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

OMB Number: 0920-0639 Expires: 09/20/2013
Special Exposure Cohort Petition — Form B Page 6 of 7

F.3. O I/We 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 Q MWe 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.)

aioe saat atasa shen aaaitine A maximum of three persons may sign the petition.

afer [4
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
Division of Compensation Analysis and Support
NIOSH
4676 Columbia Parkway, MS-C-47
Cincinnati, OH 45226

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 Centers for Disease Control and Prevention
Illness Compensation Act National Institute for Occupational Safety and Health
OMB Number: 0920-0639 Expires: 09/20/2013

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.

F.1 Q IMe 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
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 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.

Name or Social Security Number of First Petitioner


yO ha a BB ls BESSS tezzeat



Special Exposure Cohort Petition . * ALF Department of Health and Human Services
under the Energy Employees Occupational 07- 28-1 1A08: 23 Centers for Disease Control and Prevention
Illness Compensation Act National Institute for Occupational Safety and Health

: OMB Number: 0920-0639 Expires: 09/20/2013
Special Exposure Cohort Petition — Form B Page 1 of 7

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 continuation 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 Division of Compensation Analysis and Support about an SEC petition:
1-877-222-8570.

QA Labor Organization, Start at D on Page 3

Ifyou Q An Energy Employee (current or former), Start atC on Page 2

are: QA Survivor (of a former Energy Employee), StartatB on Page 2
OQ A Representative (of a current or former Energy Employee), StartatA on Page 1,

A_ Representative Information — Complete Section A if you are authorized by an Employee or

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

Al Are you a contact person for an organization? OQ Yes (Go to A.2) Q No (Go to A.3)

A.2 Organization Information:

(TAA Lo: Co. Mia, FALLS NY
Name of Oraanization

Du 2. 2 @QvEsTswAd
Position of Contact Person
A3 Name of Petition Renresentative:
Mr./Mrs./Ms. First Name Middle Initial Last Name a
A4 Address:
Ctraat Ant # P.O. Box
City State Jin Cada

A5& Telephone Number:
A6 Email Address:

A.7  Q Check the box at left to indicate you have attached to the back of this form written authorization to
petition by the survivor(s) or employee(s) indicated in Parts B or C of this form. An authorization

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

OMB Number: 0920-0639 Expires: 09/20/2013
Special Exposure Cohort Petition — Form B Page 2 of 7

B.1

B.2
B.3

B.4
B.5
B.6

= 2 nee ae

Employee Information — Complete Section C UNLESS you are a labor organization.
C.1 Name of Er *

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

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

C4 Attennn n8 tate ne nee
Sjraat “Ant # P.O. Box
City State Zip Code

C.5 Telephone Number of Employee:
C.6 Email Address of Employee:

ys — ~ 4g
C.7 Employment Information Related ' Pebition:

C7a Employee Number (if known):

C.7b Dates of Employment: Start
C.7¢ Employer Name: a
C.7d Work Site Location: Hynes Paky BLV Ni Amara Faues

Supervisor's Name:

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

. OMB Number: 0920-0639 Expires: 09/20/2013
Special Exposure Cohort Petition — Form B Page 4 of 7

Proposed Definition of Employee Class Covered by Petition — Complete Section E.

E.1 Name of DOE or AWE Facility: —r,rAwiy A At oy fare NEG. Co.

E.2 Locations at the Facility relevant to this petition:
Hy oir Park 244 Wteeargs FALRS NY

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:
Aah EM PLOYES AND Fee /R Dw eEl

E.4 Employment Dates relevant to this petition:

Stat _ / ASO End 95 6
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):

Name or Social Security Number of First Petitioner