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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
illness Compensation Act National Institute far Occupational Safety and Health

OMB Number, 0920-0639 Expires: 05/31/2007
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 300 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 CDC Reports Clearance Officer, 1600 Clifton
Road, M'S-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 nereby notified of the
following:

The Energy Employees Occupational Iness 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; (0) 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 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 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.


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January 31, 2005 .

Radiation Exposure Compensation Program
U.S. Department of Justice

P.O, Box 146

Ben Franklin station

Washington, D.C 20044-0146

LETTER OF APPEAL


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PHYSICAL EXAMINATION



03713708 15:11 Boos



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oor

FAX TRANSMISSION

OFFICE OF U.S. SENATOR BARACK OBAMA
230 S. DEARBORN, SUITE 3900

TO: DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR DISEASE CONTROL AND PREVENTION

NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH
FAX:
DATE: MARCH 13, 2006

NUMBER OF PAGES:
(INCLUDING COVER)

FROM:

DIRECT PHONE:


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TO

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20


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22


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- . “ . Q02

DEPARTMENT OF VETERANS AFFAIRS
Veterans Health Administration
Washington DC 20420

sep - 3 2004



93/13/06 15:13

U.S. Department of Justice

Bois

Re:

Dear

Washingson, D.C. 20530

DEC 9 204


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03/13/06 15:11 FAX 312 886 3514 SENATOR BARACK OBAMA Mor

D2

D3

D4
DS
Dé

ecial Exp

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

under the Enoray Employees Occupational
Iiness Compensation Act National Institute for Occupational Safety and Health

Centers for Disease Control and Prevention

OMB Number: 0920-0639 Expires; 05/31/2007
Page 3 of 7

Section D ONLY if you are a labor organization,

osure Cohort Petition — Form B
Ldbor Organization information — Compte

Lubor Organization Information:

Name of Organization

Position of Contact Person
Name of Petition Representative:

Address of Petition Representative;

Street Apt # P.O. Box

City Zip Code

Telephone Number of, ion Representative: ¢ 5) -

Email Address of, ition Representative:

Period duri ich labor organization represented employees covered by this petition
+h documentation): Start End

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

Name or Social Security Number of First Petitioner:



03/13/06 15:15 @osa


03/13/06 15:26 Boss



03/13/06 15:15 Bos


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Boos

UNITED STATES SENATOR BARACK
OBAMA

CHICAGO OFFICE

im PRIVACY ACT RELEASE FORM |

Tue provisions of Public Law 93-579 (Privacy Act of 1974) prohibit the disclosure of
information of a personal nature from the files of an individual without their consent.

Accordingly, I authorize the staff of Senator Barack Obama to access any and all of my
records that relate to the problem stated below,

Signature: Date: 2? -/4-0G

To begin processing your case, please complete the following information:

Name: Date of Birth: _

Address: ____

City: State; ip: Home Phone: ” ~
Place of Work: Bevin CHET UCAL. =

address: LAE CD,

City: State: Zp: _ —
‘Work Phone: __4/4 Email Address: __4oae.

‘Social Security Number. _. Section 8 No: 2

Alien Registration Number. FEIN No:

Branch Scivice: -__ —_ * Rank 2

Briefly explain your problem or the information desired: eetieg fale ——
L " t ,

PLEASE RETURN YOUR COMPLETED FORM TO ONE OF SEN. GBAMA’S STATE OFFICES:
230 S. Dearbom St, Ste. 3900. _ 607 F. Adams St T21N. Cont Strcet
jcago, IL, 60604" * Speingfield, IL 62703.: -- . Marion, 1 62959

Chicage,
12) 886-3514 ~FX 17) 492-5099 -EX (618) 997-2850 ~FX



+ 03/13/06 15:11

007

FEB 2 8 2008

United States Senator Barack Obama
230 S. Dearborn St., #3900
Chicago, IL 60604

RE: Special Exposure Cohort Petition
Joliet Blockson Olin Chemical

Dear Senator Obama,


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@oio

under the Energy Employeas Occupational
lines. Compensation Act

Ne shiv

Ba Name of Survivor.

OMB Number. 0920-0639
ure Cohort Petition — Form B

Special Exposure Cohort Petition U.S. Department of Health and Human Services
Centers for Disease Control and Prevention
National Institute for Occupational Safety and Health

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

B.2 Social Security Number of Survivor:

Mr/MrsJMs, First Name Middle initial Last Name

B.3 Address of Survivor.

Q Grandparent Q Grandchild

Street Apt # P.O, Box
City ate Zip Code

Ba Telephone Num) of Survivor: ¢ 2 =.

8.5  Ernail of Survivor:

B.6 _ Reltfonship te Employee: Q Spouse Q Son/Daughter 2 Parent

ag

Sc.

mployee Information — Complet uare a labor or

C.1 Name of Emplovee:

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

First Name iagie inimat Last Name

nization

C.3 Social SecurityNumber of Employee: = __
C.4 Address of Emplpyee (if living):

fA
Wir/Mrs./Ms. First Name Middle Initial Last Name

Sire “ae PO. Box
City State — in Code

C.5 Telephone Number of Employee:

CS Email Address of Employee: fe

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

7b DatesofEmployment: stat OF7/I94'7 = end _ 0O/IGFIO

C7e Emplyername: __3/arkeon- hn Chamisal

C.7d Work Site Location: Lhhersan 4.

C.7e Supervisor's Name:

Name or Social Security Number of First Petitioner:


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“03/13/06 18:10

a Booz
BARACK OBAMA COMMITTEES:
TUUNOIS, NVIRONMENT AND
PUBLIC WORKS
- FOREIGN RELATIONS
WPnited States Senate VETERANS: Arman
WASHINGTON, DC 20510
March 13, 2006

Department Health and Human Services
Centers for Disease Control and Prevention
National Institute for Occupational Safety and Health

Dear Agency Official:
The enclosed correspondence was received in my Chicago office from my constituent,
Attached you will find his letter which gives a more accurate description and

explanation of his issues as well as all relevant documentation.

I would appreciate your looking into this matter at your earliest convenience. Please advise
who assists me in these matters, of your findings.

If you require any further assistance or have additional questions, please do not hesitate to
contact

Thank you for your attention to this matter.

Sincerely,

Senator Barack Obama
United States Senator
230 S. Dearborn, Suite 3900

Chicago, IL 60604
238 RCVD
95-11-06P12:38 RC
cc: BOfjp
Wasnmcran Coed Seamanno Ornce Mason Once ‘quan Cmea Omce
‘733 HART SENATE OFRCE BULOMS 20 S. Dranwonn 607 East ADAMS 701 Noreres COURT STREET ‘1911 S2Np Avenue
Washaccto0, OC 0530 ‘SUITE 2000, ‘Surre 1620 Maraon, IL 52358, Moun. 61285
‘Onnes (202) 22 Grscacco, COBO ve. tL S270 ‘Gence (618) 937-2402 eres 19091 738-1217
Fax (202) 226—821 OFRCE (312) 306-2806 (Ormsce (217) 432-5830 Fax (618) 997-2550, Fax (309) 736-7209
Fax 12} 228-9518 Fad 7] 652-8088


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_ __03/13/06__15:12 013

[Special Exposure Cohort Petition . Department of Health and Human Services

urider the Energy Employees Occupational Cantars for Disease Contra! and Prevention
Iiness Compensation Act National institte for Occupational Safety and Health
OMB Number: 0920-0639 Expires: 05/31/2007

e Cohort Petition — Form B “ Page 5 of 7
cords and Information are Inadequate for Individual Dose —

B4sis for
Cempie

osing that R
ion 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.

F1 Q Ie 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, eithar 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 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.

‘Part F is continued on the following pagé.

