Fl

‘To the best of my knowledge, 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.

Jate_ 6// 2/0 £

FRANCES L.
Notary Mulls, sot RR Wissourt

om ous County
Commission # 06956568“
ty Commission Expires Oatoher 18, 8010



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

OMB Number: 6920-0639 Expires: 05/31/2007
pecial Exposure Cohort Petition — Form B Page 5 of 7

E)
F 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.

Ft yi {Ve 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.

F2  () I/We have attached either documents or statements provided by affidavit that indicate that
radiation manitoring 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 fost, altered illegally, or destroyed.

Part F is continued on the following page.

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
iliness Compensation Act Nationa! institute for Occupational Safety and Health

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

Use of this form ig voluntary. Failure to use this form will not result in the deniat of any right, benefit,

instructions:

If you wish to petition HHS to consider adding a class of employees to the Special Exposure Cohort and you
are NOT either a member of that class, a survivor of a member of that class, or a labor organization
representing or having represented members of that class, then 42 CF R Part 83, Section 83.7(c) 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 form to NIOSH with the related petition. Please print legibly.

For 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: 1-800-356-4874.

Authorization for Individual or Entity to Petition HHS on Behalf of a Class of Employees for
Addition to the Special Exposure Cohort

Name of Class Member or Survivor
sem “

rs
ce ee eee —p- _ -—_-
Street Address of Class- Member or Syrvivor Apt. # P.O. Box
City, State, Zip Code of Cldss Member or Survivor

do hereby authorize: 4». ht D 1]
Name of Petitioner on ~~

Tan o a ry

Address of Petitidner | Ay J . Apt P.O. Box

City, State and Zip Code of Petitioner
to petition the Department of Health and Human Services on behalf of a class of employees
that includes:

”

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

for the addition of the class to the Special Exposure Cohort, under the Energy Employee's
Occupational Illness Compensation Program Act (42 U.S.C. §§ 7384-7385).

In providing this authorization, | recognize that the petitioner named above will have all the rights
ofa patitioner as provided for under 42 GFR Part 83.
A -

Sigfture of Class MSmber or Survivor Date

Name or Social Security Number of First Petitioner: ee



Special Exposure Cohort Petition
under the Energy Employees Occupational
lWIness Compensation Act

Special Exposure Cohort Petition — Form B

U.S. Department of Health and Human Services
Centers for Disease Control and Prevention
National institute for Occupational Safety and Health

OMB Number: 0920-0639 Expires: 05/31/2007
Appendix ~~ Petitioner 2

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

| B.1 Name of Survivor:

MriMirs/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
B4 Telephone Number of Survivor: ( ) - a
B5 Email Address of Survivor:
B.6 ‘Relationship to Employee: Q Spouse ( Son/Daughter Q Parent
Q Grandparent Q Grandchild
Go to Part C.
3 | Employee information — Complete Section C.
C.1 Name of Employee:
Mr/Mrs.JMs. First Name Middle Initiat Last Name ~
C2 Former Name of Employee (e.g., maiden name/legal name change/other):
Mr/Mrs/Ms. First Name Middte initial Last Name ~
C.3 Social Security Number of Employee: __ oe
C4 Address of Exeployee (if living):
Street ~ Apt P.O.Box
City State Zip Code °
C5 Telephone Number of Employee: ()
C6 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 EmployerName; —
C.7d Work Site Location: 2 ee
C.7e Supervisor's Name: _ eerie ween

Sign Part G of the original petition.

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 Genters for Disease Control and Prevention
iiness Compensation Act National institute for Occupational Safety and Heaith

| OMB Number: 0920-0639 Expires: 05/31/2007
Special Exposure Cohort Petitian -—— 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, MS-E-11, Atlanta GA, 30333; ATTN:PRA 0920-0639. Do not send the compieted 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
Contral 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/CDG/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 entitles 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 or a
Congressional staff member in response to a verified inquiry.

This notice applies to alt 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 spacified 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 Gohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupationat Centers for Disease Control and Prevention
\iness 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
F.3d JAVe 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.)

FA @ I/We have attached a scientific or technical report, issued by a government agency of the
Executive Branch of Government or the General Accounting Office, the Nuciear 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.)
Go to Part G.

Signature of Person(s} Submitting this Petition — Complete Section G.

All Petitione’= ~*~"! -‘gn and date the petition. A maximum of three persons may sign the petition.
a wee 7

— _ O-ft.~O8
Signate. ; yn un Date
ve Gof RefI
Signature Nate
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 civit 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, MS-C-47
Cincinnati, OH 45226

If there are additional petitioners, they must complete the Appendlx Forms for additional petitioners.
‘The Appendix forms are located at the end of this document.

Name or Social Security Number of First Petitioner: _ > 7


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

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

OMB Number: 0920-0639 Expires: 05/31/2007
Petitioner Authorization Form Page 2 of 2
Public 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 respond 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 result in the denial of any right, benefit, or
privilege to which you may be entitled.

Name or Social Security Number of First Petitioner: ; _ _



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

under the Energy Employees Occupational Centers for Disease Control and Prevention
Jiiness Compensation Act National institute for Occupational Safety and Health

- OMB Number: 0920-0639 Expires: 05/31/2007
Special Exposure Cohort Petition — Form B Appendix -— Petitioner 2

Use of this form and disclosure of Social Security Number are voluntary. Failure to use this form or disclose
this number will not result in the denial of any right, benefit, or privilege to which you may be entitted.
oe

Use this Appendix for Petitioner 2.

This appendix form is to be used as needed. Petitioner 2, or his or her representative, should complete the
parts applicable to him or her.

Refer to the General Instructions on completing petitioner information for Parts A, B, or C.

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.

Except for signatures, please PRINT all information clearly and neafly on the form.

(An Energy Employee (current or former), Start at C

ff you are; |) A Survivor (of a former Energy Employee), Start at B

(1 A Representative (of a current or former Energy Employee), Start at A

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

Are you a contact person for an organization? © Yes (Go to A.2) {1 No (Go to A.3)
A2 Organization Information:

Name of Organization

Position of Contact Person

A3 Name of Petition Representative:

We iNirs (Ms. First Name Middle Initiat === LastName
A4 Address:
Street — Apt “P.O. Box

City * “Zip Code
AS Telephone Number: (_ } -
A6 Email Address: _

AZ (i 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
form for this purpose is provided.

If you are representing a Survivor, go to Part B; if you are representing an Employee, go to Part C.

Name or Social Security Number of First Petitioner: o. a


Special Exposure Cohort Petition U.S. Department of Health and Human Services |
under the Energy Employees Occupational Centers for Disease Control and Prevention

q
liness Compensation Act 06-15-08 PI?2259 IN National Institute for Occupational Safety and Health
7 _ OMB Number: 0920-0639 Expires: 05/31/2007
Special Exposure Cohort Petition — Form B Page 1 of 7

Use of this form and disclosure of Social Security Number are voluntary, Failure to use this form or disclose
this number will not result in the denial of any right, benefit, or privilege to which you may be entitled.

General Instructions on Gompleting this Form (complete instructions are availabie in a separate packet):

Except for signatures, plaase 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
fo 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 cail 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.

A Labor Organization, StartatD on Page3

Ifyou {J An Energy Employee (current or former), StartatC on Page2
are: {2 A Survivor (of a former Energy Employee), StartatB on Page2
§@ A Representative (of a current or former Energy Employee), StartatA on Page 1

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

A1 Are you a contact person for an organization? Q Yes (Go to A.2) %_ No (Go to A.3)

A2  Qrganization Information:

Name of Organization —

Position of Gontact Person
A323 Name of Petition Representative: _

“ant Rneee Middle Initial Last Name

A4 Address: . '

Sret 4 JO Rpt tt P.O. Box

City ~ Sate t—~S Zip Code
A.5 Telephone Number: - oo ee

A& Email Address:

~ w 7
AZ SA 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

if you are representing a Survivor, go to Part B; if you are representing an Employee, go to Part C. |

Name or Social Security Number of First Petitioner: _ _



Special Exposure Cohort Petition
under the Energy Employees Occupational

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

National Institute for Occupational Safety and Health

OMB Number: 0920-0639 Expires: 05/31/2007
Appendix — Petitioner 3

Illness Compensation Act

Special Exposure Cohort Petition — Form B
Complete Section B if you are a Survivor or representing a Survivor.

B Survivor Information —

BA Name of Survivor:

MriNirs/vis, FirstName Middle Initial 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: ¢ ) -

B.5 Email Address of Survivor:

B6 Relationship to Eraployee: Q Spouse Q Son/Daughter Q Parent

Q Grandparent Q Grandchild

Go to Part C.

tion C.

Empioyee Information —- Complete S:

C.1 Name of Employee:

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

Mr/iirs./Ms. First Name Middle Initial Last Name
C.3 Social Security Number of Employee: —
C4 Address of Employee (ff living):
Street — Apt # P.O. Box
City State Zip Code ~
C.5 Telephone Number of Employee: (_ ) 5
C6 Email Address of Employee: __
C7 Employment Information Related to Petition:
C.7a_ Employee Number (if known): rae
C.7b Dates of Empioyment: Start . End
C.7¢ EmployerName:
C.7d Work Site Location: __ — —
C.7e Supervisor's Name: ——

Sign Part G of the original petition.

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
iness Compensation Act National Institute for Occupational Safety and Health

. OMB Number: 0920-0639 Expires: 06/31/2007
Special Exposure Cohort Petition —- Form B Appendix — Petitioner 3

Use of this form and disclosure of Social Security Number are voluntary. Failure to use this form or disclose
this number will not result in the denial of any right, benefit, or privilege to which you may be entitled.

Use this Appendix for Petitioner 3.

