.. I (!9 i Special Exposure Cohort Petition j' under the EneIgY Employees O<x:upational

Ilk\ess C<M1'4)en88tion Pd

U.S. Department of Health and Human Services

Cen1efI for [Xseae Contini aOO ~

NatjO(1aIlnstikde f« ~-~t Safely and He8!h

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

PaQe1rA7 : Special ExpOSure Cohort Petition - Form B

: General Instructions on Completing this Form (complete instructions are available in a separate packet): .. , Except for signatures, please PRINT an information clearly and neatly on the fonn.

. Please read each of Parts A - G in U\is fonn and complete the parts appropriate to you. Jf_ttlere is more

i bn one ~2D§!. then each petjfK)ner should complete those sections of paJ1s A - C of the form that apply

: to them. AdditkJnal copies of U\e first two pages of this form are provided at the end of the form for this purI pose. A maximum of three petitioners is aUowed.

I

tf YOU need more soace to oroykje add;tJonal information. use the continuation page provided at the end of

the form and attach the completed continuation page(s) to Fonn B.

I

~ If you have questions about the use of this fonn, please caD the following NIOSH toIl-free phone number and

I request to speak to someone In the Office of Compensation Analysis and Support about an SEC petition:

: 1-800-356-4674.

lOA labor Organizaoon. Start at 0

! a An Energy Employee (current or fanner), StartatC

on Page 3

on Page 2

on Page 2

on Page 1

If you

are: 0 A Survivor (of a former Energy Employee), Start at B

I [J A Representative (of a current or former Energy Employee), Start at A

! A.1

A.2

Are you a contact person for an organization? 0 Yes (Go to A2)

Organization Information:

CJ No (Go to A.3)

:A.3

Name of Organization !

~ n__I&S_- -~ ,,_-&-..£ n - =

Position of Contact Person N

~

Name of Petition Representative:

~

Mr JMrs./Ms. FIrst Name Mkidle Initial L88t Name 3-

Add,...: . "', - ~

Street Apt, P.O. Box

IA4

IA5 IA6

,A7

- -.

City State ZIp Code

Telephone Number: L - ) -

Emall Address: - - -

I:J Check the box at left to indicate you have at1ached to the beck of this form written authorization to

petition by the surviwr(s) or employee(s) tndicated in Parta B or C of this fonn. An authorization

Name or Soda! Security Number of First Petitioner:
ISpeclaJ Exposure Cohort Petition"

I under the Energy Employees Occupational,

Illness ~alion Act

u.s. Department of Health and Human ServIces

Centecs for Diseaae ConWl.8nd Prevention

NationallnatiWte for ~!~-~nal Safety and Health

OMB Number: 0920-0639 Expires: 05/31/2907

P-.2of7 I Special Exposure Cohort Pe6tion - Form B

!8.1

1 8.2

8.3

Name of SurvIvor: . . " -

Mr .l.MrsJMs. First Name Middle Initial Last Name . Social Security Number of Survivor: ~ ,

Address of Survtvo~

Street Apt, P.o. Box

City State ZIp Code -

Telephone Number of Survivo~ I , -- . Emait Address of Survivor:. ..' 

Relationship to Employee: 0 Son/Oaughter

0 Grandchild

a Parent . Q Spo'use

CJ Grandparent

IC.1

last Name

IC

Ic

.3

,.4

Zi .~ -

r - .. L

I citY -- -- - state. - --

/ ~.5 Telephone Number of Employee: :

I C.~ Em~" Address of Employee:

,=.7 Employment Intonnatlon..Related to p~tlHnn~

i C.78 Employee Number (if known): -

I C.7b:l.Oates of Employment: I ;

I C.7c Employer Name:

I "",7d Walk Site Location:

Start . . - . End - ~.~ ~

~ .e: f\;' /V~ S ~ ~... tJ4-s-t ~ _.It' Cd "'"-Po -~

\£-,1- l"1J..c..ff l?;..l1~." TN'. -"

1C Supervisor's Name:

Name or Social Security Number of First Petitioner: ' ~

.
10 -~ ---

Special Exposure Cohort Petition I '-'\der lie Energy ~ o~ ~

I~~ 1Sation Act

u.s. Department of Health and Human Services

Centefl b' ~ Control and ~

National Institute fOC' OccJpationaf safety and HeaIt\

OMS Number: 0920-0639 Expim: 05/31/2001 Special EXpOSure Cohort Petition - Fonn 8

'0.1 Labor Organization Information: \

Name of Organization

10.2

Position of Contact Person

Name of Petition Representative:

