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: 05/31/2007
Special Exposure Cohort Petition — Form A Page 1 of 2

Use of this form and disclosure of Social Security Number are voluntary. Failure to use this form or disclose
this number wil! 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 ciaim.

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

For Further Information: If you have questions about these instructions, please call the following NIOSH
toll-free phone number and request to speak to someone in the Office of Compensation Analysis and
Support about an SEC petition: 1-800-356-4674.

A NIOSH Claim Information — Complete as much information as you can jn Section A.

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

A2 Print Name of Enerav Emolovee for whom this claim was filed:

Mr/Mrs./Ms. First Name Middle Initial 7 Last Name
A3 Social Security Number of Eneray Employee for whom this claim was filed:

Signature of Person Submitting this Petition — Complete Section 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 vour name below: Sian vaur name below: n

| First Name~ Middle Initial Last Name” First Nafne ~~ Middie Initial’ Last Name

Cc 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 yaur petition.

Send this form to: SEC Petition

Office of Compensation Analysis and Support
NIOSH

4676 Columbia Parkway, MS-C-47
Cincinnati, OH 45226

Name or Social Security Number of First Petitioner:



Special Exposure Cohort Petition
under the Energy Employees Occupational
liiness 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: 05/31/2007
Appendix — Petitioner 3

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

Special Exposure Cohort Petition — Form B

Name ofjemenr _@ .
First Name Middle Initial Last Name
B.2 Social Security Number of Survivor:
B3 Address of Survivor: a —\ -_
| ~ * Ant # DTY Box
City * y State To Cade
B.4.__ Telephone Number of Survivor:
B.5 Email Address of Survivor:
B.6 Relationship to Employee: OQ Spouse MM Son/Daughter Q Parent
Q Grandparent QO Grandchild

C.1 Nay
FirstName CO Wore rasta
C2. Former Name of Employee (e.g., maiden name/iegal name change/other):
SkKmeE

MrJMrs/Ms. - First Name Middle Initial Tast Name
C.3 Social Security Number of Employee: _
C4 Address of Employee (f living):

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): 7 ] % x ?
C.7b Dates of Employment: Start gD End 2 2
C.7c Employer Name:
C.7d Work Site Location: __ i iddli E Le Von ry Lew) ———___ _
C.7e Supervisor's Name: |

Sign Part G

Name or Social Security Number of First 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 Act National Institute for Occupational Safety and Health
OMB Number: 0920-0639 Expires: 05/31/2007

Special Exposure Cohort Petition — Form A Page 2 of 2
Public 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; ATTN:PRA 0920-XXXX. 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.

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
liiness Compensation Act National Institute for Occupational Safety and Heaith

OMB Number: 0920-0639 Expires: 05/31/2007
Appe! Petitioner 2

dige

etition — Form B

ure of a

Special Exposure Cohort P

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.

ee

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

If you are: | Q A Survivor (of a former Energy Employee), Start at B

OA Representative (of a current or former Energy Employee), Start atA

A_ Representative Information — Complete Section A if you are authorized by an Employee or
Survivor(s) to petition on behalf of a class.

Are you a contact person for an organization? O1 Yes (Go to A.2) Q No (Go to A.3)
A2 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

A5 — Telephone Number: ¢__ )
A6 Email Address:

A.7 1 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 represent 0 to Part B; if you are represent

Name or Social Security Number of First Petitioner: _

x \


B.4

B.2
B.3

B4
B.S
B.6

C.1

C.2

C.3
C4

C5
C6

C7
C.7a

C.7b
C.7c
C.7d

C.7e

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

| rts

OMB Number: 0920-0639 Expires: 05/31/2007
Appendix — Petitioner 2
Survivor Information — Complete Section B if you are a Survivor or representing a Survivo

ce
Mr./Mrs./Ms.  FIrstNal
Social Security Number of Survivor:

Adrirass of Survivor:

City _ State Zip Code
Telephone Number of Survivor

Email Address of Survivor:

Relationship to Employee: Q Spouse & Son/Daughter QO Parent
Q Grandparent Q Grandchild

Employee Information — Complete Section C.

Name of Epontowne: a

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

Same
Mr/Mrs./Ms. First Name Mint rere see
Social Security Number of Employee: /

Address of Employee (if we ad

Street Apt # P.O. Box

City State Zip Code
Telephone Number of Employee: hon ma

Email Address of Employee:

Employment information Related to Petition:
Employee Number (if known): _ a 7

Dates of Employment: Start

Employer Name: Alene fneesy Conmioon Pa) oP Qi iP
Work Site Location: _My' dds Low!) Dowae.

Supervisor's Name: 1

Sign Part 6 of the origina’ petition.

Name or Social Security Number of First Petitioner:

=-o6

i)
no
1
2



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

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

OMB Number: 0920-0639 Expires: 05/31/2007
Special Exposure Cohort Petition — Form B Appendix — Pet er 3

FS

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.

{f 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.

0 An Energy Empioyee (current or former), Start at C
If you are: EG Survivor (of a former Energy Employee), Start at B
OA Representative (of a current or former Energy Employee), Start atA

A Representative Information — Complete Section A if you are authorized by an Employee or
Survivor(s) to petition on behaif of a class.

A‘ Are youa contact person for an organization? Q Yes (Go to A.2) O No (Go to A.3)

A2 Organization Information:

Name of Organization

Position of Contact Person

Ad Name of Petition Representative:

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

A4 _ Address:
Street Api # P.O. Box
City “State Zip Code

A5 — Telephone Number: ( ) =
A6 Email Address:

AZ QO 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 orovided.

Name or Socia! Security Number of First Petitioner: