June 7,2007 

Mr. Larry Elliott 

Director, Office of Compensation Safety and Health 

4676 Columbia Parkway, MS C46 

Cincinnati. Ohio 45226 

Dear Mr. Elliott: 

Subject: Special Exposure Cohort Petition 

Please find enclosed my petition along with former employees, petitioner #2 . _ ind 

petitioner #3 designate a class of employees of the Mound Plant in 

Miamisburg, Ohio to be included in the Special Exposure Cohort (SEC) under the EEOICPA of 

2000. The period of activities covered by this is 1943 to 1970. 

The work at Mound was performed in one of the earliest environments where nuclear materials 

were processed, with exposure controls that, although normal at that time, would be deemed 

unsuitable by today's standards. Very limited, if any monitoring and exposure data are available 

for the time period involved, and there are significant uncertainties regarding the monitoring 

techniques in place at that time. It is likely that radiation and chemical exposure doses during 

this period could have endangered the health of members of this class of employees and it is not 

feasible to estimate exposures with reasonable accuracy. 

I appreciate your efforts to assist the former employees and their suwiors through the 

SEC process. 

Thank You 

Sincerely, ,, , 

-. - .. ,'I 
.2 Omanlzation Information: 

Name of Organhation 

Position of Contact Person 

A.3 Name of Petition Representative: 

Mr.lMrs.IMs. First Name Middle Initial 

A.4 Address: 

A.5 Telephone Number. 

k6 Email Address: 

A.7 0 Check the box at left to indicate you have attached. to the back of this form written authorization to 

petition by the su~ivor(s) or empioyee(s) Indicated in Parts B or C of this form. An authorization 

-. . 

Name or Social Security Number of First Petitioner: -. 
Special Exposure Cohort Petition 

under the Enargy Employees Occupational 

Illness Compensation Act 

U.S. Deoartment of Health and Human services] 

Centers for D ssase Control and reve en loon' 

National InstitJte for Occupat'onal Safety and Health 

1 Soecial EXDOSU~~ Cohort Petltlon - Form I3 

OMB Number. 0920-0639 Explres: 05/31/2007 

Pam 2 nf 7 

I 

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

8.2 Social Security Number of Survivor: 1 

8.3 Address of Survlvor: I I I 

Apt # P.O. Box 

I Mr.lMrs.lMs. First dame Middle Initial Last Name I C.2 Former Name of Em~loyee (e.g., maiden namenegal name changelother): I 

.--. ( ~f'.l~rs.;h;s. ~irsi I - tmiddle Initial Last Name I 

C.3 Social Security Number of Employee: 

C.4 Address of Employee (if living): 

3.05 eas e4 

Street Apt # P.O. Box 

City State Zip Code 

C.5 ~elephone Number of Employee: I h' 

C.6 Email Address of Employee: Ah4 

C 7 Embloyment Information Related to Petition: 

C 7a Employee Number (if known): 

C 7b Dates of Employment: 

""" 2FPKx End 1983 

C 7c Employer Name: m0 

C 7d Work Site Location: Y'kl"nrd1~ ~?UW oh,'& $.Y~&L 

C.7e Supervisor's Name: Z I ..,. . - : ..,. . .', '. , . - m-' . -... ,. , . ., Go to Part E. - . . . . .- .. . . - I 

Name or Social Security Number of First Petitioner: ! 
I Snecial Exnosure Cohort Petition U.S. Denartment of Health and Human Services I 

un'der the ~n&~ Employees Ocarpational 

Illness Compensation Ad 

Centers for Disease Control and Prevention 

National Institute lor Occupational Safety and Health 

Labor Organization Information: 

Name of Organization 

Position of Contact Person 

Name of Petitlon Representative: 

Address of Petitlon Representative: 

Street Apt # P.0 Box 

C~ty State Zip Code 

Telephone Number of Petitlon Representatlve: 1 

Email Address of Petition Representative: I D6 Pe"od during which labor organization represented employem covered by hls petition 

(please attach documentation): Start End I 

D.7 Identity of other labor organizations that may represent or have represented this class of 

trmpioyws (if known): 

Name or Social Security Number of First Petitioner: - 
Special Exposure Cohort Petition 

Lnder the Energy Employees Occupatona 

Il'ness Compensation An 

U.S. Department of Health and Human services1 

Centers for Disease Control and Prevent on 

hational lnsritdle for Occupallonal Safely and Heallh 

E.l Name of DOE or AWE Facility: JMound Laboratory Miamlsburg, Ohlo 1 

E.2 Locations at the Facility relevant to this petition: 

E.3 List job titles andlor job duties of employees included in the class. In addition, you can list by I name any individuals other than wetitioners identified on this form who you believe should be I 

included-in this class: 

maintenance, prod 

administrattve and support staff in these same workareas 

Emwlovment Dates relevant to thiswetition: 

Start End 

Start End 

. . 

