~

! Special ExpOSUr8 Cohort Petition U.S. Department of Heal'" and Human Ben

under the Energy Employees Q<x:upatlonal Centers for Dlaeese Control and Prev

Illness ComP«\sation Act Nationallnsttute fa' Oa:upational Sdety aoo I

OMB Number: ~ Expires: 05/31

Special Exposure Cohort Petition - Form B P2

uSe of this form and disdosure of Social Security Number are voluntary. Failure to U88 this tonn or discs.

this number will not result In the denial of any right, benefit, or privilege to which you may be entitled.

I GenerallMtruetiona on Completing this Form (complete instructions are aval7ab#e in a separate pad

Except for signatures, please PRINT all infonnation clearly and neatly on the fon'n.

Please read each of Parts A - G In this form and complete the parts appropriate to you. If bra Is more

I than one oetitIoner. then each petitioner should complete those sections of parts .A. - C of the fonn that a

to them. Additional ooples of the first two pages of this tonn are provided at the end of the fonn for this ~

pose. A maximum of three petltJoners is allowed.

If YOU need more SD8C8 to crovide additional Information. use the oontinuatlon page provided at the end

the form and attadt 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

request to speak to someone in the Office of Compensation Analysis and Support about an SEC petition 1-800--358-4874. '

10 A Labor OrganiZatIon. StartatD on Page 3

i 0 An Energy Emplo~ (cun-ent or former), Start at C on Page ~

I'-A Survivor (of a fom.r Energy Em~). Start at B on Page 2

If you

are:

I Q A Representative (of a CUn8nt or former Energy Emp~), StartatA on Page 1

Are you a contact person for an organization? 0 Yes (Go to A.2) C No (Go to A3)

OrganiZation Infonnation:

1 A.1

A.2

Name of Organization

-- ~~

Position of Contact Person

!A.3 Name of Petition Representative:

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

1A.4 Address:

Street Apt # P.O. Box

City State Zip Code

Telephone Number: ( \ -

Emall Address:

0 Check the box at left to IrMilC8t8 ~ h8ve attad* to the back of this fom1 written authorlzatic

petition by the surviYor(a) or emplo'Je8<a) 1ndiQated In Parts B or C of this fom1. An authorizat

IA.S

IA.S

A.7

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

Name or Soda Security Number of First Petitioner:

01-03-05P12:50 RCVD
u.s. Department of Health and Human Sen

Cen18r8 for DIsease Cor*o! and PreY

NatiooaIlnstituW for Oc<:Upatlonal Safety and I

OMB Number: ~ Expires: 05/31

~

Special Exposure Cohort Petition

und« the EneIgY Empklyees Qcx:upational

Iines$ ~pensatioo Ad

- Fonn B

18.1 NameM;]Mrs./Ms. First Name MiQ1Ie Initial LaSt Name

Sodal Security Number of Survivor: - .

Addren of SUrvlvo~ -

'- - - - - -

Street 1'"\ I' Am" - P.O. Box

\ ( CIty State ~ Code

- -~-

Telephone Number of SurvIvor: ,.

Emall Address of Survivor:

Relationship to Employee:

8.2

8.3

18.4

18.5

8.6 0 Son/Daughter

0 Grandchild

Spouse 0 Parent

Grandparent

'-

v.1 Name of EmoloV88: ,

. .I

~"]M'r8:. .. -.' MIOOlelnlUaJ' Last Name

Forme, Name of Employee (e.g.. maiden namel1egat name change/other):

~-

";,2

Middle Initial '..ast Name

,

""i ,C.43

~-

Mr ./Mrs./Ms. First Name

Social Security Number of Employee:

Addre.. of Employ.. (if living):

Street Apt#' P.O. Box

~y state -- ZJp Code -

Telephone Number of Employee: ( , .

Email Address of Employee: ~ ~-

Employment Information Related to PetItIon

Employee Number (If known): -

Dates of Employment: "

Employer Name: "

Work Site Location:

,C,5

'""",6

1~j"'" 7

IO,7a

,0.7b

IC.7C IC.7d

v.7e Supervisor's Name:

Stan End

Lt.NL

"If: /J e Jt/ tI'pe::tMO~g,. l'A-~ R>NNI'~ .. v "

a" /jQl-' l'~c.Ia./' - ---

Go to P.rt Eo

Name or SocIal Security Number of First Petitioner:

01-03-05P12:50 RCVD
U.s. 08~ent of Health and H&Dan Ser\

Cent.,. for Di8e88e Control aI1d prey

Netionallnstitute for Occupetional Safety and I

OMS Number: 0920-0639 Expires: 05/31.

