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

under the Energy Employees Occupational Centers for Disease Control and Prevention
lliness Compensation Program Act National Institute for Occupationa) Safety and Heaith
OMB Number: 0920-0639 Expires: 07/31/2016

Special Exposure Cohort Petition — Form B Page 4 of 7
Proposed Defi

E.1 Name of DOE or AWE Facility:
E.2, Locations at the Facility relevant to this petition:

Walnut Cwek COP ws AKA Prlsbrere, CH

E.3 List job titles and/or job duties of energy 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:

Ail workers ty all aveas who _ worked Sor bow!
uy @ » on Pittshura. CA (AK 2) ‘eed2
Kym 1447-116 F.

&.4 Employment Dates relevant to this petition:

4

Start Mayen _1 9S
Start End .
Start End
E.5 1s the petition based on one or more unmonitored, unrecorded, or inadequately monitored or
recorded exposure Incidents?: [ Yes O No °

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



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 Program Act National Institute for Occupational Safety and Health

Special Exposure Cohort Petition — Form B OMB Number: 0820-0639 eee ger ory
Public Burden Statement

Public reporting burden for this collection of information is estimated to average 5 hours 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 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 Iliness Compensation Program Act (42 U.S.C. §§ 7384-7385)
(GEOICPA) 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 Nationa! Institute for Occupational Safety (NIOSH), an institute of the Centers for Disease
Control and Prevention. Informatién 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 and
WTC Health 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,
(©) 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 raceive 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,



DA

D.2

D3

D4
D6
D6

D.7

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

under the Energy Employees Occupational Centers for Disease Control and Prevention
UIness Cornpensation Program Act National Institute for Occupational Safety and Health

cos OMB Number: 0620-0639 Expires: gristan16
Special Exposure Cohort Petition --- Form B MB Number " age 3 of7

Conipléte'Part Di Vou area labor-.organ

Labor Organization Information:

Name of Organization

Position of Contact Person

Name of Petition Representative:

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

Address of Petition Representative:

Street Apt # P.O, Box
City State Zip Code
Telephone Number of Petition Representative: ( )

Email Address of Petition Representative:

Period during which labor organization represented energy employees covered by this petition
(please attach documentation):
Start End

Identity of other labor organizations that may represent or have represented this class
of energy employees (if known):



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

under the Energy Employees Occupational Centers for Disease Control and Prevention

iIness Compensation Program Act Nationa! Institute for Occupational Safety and Health
OMB Number: 0920-0639 Expires:

Special Exposure Cohort Petition — Form B lumber: 0 oe ey

Basis for Proposing that Records and taformation are Inadequate for Individual Dose

Reconstruction — Complete Part F,

Compléte.at least one of the following entries in this section by checking the appropriate box and providing
the required information related to the selaction. You are not required to complete more than one entry.

Fl wy Wwe 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 through personal monitoring or through area
monitaring. ,

(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.

wide ni vitormnaten are
inadeg ware fo eckymnate. the radiator
0S2 ig iniveck Joige mMenbece of “the
pte pos SCA” Class pe employees a with
au iownt ALEUNBLAL

Theo descruphon states «The Tw opeton mel
pues ¢ tudes. aad exper wae tatesins, investigations a

AkGwat WRN O2S gr Thorium beer Nin ONES, Uf
pilet sale. solvent extac#how Com phe eS aste
F.2 (] 1/\We have attached either documents or statements provided by affidavit that indicate that
tadiation 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 energy 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.



This page intentionally left blank.


Josh Kinman

SEC Petition Advice Specialist

Division of Compensation Analysis and Support
NIOSH :

4676 Columbia Parkway, MS-C-47

Cincinnati, OH 45226

“June 11, 2014

Dear Mr. Kinman,


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 Program Act National Institute for Occupational Safety and Health
was, OMB Number: 0920-0639 Expires:

Special Exposure Cohort Petition — Form B umber Pires: Page pat °

F.3 © WWe 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 0 WWe 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 energy
employees covered by the petition.

(Attach report to the back of the petition form.)
Ce ou oe

Signature o}

Saree ai
erson(s) Submitting this

All Petitioners should sign and date the petition. A maximum of three persons may sign the petition.

Signature Date"
Signature Date
Signature Date

Notice: Any person who knowingly makes any false staternent, 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 imprisanment or both. | affirm that the information
provided on this form is accurate and true.

Send this form to: SEC Petition
Division of Compensation Analysis and Support
NIOSH
4676 Columbia Parkway, MS-C-47
Cincinnati, OH 45226



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

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

. OMB Number: 0920-0639 ires: 07/31/2016
Special Exposure Cohort Petition — Form B umber Expires Page 1 of 7

eae Tae RT aT

Genefal.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 sections appropriate to you. !f 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
purpose. A maximum of three petitioners is allowed.

If you need more snace to provide additional information, use the continuation page provided at the end of
the form and attach the completed continuation page(s) to Form 8,

For Further Information: 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 Division of Compensation Analysis and
Support about an SEC petition: 1-877-222-8570, .

Labor Organization, . Start at D
if you 1 Energy Employee (current or former), Start atc
are: Survivor (of a former Energy Employee), Start at B

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

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

rs

Ai Are you a contact person for an organization? O1 Yes (Goto A.2) 0 No (Go to A.3)
A2 Organization Information:

Name of Organization

Position of Contact Person

A.3 Name of Petition Representative:

Mr/Mrs./Ms, First Name Middle Initial Last Name
Ad Address of Petition Representative: :

Street 7 Apt # P.O, Box
City State Zip Code
A5 Telephone Number of Petition Representative: ( ).

A6 Email Address of Petition Representative:

A.7  O Check the box at left to indicate you have attached to the back of this form written authorization to
by the sui loyee(s) Indicated in Parts B or C of this fo!



rd
. 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 Program Act National Institute for Occupational Safety and Health
Number: 0920-0639 ires: 07/31/2016
Special Exposure Cohort Petition — Form B OMB Nurnber: meres Page 2 of7

Survivor Information — Complete Part D if you are a Survivor or representing a Survivor,

B.1 «Name of Survivor:

Mr/virs/Ms. First Name ‘Middle Initial Last Name

B.2 Address of Survivor:

Street ; Apt P.O. Box

City State Zip Code

B.3 Telephone Number of Survivor: ( ).

B4 Email Address of Survivor:

8.5 Relationship to Energy Employee:

C1 Name of Energy Employee:

Mr/Mrs./Ms, First Name Middle Initial Last Name
C.2 Former Name of Energy Employee (c.g., maiden name/legal name change/other):

Mr/Mirs.(Mis. First Name Middle Initial Last Name
6,3 Address of Energy Employee (if living):

* Street Apt F.0. Box
City State Zip Code
C.4 Telephone Number of Energy Employee: ( )

c.5 Email Address of Energy Employee:
C.6 Employment Information Related to Petition:
C.6a Energy Employee Number (if known):
C.6b Dates of Employment: ‘ Start Eat? 145)

‘ : _ 3 Mo ‘. } P i ry
C.6c_ Employer Name: Ww neu sa We Career, CPF Ashe

C.6d Work Site Location: r ;
Yitsbura, CAC

€.6e Supervisor's Name: