PAGE 01 

09-1d-J /fJ?. q4 ',r,,, 

Exposure Cohort Petition u.S. 0epa&-in't of Health and Human Services I 

under the Enecgy Employees ~pational Centers for Disease Ccntml and Preventlm 

Illness Compensation Act bti-1 tnstiwte for Occu~atiOnal Safely and Health 

OMR - . . . - Nurnher: . . -. - - 09209639 Expires: 05/3VZ007 

Speclal Exposum Cohort Petltion - Form A Psge 1 of 2 - 

., ~~~~~~l~~~~day~~~&.&:~:$~~~ty kwbw a~volun~&-Fatluieto us@ Wbh of'discl-. 

. , .~ .thb number:wlll , . . . . .nd.)BBult'iithe . denblot my tight, benen:, or prlvllegr to whldr'you,@ay be entitled. . ... . .. . ,..,.., ... " .. . . ~ 

. . 

lnstructlons on Completing thls Form: 

I You should use this petition form only if NlOSH has reported to you in writing that it cannot complete the 

dose reconstruction needed for your cancer claim. 

IAII other petitioners should use Petition Form B to submit a petition to NlOSH. 

I Foc Further Wormation: If you have questions about these instructions, plaase call the fdlowing NlOSH 

toll-free phone number and request to speak to someone in the Office of Cornpensetion Analysis and 

Support about an SEC petition: 1-800-3564674. 

I A.l NIOSU T rarkinn Number {ind~cafd on all NlOSH carrespondence): 

I . _ ._. --_ 

A.2 Print Name of Energy Employee for whom thisflalm was filed: .,, d A n 

Mr.lMn.1~~. First Nan$ Middle Initial Last &me ,___. - . - - 

A.3 Soclal Security Number of Energy Employee for whom this claim was filed: . -. 

tracking number or name under entry 1 above. 

Sign your name below: 

\- ~ - 

I I 

First Name Mlddle lnttlal Last 'Name First Name - Middle lnlal Last Name 

Once NlOSH receives this form. Me U.S. Department'd Health and Human Servlces wlll consider adding a 

class of employees to the Special Exposure Cohort. Your contact at NlOSH will be available to inform you of 

the progress of your petition. 

Send this form to: SEC Petition 

Ofbe of Compensation Analysis and Support 

NlOSH 

I'nGL; led cop1 

4676 Columbia Parkway, MSG47 -t~ +r~d -, . Cincinnati. OH 45226 - -.- - 

- - - ' . Name or Social Securily Number of First Petitioner. - .- 

U 
~pecial Exposure Cohort Petition U.S. Department af Health and Human Servlccni 

under the Energy Employees OEwpational Centers fw Disease Control and Prevention 

Illness CompensaUon M National Instilub for Ocapatioml Safety and Health 

OM6 Number: 0920-0639 ~xpires: 05/31/2007 

Speclal Exposure Cohort Petition - Form A pap20f2 

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 -zommentS 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 Clion 

Road, MSE-11. Atlanta GA, 30333: Am.PRA 092C-0539. Do not send the completed petition form to this 

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

Persons are not required to &pond to the information collected on this form unless it displays a currently 

valid OMB number. 

Prlvacy 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 Occupz$iokl Illness Compensation Program Act (42 U.S.C. $5 7384-7385) 

(EEOICPA) authorizes the President to designate additional classes of employees to be included in the 

Special Exposure Cohort (SEC). EEOICPA authgrlzes 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. lnformation obtained by NlOSH in connection wth 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. 

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

Privacy Act, 09-20-147 Wccupational Heath Epidemiologicar Studies and EEOICPA Program Records. 

HHSICDCINIOSH.' These records are treated in a confidential manner, unless otherwise compelled by law. 

Disclosures that NlOSH may need to make for the processing of your petiion 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 thest? entities to 

retrieve records required by NIOSH; (b) identifled witnesses as designated by NlOSH so that these . . 

individuals can pmvide information to assist with the evaluation of SEC petitions; (c) coIltfaC&orS assisting 

NIOSH: (d) collaborating researchers, under certain limited circumstances to conduct f~rVler investigations; 

(e) Federal, atate and local agencies for law enforcement purposes; and (9 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 ~0rmedon 

with the evaluation of an SEC petition. 

Use of me NlOSH petiion fops (Aand B) is voluntary but your provision of information requid by these 

forms is mandatoryfor 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. 

C 

Name or Social Seculity Number of Fimt Petitionec A . . . . . - - i 
>pecial Exposure Cohort.Pet'd0n U.S. Department of HeaIfb end Human ~ervleesl 

anters for ~lsease Controland PMntion 

under the ~nergy Emplaw Occupational N&~~~( ~~yfiule for ~aupational Safe~l and Health 

lllnass CornpeW.atlon Act OMS N,,~W. 092%06?.9 Expires: O5/3I/2007 

peg8 1 of 2 

special mposure Cohoit Petittan -Form A .,, ..,? ..,,,,.,/ ;..y. <. .- ,. 2 .? '. -. . . Sr alun&Z.M~um~ & tflii to+or ~&!OSB :. :~~~:,;;~~tifd~@&ddi~&~~~f;$d~$($$p~~~@C~~PP~ 

~;~~~~&~~~~~.~~~bpnn a ~TLGI~ .. to .wN.ch . YOU u""ba e!tlr. 

.' :. . . , . ,, ; , , ;. . .' . . . . . . :,> 

Instructions on Completing this Form: 

I You should use this petition form only if NIOSH.has reported to you in writing that it cannot complete the 

dose reoonstr~clion needed for your cancer claim. 1 

All other petitioners should use Petition Fom B to submit a petitloo to NIOSH. I 

For Further Information: If you have questions about these instructions, please call the following N~OSH 

toll-free phone number and request to speak to someone in the Office of Compensatlon Analysis and 

Slrppoe about an SEC petition: 1800-3664614. 

A.l NlOSH Tracking Number (indicated on all NlOSH correspondence): - - -- - <.r . .- - , 

A.2 Print Name of Energy - Employee for whom thbflaim was filed: A 4. 

I -. -" 

Mr.lMrsJMs. Fimt ~a& ~iddje Initial Last @me 

A.3 Soclal Security Number of Energy Employee for whom mls claim was filed: 

Prlnt vour name below: I .. ,61gn your name below: I I - vimt Name Middle Initial Last Name 

Once NlOSH receives this form. the U.S. Department of Health and Hu,man Services will consider adding a 

class of employees to the Special Exposure Cohort. Your contact at NlOSH will be available to inform you of 

the progress of your petition. 

Send this form to: SEC Petition 

Office of Compensation Analysis and Support 

NIOSH 

4676 Columbia Parkway, MS-C-47 -. - . Cincinnati, OH 45228 - ~.- - 

- - -- Y- d ,\ . Name or Social Secutity Number of First Pei~Noner: 

X * -. - 
09/28/2007 07: 40 PAGE 02 

Name or Soda1 Security Number of First Petitioner: A .. . - - 

I 

+cia1 Exposure Cohort Petltion U.S. Department of Health and Human Services 

under the Energy Employees Ocwpational Can- for Disease ConWl and Prevention 

Illness Compensation Ad Nabnal lnsti~te for Occupetionel Safety am Heam 

OM5 Number: 0920-0639 Expires: 05/31/2007 

SpecIal Exposure Cohort Petltfon - Form A Page2of2 

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 CM: Reports Clearance ORcer, 1600 Clion 

Road, MS-E-11, Atlanta GA, 30333; AlTN: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 instructions. 

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

valid OMB number. 

Prlvacy 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. $1 7384-7385) 

(EEOICPA) authorizes the Presldentto 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 Centen for Disease 

Control and Prevention. Information obtained by NfOSH in connection with petitions for including additional 

classes of employees in the SEC will be used to evaluate Me petition and report findings to the Advisory 

Board on Radiation and Worker Health and HHS. 

Records containing identifiable information become paR of an existing NIOSH system of records Under the 

Privacy Act, 0420-147 'Occupational Heaith Epidemiological Studies and EEOICPA Program Records. 

HHSICDCINIOSH.' These records are treated in a confidential manner, unless otherwise compelled by taw. 

D~sclosu~s that NIOSH may need to make for the processing of your petition or other purposes are listed 

below. 

rJlOSH may need to #isclose personal identifying lnformatlon 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) identifed witnesses as designated by NIOSH so that these 

individuals can provide information to -i$i with the evaluation of SEC petitions; (c) cantracton assisting . 

N(0SH; (d) collaborating researchers, under certain limited circumdances to conduct further investigations; 

(e) Federal, state and local agCncies 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 p&on forms (A and 8) is voluntary but your provision of information required by these 

forms is mandatory for the oonsideration of a petltion, as specified under 42 CFR Part 83. Petiions that fail to 

provide required information may not be considered by HHS. 

-