Name or Social Security Number of First Petitioner:


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18:12 Moz

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

under the Eneray Employoos Occupational Centers for Disease Control and Prevention

liness Compensation Act National Institute for Occupational Safety and Health

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

lal Exposure Cohort Petition — Form B Page 4 of 7
fe oposed Definition of Employee C Covered by Petition — Complete Section E.

i=l Name of DOE or AWE Facility: 1

£2 Locations at the Facility relevant to this petition:

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 rines:

E.4 Employment Dates relevant to this petition: ‘
stat _oT/( P47 end 06/1990
Start . End
Start End

E.5 fs the petition based on one or more.unmonitored. unrecorded, or inadequately monitored or

recorded exposure incidents?:

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

- Goto Part F.

Name or Social Security Number of First Petitioner:



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03/13/06 Ziors



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03/13/06 18:11 @oos
Special Exposure Cohort Petition U.S. Department of Health and Human Services
under the Energy Employees Occupational Conters for Disease Control and Pravantion
llinass Compensation Act National Institute for Occupational Safety and Health

wal OMB Number, 0920-0639 Expires: 05/31/2007
Special E

xposure Cohort Petition—FormB : Page 10f7

— = _ — = = i
General [instructions on Completing this Form (complete instructions are available in a separate packet):
Except for signatures, please PRINT ail 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. Aimaximum of three petitioners is allowed.

{f 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 Office of Compensation Analysis and Support about an SEC petition:
1-800-355-4674,

—
A Labor Organization, StattatD on Page3
— _
ra An Energy Employee (current or former). StartatC on Page2
you —
are; A Survivor (of a former Energy Employee), StartatB on Page2

A Representative (of a current or former Energy Employee), StartatA on Page 1

osentative Informat
vor(s) to petition on

— Complete Section Aif you are authorized by an Employee or
ehalt of a class.

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

Name of Organization

Position of Contact Person
AS Name of Petition Representative:

Mr/Mrs/Ms. First Name Middle initial Last Name
A4 Address:

Street Apt # P.O. Box
City State Zip Code
AS Talephone Number: , ) :

A6 Email Addr

AZ Cl 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

go to-Part B; If you ara rapresonting ari. Employde, go to Part C.. -

Name or Social Security Number of First Petitioner:


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1

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03/13/06 15:26 Jose


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oie

(Spectat Exposure Cohort Petition

under the Energy Employees Occupational
Iliness Compensation Act

Special Exposure Cohort Petition —

Continuation

U.S. Department of Health and Human Services
Centers for Disease Control and Prevention

National inatituts for Occupational Safety and Health

OMB Number. 0920-0633 Expires: 05/31/2007
Appendix — Continuation Page

, Attdich 6'Fori'B if necessary.

Name or Social Security Number of First Petitioner.


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03/13/06 15:13

018
Special Exposure Cohort Petition U.S, Department of Health and Human Services
under the Energy Employees Occupational Centers for Disease Control and Prevention
Mines Gompersation Act National institute for Occupational Safety and Health
OMS Number. 0920-0639 Expires: 05/31/2007
Petitionar Authorization Form Page 2of2
Bk 8 Rll td as LL

_ -
Publilc 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 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 raspand to the information collected on this form unless it displays a currently
valid OMB number.

Use of this form is voluntary. Failure to use this form will not resuit in the denial of any right, benefit, or
privilege to which you may be entitled.

Name or Social Security Number of First Petitioner:


03713706 15:10

Boos

United States Senator Barack Obama
230 S. Dearborn St., #3900
Chicago, IL 60604

RE: Special Exposure Cohort Petition
Joliet Blockson Olin Chemical

Dear Senator Obama,



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03/13/06 15:14 Ho27


+03713706 15:10

@oos

UNITED STATES SENATOR BARACK
OBAMA

CHICAGO OFFICE

[ PRIVACY ACT RELEASE FORM |

‘The provisions of Public Law 93-579 Privacy Act of 1974) prohibit the disclosure of
information of a personal nature from the files of an individual without their consent.

‘Accordingly, I authorize the staff of Senator Barack Obama to access any and all of my
records that relate to the problem stated below.

Signature: Date: 12-2205

To begin processing your case, please complete the following information:

Name: ___Date of Birth: __ _

Address: _—
ity: State: Zip: —Home Phone: _

Place of Work: O77 Le

Address: LATERM LD. :

City: Z State: (‘a Zip:

Work Phone: (A. Email Address: __goneé.

Social Secisity Number: Seetion 8 No: :

Alien Registration Number: FEIN No:

Branch Service: "Rank.

Briefly explain your problem or the information desired:
4 t hl

Tak
PLEASE RETURN Your COMPLETED F FORM TO ONE OF SEN. OBAMA’S STATE OFFICES:
230S. ‘Dearborn St, Ste, 3500" . . E. Adams St 721 N. Court Street

Chicaga, IL 60604-" Sree TE e2703- oe Marion, IL 62959
12) 886-3514 - FX (217) 492-5099 - FX (618) 997-2850 - FX



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03/13/06 15:15 Boss


_ . 03/13/06 15:20 Boos



03/13/06 15:15 @os0


03/13/06 15:12 oi

F.4

Special Exposure Cohort Petition U.S. Department of Heaith and Human Services
under the Energy Employees Occupational Centers for Disease Control and Prevention
lines Compensation Act : National Institute for Occupational Safety and Health

OMB Number. 0920-0639 Expires: 05/31/2007
Special Exposure Cohort Petition — Form B Page 6 of 7
FS © IWe 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
fadiation exposures at the facility, as relevant to the petition. The raport 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.

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

QWs 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.)

All Petitic

Submittin ition — Complete Sec

oners should sign and date the petition. A maximum of three nareane may ign the petition.

Signature Cas
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

Office of Compensation Analysis and Support
NIOSH
4676 Columbia Parkway
Cincinnati, OH 45226
hey must complete the Apperidix Forms for
forms are located at the end of thie documei

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 Prevenfian
Hines Compensation Act National Institute for Occupational Safaty and Health

OMB Number: 0920-0639 Expires: 05/31/2007
Petitioner Authorization Form Page 1 of 2

Use of this form Is voluntary. Fallure to use this form will not result in the denial of any right, benefit,

Instructions:

if you wish to petition HHS to consider adding a class of employees to the Special Exposure Cohert and you
are NOT either a member of that class, a survivor of a member of that class, or a labor organization
tepresenting or having represented members of that class, then 42 CFR Part 83, Section 83.7(¢) requires
that you obtain written authorization, You can obtain such authorization from either an employee who is a
member of the class or a survivor of such an employee. You may use this form to obtain such authorization
and submit the completed farm to NIOSH with the related petition, Please print legibly.

Fer Further Information: If you have questions about these instructions, please call the following NIOSH
toll-free phone number and request to speak to someone in the Office of Compensation Analysis and
Support about an SEC petition: 1-800-356-4674.

Name of Class Member or Survivor

Street Address of Glass Member or Survivor Apt. # P.O. Box

City, State, Zip Bode of Gaass Memuoer oF our vivur
do hereby authorize:

of Petit ia

Name itioner

280.9. Dearborn S, £3900

_ Kddtess of Peiitioner Apt. # P.O. Box

 Chieagd, ZL Goteay

7

ity, State andZip Code of Petitioner ,

to petition the Department of Health and Human Services on behalf of a class of employees
that includes:

Name of Glass Member (employee, not the employee's survivor)

for the addition of the class to the Special Exposure Cohort, under the Energy Employee's
Occupational Iiness Compensation Program Act (42. U.S.C. §§ 7384-7325).

In providing this authorization, I recognize that the petitioner named above will have all the rights
of a petitioner as provided for under 42 CFR Part 83.
PHL

Signature of Class Merfiber or Survivor . Date

Name or Social Security Number of First Petitioner