Is the petition based on one or more unmonitored, unrecorded, or inadequately monitored or 

recorded exposure incidents?: P Yes 0 No 

Start 41943 

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

as necessary): 

End 1970 

I 

The definition of incident is prcblematic. There is no intention to claim an exposure 

incident comparable to an uncontrolled fission reaction or criticality incident, only a 

claim of inadequately monitored and inadequately proteczed radiation exposed workers. 

This SEC petition is based on che fact 'chat large quantities of severai radion:uclides 

were processed withouc engineering controls or protectionas would be expected by 

coday's standards thus representing a real or ratiocally expected potential for 

significant risk from occnpational exposcre to radiation. In addition radiation 

rnonicoring was not uniform, in 'chat noc all workers were.routj.nely monitored. Selection 

of workers for monizoring was noc necessarily based on worst case scenarios, inother 

words rhe exposure dara available for subsets of tie- populafion nay not. represent the 

highes'c exposures experieaced. This facility was involved in large part in excracrion of 

Poloni2n 210 for roanufacture of atomic xeaFons Pu-3e neutron ini=iators bu: was also 

involved in research and developmen-. activities involving a variety of other 

radionuclides including: Ra-226, Ac-227,Th-228. Th-232, Th-230, Pa-231, and U-233 as 

well as exrraction and purification of Ra-226, Ac-227, Th-230 and Pa-231. 

The SC&A consultation report on the NIOSH Site Profile does not inspire con5idence in 

:he claimant's.thhat ~ .. accurate,~aefensi_4le,~dose~gcons~~ructjons . are possible. ,~ , ,. , ,.~ ,... . 

These comencs are a11 referable to secillon F-1 below as the unmonitored exposure 

situa:ioc at chis FacLlity represents a day by day realiry and n3r a discrete "incident" 

u per se. 
Sp'ecial Exposure Cohort Petition under lheEnergy Employees Occupational 

liiness Compensation Act 

U.S. Department of Health and Human Services 

Centers for Disease Control and Prevention 

National Institute for Occupational Safety and Health 

I OM6 Number: 0920-0839 Ex~lres: 05/31/20071 

I 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. I 

F. 1 n iWe have attached either documents or statements provided by affidavit that Indicate that I 

radiation exposures and radiation dosespotentially incurred bymembers of the proposed class, 

that relate to this petition, were not monitored, either through personal monitoring or through area I 

monitoring. I 

I (Attach documents andlor affidavits to the back of the petition form.) I 

Describe as completely as possible, to the extent it might be unclear, how the attached 

documentation andlor affidavit(s) indicate that potential radiation exposures were not monitored. 

Ths NSCBH site profiie eppearii t.,> make niany assurnpt:i.ons regarciiog ezposure assessment which aach 

carry with them a degree of uncartai.nty and pctcnt:iul error. Of n;te are the reported'high 

teEperiture processing proce,iures inrn?lvi.r,q t.ot:h Plul:onium, Thorium md Polonium isotcpes. J-sr. 

for those for whom any eYposure data ia ovallalls, i.t appaars that neither biomonitor&ng nnr 

Plnvironmenrsl monitoring datj. are suffic:Lent. .for: :individual dose characterizations xithout 

several .ascumy;tions and extraprj1al:iona rsgurding bioava.il.ibili.ty, abShEbtiOiY ad excierion.' In 

additior: any application c9f m,xe recent exposure daat to older 2ituation.r is wit? likely to 

ur~dereztintate 3xposilres given the prgr.casi.re imprcrremanta in anginneririq controls and changes in 

pr~duction techologies. In this .same veing we tjelinve that the health physics technoloaies and 

aclministrati.fe procedures wed for sxposure a~se3ement in the earliest years were neither 

acQurate nor consistent. Deficiencies in dost? estimations &re expecte", and too miany ascuuptiocs 

i:d eztranolncron+ 3r~ he2a.l made fcr sclen:rfic ii?l:ecrlt; -. - . . .- - - . . . . . . . - -. . . . . . - -. . - - -. - - - - .- - . I F.2- -By I1 We have attached either documents or statements provided by affdav:t that indicate that7 -

radiation monitoring records for members of the proposed classhave been lost, falsified, or I 

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

from the site where the employees worked. '. I 

(Attach documents andlor affidavits to the back of the petition form.) 1 

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. 

