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.1 - We 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.

Ta the EST °F ny KhnowilLE0E€ THERE
WAL hd ZntA 'Motutoging Ar VEntfon
CoRF0EATION

2% \/ 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.

Gi T Gf n WLE 06E E
UA 1d. 2trntEenl ' ne yitillag At—~ VEOV

nae 7 S
ee Col BE fous:
Part F is continued on the following page.
Stine PASRCOHEIS Comp WO—e3 Py
Ontis 22 day Mover or 721 before me, the undersigned notary publi,
personally ape Drovod to me through satisfactory
evident of| Bais Lian _,
{th bo the parton whose name is Ste we ed iment, and
hesceli higatsP etitioner _—-

ms M (Official signature and seal of notary)
Wyconntsinegie (0/7/2016



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 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 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:



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

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

Special Exposure Cohort Petition — Form B

OMB Number: 0920-0639 Expires: 09/20/2013
Page 4 of 7

Proposed Definition of Employee Class Covered by Petition — Complete Section E.

E.1. Name of DOE or AWE Facility:
E.2 _ Locations at the Facility relevant to this petition:
FOUN OLY
{£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:
MEA e6ag OPEL AEE
EleEctkic FURNACE OFERATZ.
E.4 Emplovment Dates relevant to this petition;
Start LLY End -¥7
Start YG End 719
Start End
E.5 _ Is the petition based on one or more unmonitored, unrecorded, or inadequately monitored or

recorded exposure incidents?: mm Yes Q No

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

Doki tHe A BevE Empgoymenrl DATES
QO To TH. AV a WIlE0ce THEE
WA. OF : .

Bet Aisicrens Guid Were Ar

G0.to-Part F.

Onthis 20_Dey of Vorendy~ toll betoce me, the wncersigmed netary pl,
personally appesred .» proved tg me through sailstactory
evideace of identification, which wero, riers be eae ;

‘to he tho person whore name is slened on the preceding of atizohad deoursant, and
Nae -Seeurbe Number:

My coraralssion expires,

1a of Fipet:Petitioner: __
ye {Official slyisture ond seal of retag)
ol 7/20l¢



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

under the Energy Employees Occupational Centers for Disease Contro! and Prevention
lilness Compensation Act National Institute for Occupational Safety and Health

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

F.3  IWehave 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 repo to the back of the petition form.)

*.Go to Part G.

Signature of Person(s) Submitti omplete Section G.

All um of three persons may sign the petition.
/~30-(/
Date

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
Division of Compensation Analysis and Support
NIOSH
- 4676 Columbia Parkway, MS-C-47
mop, Cincinnati, OH 45226

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

Stotaot MMASeCc Ell 5 County ok orees Fem

Onthis 30 Day ot. Mover Yr .2(/ before ma; the undersigned notary publ,
personally appeared vet oe asec
Tiers

evidence of identification, which were,

to be the person whose name is signed on the preceding or attached document, and

af

ans teatro Hichel ak Setwolitpadperibevtet euee-Petitioner:
(Official signature and seal of netaey

ycannisin spies (217 [201.6





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 12-05-11P04: National Institute for Occupational Safety and Health
- 04:05 RCV .
Shi Number: 0920-0630 Expires: 09/20/2013

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 {n.the denial of any right, benefit, oF 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 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 neatly on the form.

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

1 A Survivor (of a former Energy Employee), Start at B
Start at A

if you are:

QA Representative (of a current or former Energy Employee),

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? Q Yes (Go to A.2) No (Go to A:3)
A2 Organization Information:

Name of Organization

Position of Contact Person
A3 Name of Petition Representative:

Mr/Mirs./Ms._ First Name Middle Initial Last Name

A4 Address:
Street Apt # P.O. Box
City State Zip Code

A5 Telephone Number: ( » -
A6 Email Address:

A7 (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'aré 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 U.S. Department of Health and Human Services
under the Energy Employees Occupational Centers for Disease Control and Prevention
National Institute for Occupational Safety and Health

OMB Number: 0920-0639 Expires: 09/20/2013
Special Exposure Cohort Petition — Form B Appendix — Continuation Page

n AS A

Eth Hue gical 2 PEAT I. At. ETAT OTe
Web THE WAS Al At Expeeimer7itt ELE Ric
_f~ubnae obekutck, Arttat 3ob HE MELtE) Arvo

—fMecéSep MATELAL Such AS. LP Abdi AD
—tHokLuing |

Her of Leap sini brie cx. rity Po DEERE

Illness Compensation Act

Continuation Page — Photocopy and complete as necessary.

Ll—30— 20 if

personally ii Era
or ei Vi les Sen

yon whose name is signed ort the precodlg 0 of attached ceeuit and

a eee Attach to Form B if necessary.

* 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
lllness Compensation Act National Institute for Occupational Safety and Health

OMB Number: 0920-0639 Expires; 09/20/2013
Special Exposure Cohort Petition — Form B Appendix — Petitioner 3

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

B.1 Name|

First Name Middle Initial Last Name”
B.2 Social Security Number of Survivor:
BQ AetAnann AE Cremstenen
cay DIATE

B.4 Telephone Number of Survivor:
B.5 Email Address of Survivor:
B.6 _—_—- Relationship to Employee: |

<2 Goto Part C.

Cc Employee Information — Complete Section C.

C.1. Name of Employ---

Mr/Mrs./Ms. Firsciwame Wrage Tita Last Warne

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

Mr./Mrs./Ms. First Name Airtel Initial Tact 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: ( ) =

C6 Email Address of Employee:

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

C.7b Dates of Employment: Start | : 44 End | ET
C.7¢ Employer Name: -a“9 = 72
C.7d Work Site Location:

Ene on CokP., BeCzeLy WA 0/9 15{
C.7e Supervisor's Name: ne

Sign Part G of the original petition.

Name or Social Security Number of First Petitioner;



D1

D.2

D3

D4
D5
D6

D7

Special Exposure Cohort Petition — Form B

Special Exposure Cohort Petition U.S. Department of Health and Human Seivi¢es
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
Page 307

Labor Organization Information — Complete Section D O if you are a labor organiza
Labor Organization Information:

Name of Organization

Position of Contact Person
Name of Petition Representative:

Address of Petition Representative:

Street Apt# P.O. Box

City State Zip Code
Telephone Number of Petition Representative: ( d -
Email Address of Petition Representative:

Period during which labor organization represented employees covered by this petition
(please attach documentation): Start End

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

Go to Parte.

Name or Social Security Number of First Petitioner: