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

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.4 Q IMWe 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
WAGs nN and/or affidavit(s) indigate wa potential radiation exposures were not monitored.

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F.2. 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
propgsed class have been lost, altered illegally, or mo 7h

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Name or Social Security Number of First Petitioner: _ —


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

under the Energy Employees Occupational Centers for Disease Control and Prevention
Iliness 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

Cre KAEB Trncahe Test Rawge

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:

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E.4 Employment Dates relevant to this petition:

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End

Start.
Start End -

E.5 Is the petition based on one or more unmonitored, unrecorded, or inadequately monitored or
recorded exposure incidents?: Q Yes Q No

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

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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

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

F.3. QO 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 IMWe 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

G Signature of Person(s) Subm ig this Petition — Complete Section G.

All Petitinnece chauld inn and dhtn tha masition, A maximum of three persons may sign the petition.

2-7 ft
ciate sort - Date
Pier ctee 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

IIness Compensation Act 07-18-11P01:14 RCVD National Institute for Occupational Safety and Health
OMB Number: 0920-0639 Expires; 09/20/2013

Special Exposure Cohort Petition — Form B of

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.

MA Labor Organization, — Start at D on Page 3

It you OQ An Energy Employee (current or former), StartatC on Page 2
are: QA Survivor (of a former Energy Employee), StartatB on Page2
QO A Representative (of a current or former Energy Employee), StartatA on Page 1

Representative Information — Complete Section A if yo authorized by an Employee or

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

A.1 Are you a contact person for an organization? Q Yes (Go to A.2) Q No (Go to A.3)
A.2 Organization Information:

Name of Organization

Position of Contact Person
A3 Name of Petition Representative:

Mr./Mrs./Ms. First Name Middle Initiat Last Name

A.4 Address:
Street Apt # P.O. Box
City State Zip Code

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
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 7 of 7

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 Illness Compensation Program Act (42 U.S.C. §§ 7384-7385)
(EEOICPA) 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 National Institute for Occupational Safety (NIOSH), an Institute of the Centers for Disease
Control and Prevention. Information 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.
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;
(e) Federal, state and local agencies for law enforcement purposes; and (f) a Member of Congress ora
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 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.

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

Survivor Information — Complete Section B if you are a Survivor or representing a Survivor.

B.1_ Name of Survivor:

Mr./Mrs./Ms. First Name Middle tnitial Last Name
B.2 Social Security Number of Survivor: :

B.3 Address of Survivor:

Street Apt # P.O. Box

City State Zip Code
B.4__ Telephone Number of Survivor: d

B.S — Email Address of Survivor:

B.6 _ Relationship to Employee: Q Spouse Q Son/Daughter Q Parent
Q Grandparent Q Grandchild

Complete Section ESS you are a labor organization.

C.1 Name of Employee:

Mr./Mrs./Ms. 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:

C.4 Address of Employee (if living):

Street Apt # P.O. Box

City State Zip Code
C.5 Telephone Number of Employee: ( ) =

C.6 Email Address of Employee:

C.7 Employment Information Related to Petition:
C.7a Employee Number (if known):

C.7b Dates of Employment: Start End
C.7c¢ Employer Name:
C.7d Work Site Location:

C.7e 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
lilness Compensation Act National Institute for Occupational Safety and Health

7 OMB Number: 0920-0639 Expires: 09/20/2013
Special Exposure Cohort Petition — Form B Page 3 of 7
D Labor Organization Information — Complete Section D ONLY if you are a labor organization.
D.1.— Lahar Oraanization.Information:

Position of Contact Person
D.2. Name of Petition Renresentative:

D.3 Address dt Petitiop Representative:

— —
Street . 7 Aot # P.O. Box
City State Zip Code

D.4 Telephone Number of Petition Representative: ( es
D.5 Email Address of Petition Representative:

D.6 Period during which labor organization represented employees covered bv this netition
(please attach documentation): Start End

D.7 Identity of other labor organizations that may represent or have represented this class of
employees (if known):

Name or Social Security Number of First Petitioner: _