This appendix form is to be used as needed. Petitioner 3, or his or her representative, should complete the
parts applicable to him or her.

Refer to the General Instructions on completing petitioner information for Paris A, B, or C

Ifyou 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.

Except for signatures, please PRINT all information clearly and neatly on the form.

@ An Energy Employee (current or former), Start at C
If you are: {QA Survivor (of a former Energy Employee), Start at B
(J) A Representative {of a current or former Energy Employee), Start at A

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

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

A2 Organization Information:

Name of Organization

Position of Contact Person
A.3 Name of Petition Representative:

Me/Mirs/Ms. First Name Middle Initial ~~ Last Name

A4 Address:
Street : _ Apt #f P.O. Box
City ~~ State ~~ ~Zip Code — ~

A5 Telephone Number: ( yo

A6& Email Address:
AZ ( 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
form for this purpose is provided.

If you are representing a Survivor, go to Part B; if you are representing an Employee, go to Part C.

Name or Social Security Number of First Petitioner; _



This page left intentionally blank.


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

under the Energy Employees Occupational Centers for Disease Control and Prevention
{ness Compensation Act Nattonal Institute for Occupational Safety and Health
OMB Number: 6920-0639 Expires: 05/31/2007

Special Exposure Cohort Petition — Form B
Proposed Definition of Employee Class Covered by Petition —- Complete Section E.

E.1 Name of DOE or AWE Facility: =. ysor. “Valley Powder. Pacrrr

E.2 ations at the Facility relevant fo this petition: ,

Ai toce Mens including bubnot Limited £0, Giaed Hause, Fame Hoos,

4 wel iy, Stora etank, Maialenance »Taal Sheds Lateollia _Keads aoprox,
50ilons Cneludiirg 5 igloos awnecl by Atomic Energy ammiss can),

£3 List job titles and/or job duties of employees included in the class. ‘Ia addition, you can list by
name any individuals other than petitioners identified on this form who you believe should be

ee Nites and for. ob.cluties including, bul not limited ta, tells ing:
zt

Resident Enginece Rginesh, Custodian, Guard, Groundskeeper
Motrtenance man, Reawnman, Secuirh,/ Pateal Ractia Cantactaarzan .

E.4 Employment Dates relevant to this petition:

Page 4 of 7

stat 4772. End J/9Y9
Stat oo End oo
Start End
E.5 ts the petition based on one or more unmonitored, unrecorded, or inadequately monitored or
recorded exposure incidents?: 1 Yes ¥ No

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

Go to Part F.

Name or Social Security Number of First Petitioner: -


F4

To the best of my knowledge, 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.

Date:_G-/2.-OY

£L SY a

u

f
Noton Ase galt BR esout |

. Couts Count
Commission # 06955568
Aww My Commission Expires October 18, 2070}
Np RST AE ae SOE



F.4

To the best of my knowledge, 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.

Date:



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

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

pecial Exposure Cohort Petition
Labor Organization Informatio

[D1 Labor Organization information:

8

if you are a labor organization.

Name of Organization

Position of Gontact Person
D.2 Name of Petition Representative:

D.3 Address of Petition Representative:

Street —_ Apt # P.O. Box

Ciy State Zip Code
D4 ‘Telephone Number of Petition Representative: ¢ _)

D.5 Email Address of Petition Representative: one en nn

D.6 Period during which labor organizatlon represented employees covered by this petition
(please attach documentation): Start End _

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

—

Go to Part E.

Name or Social Security Number of First Petitioner:



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

under the Energy Employees Occupational Centers for Disease Control and Prevention
liness Compensation Act Nationat Institute for Occupational Safety and Health

OMB Number: 0920-0639 Expires: 05/31/2007
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: tee _ a

First Name Middle tnitial Last Name

B.2 Social Security Number of Survivor: . ‘
B.3 Address of Survivor:

~
Street_ . a of Apt # P.O. Box
City State ~ “ZipCode
B4 Telephone Number of Survivor ~ sean
B.5 Email Address of Survivor: - , ,
B.6 Relationship to Employee:
we te ape ents wee ee eae reese atin
Go to Part C.

, Employee Information
C.1 Name of Employee: _

“First Name Middle initial” ast Name

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

wane First Name Middle Initial LastName
C3 Social Security Number of Employee;
C.4_ Address of Employee (if living):

__Coreceased) _—

Street P.O. Box

City eee 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 | S946 End 4 LLGS?
C.7c¢ Employer Name: Ty sor Va Mey Powder Faem
C.7d Work Site Location: SY Lowls C Aid re fy

OO

C.7e Supervisor's Name: ae

Go to Part E,

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
Hiness Compensation Act National Institute for Occupational Safety and Health

. OMB Number: 0920-0639 Expires: 05/31/2007
Special Exposure Cohort Petition — Form B Appendix — Continuation Page
Pa Photocopy and complete as necessary.

Attach to Form B if necessary.

Name or Social Security Number of First Petitioner: _



Fd

To the best of my knowledge, 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.