Special Exposur8 Cohort Petition

uOOer the Energy Empioyees Ocxupationai

/l1n8S8 Compensation Act

I Soecial Exoosure Cohort Petition - Form B

D.1 Labor Organization Infon11ation:

. ~.~ ~

Name of orvanizatlon

10.2

Position of Contact Person

Name of Petition Representative:

0.3 Address of Petition Representative: ..F

/

Street- ,/.- ~. P.O. Box

IDA

0.5

0.8

I CItY~- State ,

/' ~C0c8 - - --

Telephone Number of Petition Rep,...~:, \ -

Emall Address of Petition Representative:

Period during which labor organization represent8d 8mP'G7"ae; W"yw;-~ by ~ petition

(please attach documentation): Start End

Identity of other labor organizations that may represent or have ~nted this cia.. of

employ... (if known):

0.7

Go to Part E.

Name or Social Security Number of First Petitioner:
u.s. Departl:nent of Health and Human Sen

Centers for Disease CootroJ and PreY

Natbnall nstitute for ~tIonal Safety and I

OM8 Number: 0920-0639 Expires: 05/31.

Special Exposure Cohort Petition

under the Energy Employees Occupational ! Illness Compensation Act

SpecIal exposure Cohort PetitIon - Form B

~1

2

E.3

E.4

E.5

Ust job titles and/or job duties of employees included in the class. In addition. you can lit

name any Individuals other than petitioners identified on thle form who you beUeve shoulc

Included In this class:

. SCl,/?"""f( T/".t!C (!LJl{ t<-/EK -.,,- ,"

!- 5cle-N TI>T.-r. --,~..,

Employm~'.'t D,- relevant to this petition:

Start End -

Start W End

Start End

Is the petition based on one or m~ ~nmonltored, Unr8COrded, or Inadequately monitored

recorded exposure incidents?: "~ Yes a No

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

as necessary):

~ ~ ~ ..ce ;e:- (U 1"0 t L

. .sa/~ I~ an~ .ItA ,..s: AI~

:' AlI:S ...Itr,..f ~ "t. ~rt1t.1b

~n~A .bo~ t/~

~~nc~rn Iii Ict leI""

-

~

Go to Part F..

Name or Social Security Number of First Petitioner:

Name of DOE or AWE Facility:

Locations at the Facility relevant to this petition:
Special expo8ure Cohort Petition

under the Energy Employees Occupational

Illness Compensation Act

U.S. Depament of Health and Human $en

Centers t)r Diseese Control and Pm

National Institute for Occupational Safety 800 I

OMB Number: 0920-0639 E)(pires: 05/31

Paa. Soecial ExDOSure Cohort Petition - Form 8

Complete at least one of the following entries In this section by checking the appropriate box and provid

the required Infonnation related to the selection. You are not required to compaete more than one entry.

.. 1 0 I"'" e have attached either documents or statements provided by affidavit that indicate that

radiation exposures and radiation doses potentially incurred by members of the proposed cia:

that relate to this petition. were not monitored. either through personal monitoring or through ~

monitoring.

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

Describe as comP'etely as possible. to the extent It might be unclear. how the attached

documentation and/or affIdavlt(s) Indicate that potential radiation exposures were not monitor.

F.2 a II We have att~ed either documents or statements provided by affidavit that indicate that

radiation monitoring records for membelS of the proposed class have been lost, falsified, or

destroyed; or that there is no information regarding monitoring, source. source term. or proce

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

~mentatlon and/or affidavlt(s) IndIcate that radiation monitoring records for members of th

proposed class have been lost, altered illegally. or destroyed.

Part F is continued on the following page.

Name or Social Security Number of First Petitioner:
u.s. Department of Health and Human S8M

Centers for Disease Control and PreY

National Institute for Ocx:upetia18l Safety am I

OMS Number: 0920-0639 Expires: 05/31

Page

: Special Exposure Cohort Petition

under the E~ Employees Occupational

: Illness Compensation Act

Special Exposure Cohort Petition - Form B

C.3

.4

Q l!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 spedfies the basis (0;

believing these documented limitations might prevent the completion of dose reconstructions

members of the class under 42 CFR Part 82 and related NIOSH technical implementation

guidelines.

