussed, 

you have 10 days from the date on this letter to document any 

disagreement with this action or statement by writing to the address 

given on the second page of this letter. 
4 Deficiency. In Section E, Item E.4, you have included a time period of 

through The employment period that you have listed in 

Section C, Item C.7b, for was also through 

However, the employment period that you listed in Section C, 

Item C.7b, for ,- was through' The 

employment periods listed for the former Energy Employees must fan within 

the time period listed in Section E, Item E.4. 

We asked if you would nke to expand the employment time period 

listed in Section E, Item E.4 to encompass both 's and -

verified employment periods that we have on file. We 

discussed that in addition to the previously discussed dates, we had verification of Y-12 employment for . from to 

You both agreed that you would like to have the class time 

period encompass the times that III and vorlced 

at Y-12, making the class time period from through 

As discussed, you have 10 days from the date on this letter to 

document any disagreement with this action or statement by writing to 

the address given on the second page of this letter. 

5.	 Deficiency. In Section F you indicated, by marking Item F.1 as your basis, 

that you had either attached documents or statements by affidavit that 

indicate that radjation exposures and radiation doses potentially incurred by 

members of the proposed class that relate to this submission, were not 

monitored, either through personal monitoring or through area monitoring, but 

you have not attached or included any documentation or affidavit(s). 

Additionally, you included a statement below Item F.1 that failed to support 

this basis. 

On March 28, 2005, after the consultation call questions had been 

finalized, but before the actual call, the submitted a signed, 

notarized affidavit for this submission. Acknowledgement of receipt of 

this affidavit was made during the consultation call. As discussed, you 

have 10 days from the date on this letter to document any 

disagreement with this action or statement by writing to the address 

given on the second page of this letts!: 

In Summary: Based on this consultation, the worker class definition that will be 

included in this submission is: All Steamfitters, Pipefitters, and Plumbers who 

worked at Y-12 from October, 1944 through December, 1957. 

As discussed, you have 10 days from the date on this letter to document any 

disagreement with this action or statement by writing to the address given on the 

second page of this letter.