10.3 Address of Petition Representative:

,

,0.4

r

1'0.5

D.S

10.7

_:

city State Zip Code -

Telephone Number of Petition Representative: L }-

Email Address of Petition Representative:

Period during which labor organization represented employees covered by U\1a petition

(please attach documentation): Start End

Identity of other labor organizations that may represent or have represented this class of

employees (if known):

Name or Socia( Security Number of First Petitioner:
- -- - -

, $peclaJ Exposure Cohort Petition

under the EtIefgy Employees Ocx:upatlonal

r I~ Compensation Act

u.s. Department of Hearth and Human Services

CentefS f« Disease ~ and Prevention

Nationallnsbte for 0caspd0naI Safety and Healh

OMS Number: 0920-0639 Expif8S: 05/31/2007

~4~7 I S~iaJ Exposure Cohort Petition - Form B

x

r

- -- - --- - I E.1 . Name of DOE or AWE Facility: .' . ..'

I E.2 .

IE.3 Ust job titles and/or job duties of employees included in the class. In addition, you can list by

name any individuals oUIer than peUtioners identified on thrs form who you believe should be

~~~ed in this class: ~'Jv:t ~ 1: /) ! Y. .

-IE..

IE.5

Employment Dates relevant o this petition: . Start - - End ~

Start End

S18ft End ~- --

Is the petition based on one or more unmonitored, unrecorded, or inadequately monitored or

recorded exposure incidents?: a Yes ~ No

If yea, provide the date(s) of U1e incident(s) and a complete description (attach additional pages

as necessary):

Name or Social Security Number of First Petitioner:
U.S. Department of Health and Human Services I

Centers for Oisease Control and Pre~Uon

Nationallnstilute fCX" ~I Safety and Health

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

PaaeI~7

~-

I under the EMIgy EmpioYell ~~~

lanesa CompensaGon Act

i S~ial expOSure Cohort Petition - Fonn 8 -

Complete at teaat one of the fofk>wing entries in this section by checking the appropriate box and providing

I the required information related to the selection. You are not required to complete more than one entry.

IF.1 'I: !;We have attached either documents or statements provided by affidavit that indicate that

I radiaOOn exposures and radiation doses potentially incurred by members of the proposed class,

I that relate to this petition, were not monitored, either through personal monitonng or through area

monitoring.

(Attach documents and/or affidavits to the back of the petition fOmt.)

Describe as completely as possibte, to U\e extent it might be unclear, how the attached I d~~n~ !"d(°r affidavit(s) Indicate that potential radiation exposures were not monitored.

IF.2 (:] 1/ We have attached either documents or statements provided by affkiavit 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 bst, altered Ulegally. or destroyed.

Name or Social Security Number of First Petitioner:
I Special Expoaure Cohort Petition

under the Energy Employees Occupatbna/

Illness ~tion Ad

-

U.S. Department of Health and Human Services

Centelw for DiIe88e ContoI 8nd PrewntiOn

National Institute for Occupeticx'lal Safety and Hea~ i

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

p.qeldT

; Special Exposure Cohort Petition - FOm\ B

IF.3

-.

F.4

. a lM'e have attacl1ed areport from a health physicist or other individual with expertise in - - - - - 

radiation dose reconstruction documenting the Nmitations of existing DOE or AWE records on

~diation exposures at the faciRty, as relevant to the petition. The report specifies the basis for

. bi(ieving these documented Umitations might prevent the completion of dose reconstructions for

membefS of the dass under 42 CFR Part 82 and refated NIOSH technical implementation

guidelines.

(Attach report to the back of the petition form.)

a JJWe have attached a scientific or technical report, issued by a government agency of the

Executive Branch of Govemment or the General Accounting Office. D1e Nuc)ear Regulatory

Commission. or the Defense Nuclear Faclities 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 reC(X'ds) for estWnating the radiation doses of

employees covered by the petition.

(Attach report to the back of the petition form.)

--- -- -- -- -

I All petitioners_should Sig~ and da~ the petition. A maximum of three pel'8Oll8 may 8ign the pedtJon.

I /1- .1...1:.-(19 .f -~ Dat$ Signature .

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 EEOICP A or who

I knoItvingly a<x:epts compensation to which that person is not entitled is subject o civil or

administrative remedies as well as felony criminal prosecution and may, under appropriate ,I criminal provisions. be punished by a fine or imprisonment or both. I afflnn that the informaOOn

I provided on this fonn Is accurate and true.

i Send this form to: SEC Petition

I Office of Compensatkx1 Analysis and Support

NIOSH

i 4676 Columbia Parkway, MS-C-47 I Cincinnati. OH 45226

Name or Social Security Number of First Petitioner:
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