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+ Fax Server 3/9/2016 11:16:48 AM PAGE 1/002 Fax Server

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03-01-16A09:58 RCVD

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 Program Act National Institute for Occupational Safety and Health

OMB Number: 0920-0639 Expires: 07/31/2016
Special Exposure Cohort Petition — Form B ° Page 2 of 7

Survivor Information — Complete Part D if you are a Survivor or representing a Survivor.

B1 Name of Survivor:

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

B.2 Address of Survivor:

Street Apt # P.O. Box

City State Zip Code

B.3. Telephone Number of Survivor: ( )

B.4 Email Address of Survivor:

B.5 Relationship to Energy Employee: (1 Spouse OCSon/Daughter OParent
OGrandparent OGrandchild

Go to Part C.
Cc. Energy Employee Information — Complete Part C UNLESS you are a labor organization.

C.1 Name of Energy Employee:

First Name Middle Initial Last Name

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

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

C.3_ Address of Energy Employee (if living):

Street - 7 Apt # P.O. Box

City State Zip Code
C.4 Telephone Number of Energy Employee: (_

J—_

C.5 Email Address of Energy Employee:

C.6 Employment Information Related to Petition:
C.6a Energy Employee Number (if known):
C.6b Dates of Employment: Stat | 8 End 7, BS
C.6c_ Employer Name: Bliss § Laughlin
a5 SF
C.6d_ Work Site Location: flo Hopki ns :
Buffalo, NY 14220

C.6e Supervisor's Name: _

Go to Part E.
faye | 90 Ed 7 90

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aA



Special Exposure Cohort Petition
under the Energy Employees Occupational
\lIness Compensation Program Act

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: 07/31/2016
Pag

je 4 of 7

Complete Part E.

E.1 Name of DOE or AWE Facility: B lise & lau Bol n
E.2. Locations at the Facility relevant to this petition:
Wo __ Hopkins
Buffalo, New Nork — (4aa0
E.3 List job titles and/or job duties of energy employees inctuded 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:
E£.4 Employment Dates relevant to this petition:
stat ) 38 End 4 6s
t
Start _ 90 End q 90
stat | 92 end _! 92
1 99 ! 19
E.5 {1s the peuuun based on one or more.unmonitored, unrecorded, or inadequately monitored or

recorded exposure incidents?: Yes ONo

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

ry):

No health — mendocine
tah levels oF (adsaton
aS POC Core of Engi veers

Go to Part F.



Fax Server 3/9/2016 11:16:48 AM PAGE 2/002 Fax Server

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

under tha Energy Emplayees Occupational Centers for Disease Control and Prevention

lilness Compensation Program Act National Institute for Occupational Safety and Health
Number: res:

Special Exposure Cohort Petition — Form B OMB Number: 0820-0639 Ei ae cet?

F.3 0 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
belleving 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.

i _ (Attach report to the back of the patition form.)

F.4 0] \We have attached a scientific or technical report, Issued by a government agency of the
Executlve Branch of Goverment or the General Accounting Office, the Nuclear Regulatory
Commission, or the Dafanse Nuclear Facilities Safety Board, or published in a peer-reviewed
Joumal, 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 energy
employees covered by the petition.

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

i Go to Part G.

H All Petitioners shopd sign and date the petition. A maximum of three persans may sign the petition.

38-16

Signature Date
: Signature Date
: Signature Date

Notice: Any person who knowingly makes any fatse 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 entilled Is subject to clvil 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 farm to: SEC Pelition
Division of Compensation Analysis and Support
NIOSH
4876 Columbia Parkway, MS-C-47
Cincinnati, OH 45226

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