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

"k' l/We have attached a scientific or technical report. Issued by a government agency of the

Executive Branch of Government or the Genera) Accounting Office. the Nuclear Regulatory

Commission. or the Defense Nuclear Facilities Safety Board, or published in a peer-reviewed

joumal. that ~entlfies dosimetry and related information that are unavailable (due to either a I

of employees monitoring covered or the destruction by or loss of records) for estimating the radiation doses of the petition. . ./

(Attach report to the back of the petition form.) v' ~ ~-t1~~..~'e;otl

Go to. Part G.

AIr Petitioners sh(-,II"'.lftn .nd date the oetltron.l A maxJmum of three persons .may si,gn the petit

Signature u.,,~

Signature Date

Signature Date

Notice: Any person who knowinglY makes any false statement, misrepresentation, concealment c

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 appropriat

criminal provisions. be punished by a fine or Imprisonment or both. I affinn that the Infonn

provided on this form Is accurate and true.

I Send this form to: SEC Petition

Office of Compensation Analysis and Support

NIOSH

4676 Columbia Parkway. MS-C47

Cincinnati. OH 45226

If there are additional petitioners, they must complete ther Appendix Forms for additional petitior

The Appendix forms are located at the end of this documer:at.

Name or Social Security Number of First Petitioner:
u.s. Department of Health and Human $en

Centers for Disease Control and Prev

National Institute for Occupational Safety and I

OMB Number: 0920..Q639 expires: 05/31,

PaRe

Special Exposure Cohort Petition

under the Energy Employees Ocx:upatlonal

Inness Compensation Act

Special Exposure Cohort Petition - Form B

Public Burden Statement

Public reporting burden for this oollection of Information is estimated to average 300 minutes per respom

Including time for reviewing instructions, gathering the Information needed, and completing the fonn. If yt

nave 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 Clearanc» Officer, 1600 Ctlft<

Road, MS-E-11, Atlanta GA. 30333; A TTN: PRA 0920.Q639. Do not send the completed petition fon11 to 1

address. Completed petitiol'lS are to be submitted to NIOSH at the address provided in these instruction!

Persons are not required to respond to the InfOmlation collected on this fonn unless it displays a currentt

valid OMS number.

Privacy Act Advisement

In accordance with the Privacy Act of 1974, as amended (5 U.$.C. § 552a), you are hereby notified ofth

following:

! The Energy Employees Qooupational Illness Compensation Program Act (42 U.S.C. §§ 7384-7385)

I (EEOICPA) authorizes 1he 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 Nationalinst/tute for Occupational Safety (NIOSH). an Institute of the Centers for Dis~

Control and Prevention. Information obtained by NIOSH in connection with: petitions for including addltiol

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 infom1ation become part of an existing NIOSH system of records under tI

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 compeUed by I

Disclosures that NIOSH may need to make for the processing of your petition or other purposes are liste

iDeiOW.

NIOSH may need to dIsclose personal identifying Infonnation to: (a) the Department of Energy, other fed

agencies, other government or private entities and to private sector employers to pennit these entities to

retrieve records required by NIOSH; (b) identified witnesses as designated by NIOSH so that these

IndMduals can provide infom1ation to assist with the evaluation of sec petitions; (c) contractors assistin!

NIOSH; (d) collaborating researchers, under certain limited circumstances to conduct further Investlgatio

(e) Federal, state and local agencies for law enforcement purposes; and (f) a Member of Congress or a

I Congressional staff member in response to a verified inquiry.

This notice applies to atl fOn11S and infOn11ationaJ requests that 'JOU may receive from NIOSH in connecti1

with the evaluation of an SEC petition.

Use of the NIOSH petition forms (A and 8) Is voluntary but your provision of infon11ation required by thes

forms is mandatory for the consideration of a petition. as specified under 42 CFR Part 83. Petitions that 1

! Drovide required infonT1ation may not be considered by HHS.

Name or Social Security Number of First Petitioner: -
-

Special ExpoaUN Cohort PetItIon U.s. Deparbnent of Health and Human Sen

under U1e ~ Ern~ Ocx;tipalonel Centers for O}eease ConbQi end PreY

I Illness CompensatkJn Act National Institute for Occupation81 Safety and I

OMB Number: ~ Expires: 05131 Special ExpOsure Cohort Pedtion - Fonn B AI)II88IdIx - ContIn.-tlon

~ -

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Attach to Form B if necessary.