The Mound fac~lity reportedly sent 458 boxes of plant records to Los Alamos in 

1993. these records were found to be contaminated with radiation and buried at Los 

Alamos as a health hazard. One cannot but guess what these records contained. 

The most significant fact being that these records were considered a health threat 

from uptake of radioactive particulate. This does not speak well for the historical 

hygiene at the facility 

I 

Part F is continued on the following page. 1 

I 

Name or Social Security Number of First Petitioner: 
Special Exposure Cohort Petition 

underthe Energy Employees Occupational 

Illness Compensation Act 

U.S. Department of Health and Human Services 

Centers lor Disease Control and Prevention 

National Institute far Occupational Safely and Health 

OMB Number: 0920-0639 Expires: 05/31/2007 Special Exposure Cohort Petition - Form B Page 6 of 7 

F.3 0 l'We have attached a report from a heaith physicist or other individual with expertise in 

radiation dose reconstruction documenting the limitations of existing DOE or AWE records on 

radiation exoosures at the facilitv, as relevant to the oetition. The reoort soecifies the basis for I believing these documented limiiations might preve& the completion of dbse reconstructions for 

members of the class under 42 CFR Pari 82 and related NlOSH technical implementation 

I guidelines. I (Attach report to the back of the petition form.) 

F.4 lMle 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 ~nformat~on 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 petiiion. 

I (Attach report to the back of the petition form.) 

ii :: ..A 2.. '! , .. 1 of three persons rnay sign ihe petition. 

5- 2 3 -JU&,- - - - 

Signatu. #I I, ,,, Date 

i 

/ 

I 

J Ag - ,,30~,7 A ~ak 

I - (fi.-l -G7 

Signature I/ 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. I affirm that the information 

provided on this form is accurate and true. I Send this form to: SEC Petition 

Office of Compensation Analysis and Support 

NlOSH 

4676 Columbia Parkway, MS-C-47 

Cincinnati, OH 45226 

If tlit!rc arc additional petitio~iers, they must cot~ipicte the Appendix Forms for additiorlal petitioners. 

Tlie Aouendix forms arc located at the end of tnis document. 

. -1.. 

Name or Social Security Number of First Petitioner: 
Special Exposure Cohort Petition 

under the Energy Employees Occupational 

Illness Competlsalion Ad 

U.S. Department of Health and Human Services 

Centers for Disease Control and Prevention 

National lnstitute for Occupational Safety and Health 

OM0 Number: 0920-0639 Expires 05/31/2007 Special Exposure Cohort Petition - Form B Page 7 of 7 

I 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 regard~ng the burden estimate or any other aspect of this coilection 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 NlOSH 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 I 

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 3 552a), you are hereby notified of the 

following: 

The Energy Employees Occupational Illness Compensation Program Act (42 U.S.C. 55 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 lnstitute for Occupational Safety (NIOSH), an lnstitute of the Centers for Disease 

Control and Prevention. Information obtained by NlOSH 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 Advisoly 

Board on Radiation and Worker Heaip and HHS. 

Records containing identifiable information become part of an existing NlOSH system of records under the 

Privacy Ad. 09-20-147 "Occupationai Health Epidemiological Studies and EEOICPA Program Records. 

HHSICDCINIOSH." These records are treated in a confidential manner, unless otherwise compelled by law. 

Disclosures that NlOSH 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 federat 

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 NlOSH 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 NlOSH in connection 

with the evaluation of an SEC petition. 

Use of the NlOSH 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: 4 i 
Special Exposure Cohort Petition 

under the Energy Employees Occupational 

Illness Compensation Act 

U.S. Department of Health and Human Services 

Centers for Disease Control and Preventior 

National Institute for Occupational Safety and HealtiOMB Number: 0920-0639 Expires: 05/31/2007 

-. - 

iihe iolliowing is rough transcript of a hisioqrfrom - " 

. ....~ , - ~~~ 

1 - - was hired on at Mounds around the same dayas her sister in 9-25 1956- until 1986,30 

years. ' :veloped CML and died around Christmas, 2006. They all worked in several 

buildings. A cousin so worked there and got breast cancer. i , said they wore robes, 

special shoes, caps over hair, various types of gloves, rubber, plastic and cotton, occasionally a 

mask for mixing MOCA. They always wore a picture identification badge but did not always 

-wear radiation badges. Sometimes you would wear a radiation badge almost all day but usually 

only short parts of the day. She would have to shower repeatedly. She worked with Beryllium oi - 

several occasions including various laboratories and in the early years production of parts. 

-They would travel from building to building as they bid for different jobs. 

-A bldg was administration, B was biology, C was cafeteria, D was decontamination a hot bldg. 

-lots of water that they tried to wash the facility with and contaminated the regional aquifer, had 

-to remove tons of dirt. R building was radioactive and hot. A young man got so exposed to 

-radiation in the T building that he died in the medical facility. The T building was far 

lunderground. Afker three years in the T building, sometime in the 197O's), she had to be taken 

jout because of persistent contamination of her hair. She had to wear rubber gloves at home and 

i couldn't touch or sleep with her husband for about two or three weeks until the radiation cleared 

fiom her right inn. The production areas appeared spotldss, very little dust. The areas in which 

i metallurgy was done were the dirtiest areas but these were mostly staffed by men. 

The chemical storage areas were some of the most dangerous areas. 

Made heads for the trlggers or detonators of A bombs, soldered two little silver spots and took a 

micros'copic gold wire on the detonators, and test fired these. 

She worked with beryllium off and on but did not personally sand, grind or polish such parts. 

She worked quite a bit with an explosive white powder which they would weigh out with 

stainless steel spoons. 

Some supervisors didn't tell workers what they worked with 

Workers had blue books and classified red books that told workers what they did 

There were times when :not wearing a badge but her supervisor was 

Also the men didn't seem to be as careful as the women were, they were braver. 

-- .. . . . - - .- . . . ... - . . . Anach to Form B if necessary. . . . . . . . . . . . - . . . . . - - - - . . -- 

-. - -- - . .. . . - . - 

'' -1 

~ame dr Social Security Number of First Petitioner: L 
Special Exposure Cohort Petition U.S. Department of Health and Human Services 

under the Energy Employees Occupational Centers for Disease Control and Prevention r- Illness Compensation Act National Institute ior Occupational Safety and Health 

1 OMB Number: 0920-0639 Expires: 05/31/2007 1 

Special Exposure Cohort Petition - Form B Appendix - Petitioner 2 

Use of this form and disclosure oi Social Secur:ly Number are voluntary. Failure to use this form or disclose 

t 1,s !:LltllOdr wiii 110t rfsult in tlie denial of ary rigitt, Lelicfit, or prlviiege to which you may be entlrled. 

I Use this Appendix for Petitioner 2. I 

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. 

I If vou need (more sDace to prov oe aod tioiol informa!ion. Lse the conrn-atlon pagi- p,ov:ded at :he end of 

the form anc a:tach r'ie conip eted corltlnbarlon pages, lo Form B. I 

(Except for signatures, please PRINT all information clearly and neatly on the form. 1 

d~n Energy Employee (current or former), 

If you are: 0 A Survivor (of a former Energy Employee), Start at B 

I A I Are you a contact person for an organ~zat~oq? 3 Yes (Go to A 2) 0 No (Go toA 3) 1 IA.~ Organization Information: I I Name of Organization I I Position of Contact Person 1 I A.3 Name of Petition Representative: I I Mr.lMrs.iMs. First Name Middle Initial Last Name 1 

I ~.4 Address: I 

I Street Apt # P.O. Box 

I City State Zip Code I 

A.5 TelephoneNurnber: 

A.6 Email Address: 

A.7 0 Check the box at lefl to indicate you have attached to the back of this form written authorization to 

petition by the survivor(s) or empioyee(s) indicated In Parts B or C of this form. An authorization . 

form for this purpose is provided. 

, (C,. . . , .... :.*,<". ". . . 

I ivou are re6re&ting a ~urvivor(&'to Part B;'i@& irl'rcprdsi'niing an Embloyee, goto &&c. I -. . . - .- - .- - . 

I, . - 

Name or Social Security Number of First Petitioner: 4 
pecial Exposure Cohort Petition U.S. Department of Health and Human Sewices 

nder the Energy Employees Occupational Centers for Disease Control and Prevention 

lness Compensation Act National Institute for Occupational Safety and Health 

OMB Number: 0920-0639 

I I 

Mr.lMrs.lMs. First Name Middle Initial Last Name 

8.2 Social Security Number of Survivor: 

8.3 Address of Survivor: 

Street Apt # P.O. Box 

State Zip Code I 

(8.4 Telephone Number of Survivor: L I I 

18.5 Email Address of Survivor: I 

I 8.6 Relationship to Employee: 0 Spouse SonlDaughter 0 Parent 

0 Grand~arent 0 Grandchild I 

I c.1 Name of Ernploy,ee: I I tvlr.1~. First Nami Middle Initial " Last Name I I C.2 Formereme of Employee ,. (e.g., ?aiden namebegal name changelother): I I ~r.i~rr.l~i. Fir4 Name NkCldle Initial Last Name I I C.3 Social Security Number of Employe -, -- .- I I C.4 Address of Emvloyee (if liviu \ 

