SEC. 00 -1.5 .a.. 

05-0l-19P 0 1: 

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 A 

0MB Number: 0920-0639 Expires: 10/31/2019 

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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. 

Instructions on Completing this Form: 

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

reconstruction needed for your cancer claim. 

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

For Further Information: If you have any 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. 

I 

A. NIOSH Claim Information - Complete as much information as you can in Part A. 

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

A.1 NIOSH Tracking Number (indicated on all NIOSH correspondence): 

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

B. Signature of Person Submitting this Petition - Complete Part B. 

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

of employees to the Special Exposure Cohort that would include the employee indicated by the 

tracking number or name under entry 1 above. 

Print your name below: SiQll your name below: 

First Name Middle Initial Last Name t-irst Name M1aa1e 1nma1 Last Name 

C. Please send this form to NIOSH at the address below. 

' 

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

a class of employees to the Special Exposure Cohort. Your contact at NIOSH will be available to inform 

you of the progress of your petition. 

. 

Send this form to: 

SEC Petition 

Division of Compensation Analysis and Support 

NIOSH 

1090 Tusculum Avenue 

Cincinnati, OH 45226 
Special Exposure Cohort Petition 

under the Energy Employees Occupational 

Illness Compensation Program Ad 

U.S. Deparbnent of Health and Human Services 

Centers for Disease Control and Prevention 

National Institute for Occupational Safety and Health 

Special Exposure Cohort Petition - Form A 0MB Number. 0920-0639 Expires: 10/31/2019 

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Publlc Burden Statement 

Public reporting burden for this collection of information is estimated to average 3 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 Clifton 

Road, MS-E-11, Atlanta GA, 30333; AlTN: 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 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.