Name or Social Security Number of First Petitioner:
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I1#TIIH .s-. .Lt jI/c,

. ~ ~ The leukemias: Epidemiologic ASpects
Author(s), year Study group

bIe 6-5 Studies examoog the reUtJon~ between letA<emia and exposure to ~ar weapons. faBout, or nuclear faalties

- -- - -

Type of radiati4n Amt. of radiation Findings with respeca to 1

Hiroshima: gamma

rays and

neutrons

Nagasaki: gamma

rays primarily

0-400+ rw Leukemia (including ALL, AI

CML, but not CLL) was i(

late mortality effect of nuclc

There was a stronger radial

rarcinogenic effect for Hiro:

Gamma rays from

Du<:lear tests

carried out in

Nevada during

the 1950's.

Unknown Observed leukemia mortality i

2.44-rold ror the high-e.pos

children living in high fallOt

southern Utah compared wi

ex~ure cohort or dJildren

fallout counties. Leukemia c

allailable on most death cert

Children in Utah

under \ 5 years of

age rrom 1944- 7S

including 378

dlildren who died

from leukemia or

other cancers.
Operation Hardtack I

1958 - Pacific Proving Grounds

During Operation Hardtack 1 and 2 (1958) there were 62 US atomic weapons fired

into the atmosphere, fifteen other devices were detonated underground. The Soviet Union

also fired 34 atomic weapons above ground in 1958. The British exploded 5 weapons at

Christmas Island. There were 16,000 DOD persoJUlel involved in the US tests.

Hardtack I included 35 tests, the largest test series so far (l958 in fact saw a total of??

U.S. tests, more than the three previous recQrd setting years combined). Partly this burst

of testing activity was due to building pressure for an jmmi~nt test moratorium, leading

the weapons labs to rush as many device types to the test range as possible. A total of

35.6 megatons were shot during this series.

The lab tests centered on ICBM and SLBM missile warheads and high yield strategic

bombs. The DaD Conducted high altitude multi-megaton tests to study their usefulness

for ABM (anti-ballistic missile) warheads, and discovered the high-altitude EMP

(electromagnetic pulse) effect in the process. Effects tests of tmderwater explosions were

also conducted.

The extensive test schedule required the use not only of both atolls (Bikini and Enewetak)

but Johnston Island also. This series was the last to conduct atmospheric testing at Bikini

and Enewetak atolls. Test names were taken from North American trees and shrubs.

Source: nuclearweaoonarchive.org

Hardtack I consisted of three portions; the first was the development of nuclear weapons.

This was a continuation of the type of testing conducted at Enewetak and Bikini during

the early and mid-1950s. In these tests, the weapons development laboratories, Los

Alamos Scientific Laboratory and the University of California B~~8tion Laboratory,

detonated their experimental devices, while the Department of Defense (DoD) provided

support and conducted experiments that did not interfere with Atomic Energy

Commission activities.

The second portio~ sponsored by DoD. consisted of the underwater tests WAHOO and

UMBRELLA. WAHOO was detonated in the open ocean and UMBRELLA in the lagoon

at Enewetak. The purpose of these tests was to improve the understanding of the effects

of underwater explosions on Navy ships and material. These were continuations of earlier

underwater testing that included BAKER in Crossroads at Bikini in 1946 and WIGWAM

off the U.S. West Coast in 1955.

The DoD also sponsored the third portion, addressing the military problems of air-borne

nuclear weapon defense. Three high-altitude tests featured rocket-borne TEAK and

ORANGE at Johnston Island and balloon-hoisted YUCCA between Enewetak and

Bikini.
Two major aspects of Hardtack I's experimental program were the development of the

weapons themselves and the measurement of the explosive and radiation effects. Also,

since the development of a nuclear amled fleet ballistic missile was on a fast track, a

portion of Hardtack I was devoted to testing the w3rh~d for the Polaris missile.

Tbe.1eSts: ~PIisiDg; _195~ eperat:ifm" Hmdtaek.J were as; follows.:

YUCCA, April 28, Pacific (between Enewetak and Bikini), balloon, weapons

effects, 1.7 kilotons (kt)

CACTUS, May S, Enewetak, surface, weapons related, 18 kt

F~ May 11, near Bikini, barge, weapons related, 1.36 megatons (Mt)

BUTfERNUT, May 11, near Enewetak, barge, weapons related, 81 kt

KOA, May 12, Enewetak, surface, weapons related, 1.37 Mt

WAHOO, May 16~ near Enewetak, Wlderwater, weapons effects, 9 kt

HOLL Y, May 20, near Enewetak, barge, weapons related, 5.9 kt

NUTMEG, May 21, near Bikini, barge, weapons related, 25.1 kt

YELLOWWOOD, May 26, near Enewetak, barge, weapons related, 330 kt

MAGNOLIA, May 26, near Enewetak, barge, weapons related, 57 kt

TOBACCO, May 30, near Enewetak, barge, weapons related, 11.6 kt

SYCAMORE, May 31, near Bikini, barge, weapons related, 92 kt

ROSE, June 2, near Enewetak, barge, weapons related, 15 kt

UMBRELLA, June 8, near Enewetak, underwater, weapons effects, 8 kt

MAPLE, June 10, near Bikini, barge, weapons related, 213 kt

ASPEN, June 14, near Bikini, barge, weapons related, 319 kt

WALNUT, June 14, near Enewetak, barge, weapons related, 1.45 Mt

LINDEN, June 18, near Enewetak, barge, weapons re1a~ 11 kt

REDWOOD, June 27, near Bikini, barge, weapons related, 412 kt

ELDER, Jwe 27, near Enew~ barge, weapons related, 880 kt

OAK, June 28, near Enewetak, barge, weapons related, 8.9 Mt

mCKORY, June 29, near Bikini, barge, weapons related, 14 kt

SEQUOIA, July 1, near Enewetak, barge, weapons related, 5.2 kt

CEDAR, July 2, near B~ barge, weapons related, 220 kt

DOGWOOD, July 5, near Enewetak, barge, weapons related, 397 kt

POPLAR, July 12. near Bikini. barge. weapons related, 9.3 Mt

SCAEVOLA, July 14, near Enewetak, barge, safety experiment, zero yield

PISONIA. July 17. near Enewetak, barge. weapons re~ 255 kt

JUNIPER, July 22. near Bikini. barge, weapons related, 65 kt

OLIVE, July 22. near Enewetak, barge, weapons related, 202 kt

P~ 1uly 26. near Enewetak, barge. weapons related. 2 Mt

TEAK, August 1. offlobnston Island area. rocket, weapons effects, 3.8 Mt

QUINCE, August 6, Enewetak, surface. weapons related, zero yield

ORANG~ August 12. off Johnston Island 8lQ, rock~ weapons effects, 3.8 Mt

FIG, August 18, Enewetak, surface, weapons related, 20 tons
ATTACHMENT: To be inserted in F.l in my petition #

There were several incidents at ENEWET AK ATOLL:

. Scientists gathered in areas where boxes were discovered to leak radiation

. Swimming in potentially cont8n1JMted waters from radioactive fallout

. No monitoring for internal exposmes due to ingested or inhaled radioactive material

/as part of a group gathered when a box used as a seat

was discovered to leak radiation. He expressed concern in later yeatS about swimming in

areas that were potentially contAminAted witJI radioactive fallout and also about ingesting

and inhaling radioactive material.

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CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT

State of Co ~ --- ,~R.w \ f\

Coumyof_- ~~EOf\

On ~~c..~ \ I -'-Q~SD~

'!o(~e. 7 ~;J..1. ~ . ~~N'l~

N~. Title of Otficer

penaD&Uy appeared

/am8(S) of Si&Der(s)

proV81 to me 01 the basis of 1~~~n!'Y evWielco

10 ~ me penon(s) whose JWDe(s) lS/aro Nbscribed

to ~ within instNmmt and .gbDrR~ to me

that he/she/they ex-:'::~'!~~ me SaDIO inbisIbor/tbeil'

aUlhonzed capacit.v(ieJ). aDd that by ~

.~(s~ All ~~ ~t ~ pers:ao<s). or the

mtity ap~ bebalf ofw~ tho person(s) ~

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persCX1a1ly known T.Q ~ OR

WcrNBSS my hand and offiQal seal

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Thougn tho data below iI nOt rcquued by law) It may prow valuaGle'to persens relyiDs on the documan and could

prevem ftalllj1jlmx reaaacbman armis:form.

Capacity Claimed By Si&ner Description Of attached Document

Individual

Corpome Officer

-

Title( s ) TWo or Type of'Documem

Parm.er(S) l.imi!~

General

A:D.om.ey- In -Fact Nwnber of Pages

TruSt"(I)

Guardian/C<mse lWtOf

Other:

Date ofDOC'imaII

Signer-is Reprosmnna:

Name of Persal(s) or ::Emit)(ies)

S~(s) Otber'1'han Named Above