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

OMB Number: 0920-0639 res: 05/31/2007
Special Exposure Cohort Petition — Form B © Page 7 of 7

Public Burden Statement

Public reporting burden for this collection of information 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 Clifton
Road, MS-E-11, Atlanta GA, 30333; ATTN: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 fo 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 Itiness Compensation Program Act (42 U.S.C. §§ 7384-7385)
(EEOICPA) authorizes the President to designate additional classes of employees to be inclided 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
Contro! 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

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
Congressiona! staff member in response to a verified inquiry.

This notice applies to alt 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 P



Speciat 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 B Page 6 of 7

F.3 UO INWehave 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 (© INWehave attached a scientific or technical report, issued by a government agency of the
Executive Branch of Government or the General Accounting Office, the Nuctear 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 tack
of monitoring or the destruction or loss of records) for estimating the tadiation doses of
employees covered by the petition. .

(Attach report to the back of the petition form.)
: >” Goto Part

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

All Pe ee persons may sign the petition.

[R-O2- _2O00b
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

= ————

tf there are additional petitioners, they must complete the Appendix Forms for additional petitioners.
The Appendix forms are located at the end of this document.

Name or Social Security Number of First Petition



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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
flliness Compensation Act Nationa! institute for Occupational Safety and Heaith

OMB Number. 0920-0639 Expires: 05/31/2007

Special Exposure Cohort Petition — Form 8 Page 5 of 7

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 tequired to complete more than one entry.

F.1. @ WWehave 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 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.

F.2  Q 1I/Wehave 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 following page.

Name or Social Security Number of First Petition


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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
iliness Compensation Act National Institute for Occupational Safety and Health

OMB Number: 0920-0639 Expires: 05/31/2007
Special Exposure Cohort Petition — Form B Page 2 of 7

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

Te~U4-JVOrPOT:05 RCVD

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: ¢ ) 2

B.S Email Address of Survivor:

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

Go to Part C

Employee Information — Complete Section C UNLESS you are a labor organizatio.
- C.1 Name of Emplovee:

irst Name Middle Initial Last Name
C.2 Former Name of Employee (e.g., maiden name/legal name change/other):

Mr/Mrs./Ms. First Name idelte Initial Last Name
C.3 Social Security Number of Employee:

C.4 Address of Emplovee (if living):

City State Zin Code uae
C.5 Telephone Number of Employee
C.6 Email Address of Employee:

C.7 Employment Information Relate: ro
C.7a Employee Number (if mone

C.7b Dates of Employment, ABD End oe Ss
C.7e Employer Name: sumed) NuchenR MaTeRials ¢ EQuibmedT CORP.
C.7d Work Site Location: Ato LLo , PA

C.7e Supervisors Name:

Go to Part E.

Name or Social Security Number of First Petition


Page 2 of 2

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11/27/2006


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 Health

OMB Number. 0920-0639 Expires: 05/31/2007
Special & posure Cohort Petition — Form B Page 4 of 7

Proposed Definition of Employee C!ass Covered by Petition — Complete Section E.
E.1 Name of DOE or AWE Facility: AR MATER

E.2 Locations at the Facility relevant to this petition: Avo
ALL hocaqiors oF TRE NUMGC APALO S\TE

UL0, PA.

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:

ALL EMPLNees of NUMEC AT THE APorLO S\TE

E.4 Employment Dates relevant to this petition:

Start \AS7 End _ 1963
Start End
Start End
E£.5 Is the petition based on one or more unmonitored, unrecorded, or inadequately monitored or
recorded exposure incidents?: Yes Q No

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

Basis FoR TWS  VYettTion
NioSWSs FAILVRE To PRodvce A sire fRoFILE
G NEARS AFTER The EEoichA LAW WAS ENACTED tah
The NEAR 3.090 Peas Busty WAS At
OUsER TIME LIMIT,
Niosh WAS NOT Met its Commitment To
ConGRESS To HAVE A Sifé PROFILE ComPLeten
RY MARCH 2.008,

~~ Go to Part F.

Name or Social Security Number of First Petition


Special Exposure Cohort Petition US. Department of Health and Human Services
under the Energy Empioyees Occupational Centers for Disease Control and Prevention
finess Compensation Act National institute for Occupational Safety and Health
OMB Number. 0920-0639 Expires: 05/31/2007

Special Exposure Cohort Petition — Form B Appendix — Continuation Page

Continuation Page — Photocopy and complete as necessary.

TARE Nomec Sixe CROFiLé WAS De MARCH 2005 |
\é RECORDS ARE Not AVAICABLE 1S A TIMELY
MANNER — TREN IT 1S NOY FERS\BLE To
ESTIMATE DOSE. THE NioSAW DigecroR Has TRE
DISCRETION, UNDER THE SEC Guidance , To
REQUIRE WacimMentTs AND if NOT AVAILABE J.)
Co DANS —

FOAPPROVE—SEC—on-THS BASS

- <a — oe

Attach to Form B if necessary.

Name or Social Security Number of First Petitioner. —_—.