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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
Uiness Compensation Act National Institute for Occupational Safety and Health

OMB Number: 0920-0639 Expires: 07/31/2010

Special Exposure Cohort Petition — Form B
F 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.

F.4 awe have attached either documents or statements provided by affidavit that indicate that
tadiation 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.

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29.

F.2 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 fost, altered illegally, or destroyed.

Part F is:continued on the following page.

Name or Social Security Number of First Petitioner:



SEC Petition

Office of Compensation Analysis and
Support, NIOSH

4676 Columbis Parkway, MS-C-47

Cincinnati, OH 45226


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

OMB Number: 0920-0639 Expires: 07/31/2010
Page 4 of 7

Special E: sure Cohort Petition — Form B
Proposed Definition of Employee Class Covered by Pet
E.1_ Name of DOE or AWE Facility: UnliveesrtyY 9F Roch

E.2 _ Locations at the Facility relevnt to this petition:
Roaches tea, MY

— Complete Section

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

included in this class: LAB bie tORy Te en rl

ofhe-r._Emphoyeesi .... -
10 LRAOLA HOR +,

E.4 Employment Dates relevant to this petition:

stat _ Sopt 14> — End vero Gf tds

Start End
Start End

E.5 Is the petition based on one or more unmonitored, unrecorded, or inadequately monitored or
recorded exposure incidents?: Q Yes JA No

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

Name or Social Security Number of First Petitioner: __


Special Exposure Cohort Petition
under the Energy Employees Occupational
lliness 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: 07/31/2010

Special Exposure Cohort Petition — Form B Appendix — Continuation Page

Continuation Page —- Photocopy and complete as necessary.

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necessary:

Name or Social Security Number of First Petitioner: _



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

under the Energy Employees Ocoupgtiogg-09 PO1:16 IN Centers for Disease Control and Prevention
\llness Compensation Act National Institute for Occupational Safety and Health

OMB Number: 0920-0639 Expires: 07/31/2010

Page 1 of 7

Special Exposure Cohort P:

ition — Form B

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.

lf 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 Office of Compensation Analysis and Support abeut an SEC patition:
1-877-222-8570.

QA Labor Organization, Start atD on Page 3
Ifyou WAn Energy Employee (current or former), Start atC 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 4

A. Representative Information — Complete Section A if you are a rized by an Employee or

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

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

A.2. Organization Information:

Name of Organization

Position of Contact Person

A3 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.6 Email Address:

AZ 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

‘Part B; if you are representing an Employee; go to Part

ting a Survivar, go

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
iiness Compensation Act National institute for Occupational Safety and Health

OMB Number: 0920-0639 Expires: 07/31/2010
Special Exposure Cohort Petition — Form B Page 6 of 7

£3  @ iWehave 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 O {Wehave 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.)

G
All Petitioners should sian and date the petition. A maximum of three persons may sign the petition.
4 5 6

_ 3/3 [20°
Signature . Date
Signature Date
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
Office of Compensation Analysis and Support
NIOSH
4676 Columbia Parkway, MS-C-47
Cincinnati, OH 45226

mplete the Appendix Forms for additional petition
t the end of this document. 1 Fear

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
{liness Compensation Act National Institute for Occupational Safety and Health
OMB Number: 0920-0639 Expires: 07/31/2010

Special Exposure Cohort Petition — Form B Page 2 of 7

rvivor 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: » _.
B.5 Email Address of Survivor:

B.6 Relationship to Employee: Q Spouse Q Son/Daughter Q Parent
Q Grandparent U Grandchild

in — Complete Section C UNLESS you are a lab

[om] Nama of Fmnlovee:

Mr/Mrs./Ms. First Name’ Middle Initial Last Name
C2. Former Name of Employee (e.g., maiden name/legal name change/other):

Mr/Mrs./Ms. FirstName / Middle Initial ~ Last Name
C3 Social Security Number of Employee:
CA Address of Emplovee (if living):

i —_
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 Petitio
C.7a_ Employee Number (if known):

C.7b Dates of Employment: Start Seprl94s End lu we 14 194 5
C.7c Employer Name: Vai tasty oF Rochester. Homie Eugpe 4 Project

ny LAAhetony Teoh wie ae

C.7d Work Site Location: Recheste sn, New fore

C.7e Supervisor's Name: -

erry go

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
{ness Compensation Act National Institute for Occupational Safety and Health
OMB Number: 0920-0639 Expires. 07/31/2010

Special Exposure Cohort Petition Form B Page 3 of 7
n — Complete Section D O organization.

bor Organization Informatt
D.1_ Labor Organization Information:

Name of Organization

Position of Contact Person
D.2 Name of Petition Representative:

D.3 Address of Petition Representative:

Street Apt # P.O. Box
City State Zip Code
D.4 Telephone Number of Petition Representative: ( )

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):

Name or Social Security Number of First Petitioner: