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

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

eee OMB Number: 0920-0639 Expires: 07/31/2010
Special Exposure Cohort Petition — Form B | Page 5 of 7
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.

Fut \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 throyah 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.

_ to
Lliplry EES NEVER Men aed

F.2 Q 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 lost, altered illegally, or destroyed.

Part F is continued on the foll

Name or Social Security Number of First Petitioner



SEC. fb how
fb ce of Compesssithror, Analysis ~ Support

NIOSH
4076 Columbia Farkwity , S-C- 47

Cinemnati, Ohio af5arb.


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

under the Energy Employees Occupational t Centers for Disease Control and Prevention
Mlness Compensation Act National Institute for Occupational Safety and Health
OMB Number: 0920-0639 Expires: 07/31/2010

Special Exposure Cohort Petition = Form B Page 4 of 7

Name of DOE or AWE Facility: 4 ay i
—.2 Locations at the Facility relevant to this petition:

Al |

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: i

All = laborees Tabor Supernsocs Mointers ,
arounds Dersonnel

7)
£.4 Employment Dates relevant to this petitioy i
stat ITU End Present

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

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 Petitio



F.1 Attached affidavit

| have been working on and researching information related to te claim | filed on behalf ot

, Since January 2002. In talking to aumerous people who were

employed at the DOE- Grand Junction operations office, working at the facility myself in 1976,

and looking for records, | found that employees at this facility were never monitored, including laborers

(includes who was 2 painters and grounds persons.
The dose reconstruction sent to me by NIOSH indicates thai was never monitored during

employment (1952 — 1982) at the Grand Junction operations office.

G [25 feo! O

Date

*“NOTARY PUBLIL
STATE OF COLORAD

Notary Public: Link adda’

My Commission Expires: 4-2 - y O12



06-30-10 P12:54 IN

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

OMB Number: 0920-0639 Expires: 07/31/2010
Special Exposure Cohort Petition — Form B Page 1 of 7

Use of this form and disclosure of Social. Security Number are voluntary.’ Failure to use this form or disclose
this number 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 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 cohtinuation 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 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 about an SEC petition:
1-877-222-8570. i

Start atD on Page 3
StartatC on Page2
StartatB on Page2

] Q A Labor Organization,

Ifyou Q An Energy Employee (current or former),
are: KA Survivor (of a former Energy Employee),

O A Representative (of a current or former Energy Employee), StartatA on Page 1

resentative Information — Complete Section A if you are horized by an Employee or

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

A. Are you a contact person for.an organization? O Yes (Go to A.2) _a ‘No (Go to A3)
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
A4 Address: \
Street Apt P.O. Box
\
City State Zip Code
A.5 Telephone Number: ( ) - i

A6 Email Address: .

AT OO Check the box at left to indicate you have attached to the! back of this form written authorization to
% this form, An.authe ization ,

are représehting a Survivor, go

f yor

Name or Social Security Number of First Petitione



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

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

F.3 OQ IWe 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 82 and related | NIOSH technical implementation
guidelines.

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

F.4 O Ie 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) for estimating the radiation doses of
employees covered by the petition. !

(Attach report to the back of the petition form.)
Go to.Part G.

Signature of Person(s) Submitting this Petition — Complete Section G.

1
7
|

All f three persons ma) the petition.
EF At JOIO
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 i _|
if there are additional petitioners; they must complete the Appendix F Forms for additional petitioners. |
The Appendix. forms are located at the end of this document. _— .

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 1 Centers for Disease Control and Prevention
Illness Compensation Act National Institute for Occupational Safety and Health

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

Form B
omplete Section B if you are a Survivor or representing a Survivor.

$s

pecial Exposure Cohort Petiti
vor Information —

B41

News of Garuiuan

Middle Initial | Last Name
B.2. Social Security Number of Survivor: _
BoB Pattennn Ae Crreterenes
wen. paca DA On
City State ' Zip Code ~

8.4 Telephone Number of Survivor:
B.5 Email Address of Survivor:
B.6 _ Relationship to Employee:

Employee Information — Complete Section C UNLESS you are a labor organization.

Nam "Ut
First Name Middle initiat | Last Name
C2. Former Povns 2 Racternn fo = mtidnn namalinnal nama hhannglother):
Mr/Mrs./Ms. First Name Made intai i Last Name

C.3 Social Security Number of Employee: _ —
CA Address ~£ Santana 6 titans

Street

City
C.5 Telephone Number of Employee: ( ) :

C.6 Email Address of Employee: H

C.7 Employment Information Related to Petition:
C.7a Employee Number (if known):

C.7b Dates ofEmployment: Stat _/FS2- i end _ 1982.
C.7c Employer Name: Coranck gO Unchow ¢ 2p >E ody sus aGiea - Dog
C.7d Work Site Location: Cormac. Tuwehm | Colorado

C.7e Supervisor's Name:

eee |

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: 07/31/2010

D1 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: ( !

T
D.5 Email Address of Petition Representative: i

D.6 Period during which labor organization represented employees covered by this petition
(please attach documentation): Start 1 End

D.7 Identity of other labor organizations that may represent or have represented this class of
employees (if known): i

Goto PartE. |

Name or Social Security Number of First Petitioner: