Special Exposure Cohort Petitlon 

under the Enetgy Employees Ormpatwnal 

lllneru Cwnpenretion Ad 

U.S. Deperbnent of Health and Human Servlces 

Centan for Disease Contml ard Pmwntin 

Nationel Insmuts for Ormpationel Sefely and Health 

I Mr.lMrs.lMs. hrkt Name Middle Initial & -- ~- .- Last dame I 

8.2 Social Security Number of Survivor: 

B.3 Addreaa of Survivor: . - . . 

I I - -J Apt # P.O. Box I 

/ State zip&; I A 

8.4 Telephone Number of Survivor: 

B.5 Ernail Addreaa of Survivor: 

B.6 Relationship to Employee: J4 Spouse 0 SonIDaughler 0 Parent 

0 Grandmrent 0 Grandchild 

Name of Emplyv: n 

@-. First Name Middle Initial Last Name 

Former Name of Employee (e.g.. maiden narndegai name chanwother): 

3s rv\e 

MrJMrs.lMs. First Name Middle Initial . . - .. Last Name 

Soclal Security Number of Employee: 

Address of Employee (if living): 

Street r- 

~pt # P.O. Box 

- - ciii.- -- st Ate - np Me 

Telephone Number of Employee: [ ,- 

Email Addreaa of Employee: 

Employment Infomtlon Related to Petltlon: 

Employee Number (ff known): hlnuDates of Employment: Start 14 Y 5) End 195-b - 

Employer Name: . ~ 

Work Site Location: 

I 

Supe~sot s Name: Vrl h~ 

Name or Social Security Number of First Petitioner: - 
3 List job tltles andlor job dutiessf employees included in the class. In addition, you can list by 

name any indivlduals other than petitioners ldentlfled on this form who you believe should be 

included in this class: 

.4 Employment Dates relevant to this petition: 

start !9 4S/ End 

.5 Is the petition based on one or more onitored, unrecorded, or inadequately monitored or 

recorded exposure incidents?: PNo 

If yes, provide the date@) of the lncldent(s) and a complete description (attach addmonal pages 

Name or Social Security Number of First Petitioner: 
- - . . - Section F for worker nd survivor 

Texas Chemical facilities was put at risk without their knowledge 

and consent for reason that document reveal were driven by fear of 

adverse publicity, liability and employee demand for hazardous 

duty pay. Many records have not documented of unmonitored 

expose to radiation. Employees who record of expose to radiation 

at such facilities are missing or incomplete. It is not feasible to 

estimate with sufficient accuracy the radiation dose that the 

workers received. There is a reasonable likihood that such 

radiation does may have endanger the health of the workers. Many 

workers did not have proper equipment and gear to work. They 

were not supply with this equipment to protect them ... Such 

radiation does may have endangered the health of Mr. . in 

which he have colon, bile, and lung problem. In his medical record 

show that colon has large polyps in which they did not know and 

the stalk was at fiont and to the end of the ducts. Medical record 

show that Mr. - lung and heart was deteriorates. 

-- 

- ~ visits this site and said that main expose was 

uranium dust in the recovery building. That such airborne Alpha 

participles can lodge deep in the either by ingestion or inhalation. 

From there uranium migrates over to kidney and bone can cause 

cancer long latent period of years. Uranium metal and various 

oxides such as yellow cake are radioactive and become so as the 

extracted uranium ages. 

A copy from email with :1 is enclosed. I am sent the 

medical record about the colon problem and heat and lung. You 

can request a medical record for urine test and chest X-ray full, 

Colon test and examine them to see picture in which you did not 

request fiom the hospital. 
This page let7 intentionally blank. 
Men I visited Texas Ci I waa doing an inletview that aired later a KHOU-TV in Houston wth 

air pwsonali and ( 86 producer. I did not mms to write a mmrt of eny kind. I did spena awur nw 

videotaping comments about Tm City and EEOICPA in general. I be willino to sham some of. 

tape he remrded with you. He may not have any ban-, however. Your Reprrsentstive, 

introduced a CongmMional Hwse bill caw the EEOIC ImDrwement Ad of 2006 that bied to add aweraga fo 

site ~ ~~ mntractum. ~~~ ~ ~-~- - I know ~~ -~ mnw ---I% at Tm Cllv Chemical wm such mntrectors and cannot aet mmnsat 

the present law. I sent a kkr & him to &d to the Deparbnent of ~abw and I belibe ha di that 

hear DOL's response andam intemsted in what they had to say. Specifically, we asked Labor to em theca 

pet?vd for the uranium 'Recovery Bullding' workers at Texas City Chenicak. Right now, I am helping to sel up 

Oumtach meetina with NlOSH for Blcdmn Chemical in Jdiet IL. Thev also ehtmld uranium for the AEC fro1 I phosphate mck Gmi~ar to the recovery pmcess at Texas city ~hemicai. 

w- umbm %p? MOW vl hns a tough problem in calculating Texas City Chemical radial 

because of the lack of radiation monitoring by film badges, breathing me sampling, urine bloassays, or mbie 

sampling in the Recovery Building. The hardest job will be to get NlOSH to me fornard on doing dose rm& 

Rnaliy, me Texaa CHy Chemicsl group should enmurage , mnbd me is she wants help dl 

EEOICPA claims or pefhaps in inikting a Spaual Expsun, Cohort (SEC) applicstion for Texas City Chemical. 

prssanUy am guiding one of those for the former Dow Chemical Plant in Madison. IL. 

I In a message dated 12/18iW 8:19:01 PM. 

hdb, We am talking about the mW when you can out b the sits - 

in Tern Chembl. We am still have problem with the company about 

the application and you eWn the slte and we never mueved a 

I mpxb on your find of the terns site. Please tell me what vou found I about the kalffles and how employee was exposed. rnD& a lot 
(Attach report to the back of the petition form.) 

.4 lMle have attached a scientific or technical report, issued by a government agency of the 

of monloring or the destruction or loss of records) for estimating the radiation doses of 

employees covered by the pettiin. 

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. I affirm that the informatio 

provided on this form is accurate and true. 

end this form to: SEC Petition 

Name or Social Security Number of First Petitioner: 
Special Exposure Cohort Petition U.S. Department of Health and Human Services 

under the Enwy Employees Ocwpmionsl Centera for Disease Contml and Pmventbn 

lllne~s Cornpenration M Nation& lnstauie lor Ocwpational Safety and He& 

OM6 Number: 09200839 Expires: 05/31R007 

Special Exposure Cohort Petition - Form B Page 7 of 7 

Publlc 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 yw 

have any comments regarding the burden estimate or any other aspect of this collection of information. 

including suggestions fa reducing this burden, send them to CDC Reports Clearance Officer, 1600 Clfion 

Road. MSE-1 I, Atlanta GA. 30333; ATTN:PRA 0920-0639. Do not send the completed petition form to this 

address. Completed petitions are to be submitted to NlOSH at the address provided in these insimctions. 

Persons are not required to respond to the information collected on this form unless l displays a currently 

valid OM0 number. 

Privacy Act Advisement 

In accordance with the Privacy Act of 1974. as amended (5 U.S.C. 5 552a). you are hereby notified of the 

following: 

The Energy Employees Occupational Illness Compensation Program Act (42 U.S.C. 55 7364-7385) 

(EEOICPA) euthorizes 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 lnstitute for Occupational Safety (NIOSH), an lnstitute of the Centers for Disease 

Control and Prevention. Information obtained by NlOSH 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 Waker Health and HHS. 

Records containing identifiable information become part of an existing NlOSH system of records under the 

Privacy Act, 09-20147 'Occupational Health Epidemiological Studies and EEOICPA Program Records. 

HHSICDCINIOSH.' These records are treated in a confidential manner, unless othemise wmpelled by law. 

Disclosures that NlOSH may need to make for the processing of your won or other purposes are listed 

below. 

NlOSH 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 NlOSH so that these 

individuals can provide information to assist with the evaluation of SEC petitions; (c) contractors assisting 

NIOSH; (d) collaborating researchers, under ~rlain limited circumstances to conduct further investigations; 

(e) Federal, stata 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 NlOSH in connection 

wlh the evaluation of an SEC petition. 

Use of the NlOSH petition forms (A and 0) 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 Secunty Number of First Petitioner: 
Special Exposure Cohort Petition 

under the Energy Employees Ocwpalional 1 Illness compensalion M 

U.S. Department of Health and Human Services I 

Centers for Daeare Control and Prevenllon 

hatlona tnstltde fa' Occdpal ona Safety en0 H6a.m 

1 OMB Number: 092C-0639 Exoires: 05/31/2007 1 

Anach to Form B If necessary. 

Name or Social Security Number of First Petitioner: 

... .,-- =. --= 

. .. 

- 

B(1 .thrnpghu&: the siqmid =oh and in the deafp was 2 lsng area of spasm about 10 to 32cm. Fr? 1 

The-.%~. a rou+eci radlol.ca& f~lling defect M .+Fe 

., , se:-(;PsaP: s~rpsked to lrprre a stalk on it. On ,- of t 

,fflarra:$g;,,$%e:sliw+ thme '&o a 'mtbcn lwqe radio 

frlah~: ~:"nv?& thak ~$PG~Y& ?:D have R atasz m~z. Tnmn 

wera Wtk mrn on the porr'c-miicuarim fib. 

, ' ,. ..,;,.T'~ai ', 

Tmpressia~r Spaem of the calm with what appears to 330 two :a':'..~i...i ... .;, 

polyps with sta3ks on themt or.sn&kd.e.a~n&Ln9' colon 8nG 

~e in the signold. I woufieca-saenc: a doubla air contrast 

barium en- f3r verififation.