I street -3- .I. A,. ~pt # P.O. . - BOX 

UVr 0 l 

Gate - Zip Code - C.5 Telephone Number of Employee. , . , .. - I C.6 Email Address of Employee: I 

C.7 Employment Information Related to Petition: , 

C.7a Employee Number (if known): 

C.7b Dates of Employment: Stan 9ePf: 29. I956 End MAV/: 19R6 

C.7c Employer Name: ~m .to e se~(vch CDFD. 

C.7d Work Site Location: UMOU t?d ?/&f 

m (4. w is h ~crq 4 1'0 h . i' " .- . 45342, - 

C.7e Supervisor's Name: -- - 

Sign Part G of the original petition. - -- 

Name or Social Security Number of First Petitioner: I - 
Special Exposure Cohort Petition U.S. Department of Health and Human Services 1 under the Energy Employees Ompatianal Centers for Disease Control and Prevention 

1 Illness Compensation Act National Institute for Occupational Safety and Health 

I OMB Number: 0920-0639 

-76 ,. , > -~ 

The folllo,~ing is rough transcript of a history from sister of? - 

1 

was hired on at Mounds around the same dayas her sister'in 9-25 1956- until 1986, 30 

I years. Mary developed CML and died around Christmas, 2006. They all worked in several 

buildings. A cousin also worked there and got breast cancer. . said they wore robes, 

special shoes, caps over hair, various types of gloves, rubber, plastic and cotton, occasionally a I mask for mixing MOCA. They always wore a picture identification badge but did not always 

i 

I wear radiation badges. Sometimes you would wear a radiation badge almost all day but usually 

only short parts of the day. She would have to shower repeatedly. She worked with Beryllium or 

several occasions including various laboratories and in the early years production of parts. 

They would travel 6om building to building as they bid for different jobs. 

S A bldg was administration, B was biology, C was cafeteriq D was decontamination a hot bldg. 

lots of water that they tried to wash the facility witb and contaminated the regional aquifer, had 

i to remove tons of dirt. R building was radioactive and hot. A young man got so exposed to 

i {radiation in the T building that he died in the medical facility. The T building was far 

I >underground. After three years in the T building, sometime in the 19701s), she had to be taken 

i 

8 iout because of persistent contaminationof her hair. She had to wear rubber gloves at home and 

!I Jcouldn't touch or sleep with her husband for about two or three weeks until the radiation cleared 

i 

1 4 6om her right arm. The production areas appeared spotless, very little dust. Thc areas in which 

1 metallurgy was done were the dirtiest areas but these were mostly staffed by men. s The chemical storage areas were some of the most dangerous areas. 

5 -Made heads for the triggers or detonators ofA bombs, soldered two little silver spots and took a 

t -/microscopic gold wire.on the detonators, and test fired these. 

I -1She worked with beryllium off and on but did not personally sand, grind or polish such parts. 

-:ili?c worked quite a bit with an explosive white powder which they would weigh out with 

1, Jstain~ess steel spoons. 

:Some supervisors didn't tell workers what they worked with __I 

!workers had blue books and classified red books that told workers what they did 

iThere were times when y was not wearing a badge but her supervisor was 

! 1Also the men didn't seem to be as careful as the women were, they were braver. 

-1 

/,I 

Name or Social Security Number of First Petitioner: _i - 
Special Exposure Cohort Petition 

Lnoer 'he Ena,g Emp,o)er's CY.~ rn, 

n?ss Ccnpc1sa:cn 1.r: 

U.S. Department of Health and Human Services 

Centers for Disease Control and Prevention 

National Institute for Occupational Safety and Health 

OM5 Number: 0920-0639 Expires: 05131C 

I Use this Appendix for Petitioner 3. I I 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. I I Refer to the General Instructions on completing petitioner information for Parts A, B, or C. I 

If vou need more soace to orovide additional information, use the contintiation page provided at the end of 

tne form and aflach tne completed con1 n~ation page(s) to Form 9. 

I Except for signatures, piease PRINT all information clearly and neatly on the foml. I 

I d~n Energy Employee (current or former). Start at C I 

I if you are: 1 A Survivor (of a former Energy Employee), Start at B I 

I I U A Representative (of a current or former Energy Employee). Start at A I 

.y?"!+.q>,;+#&@v# bp&$8.:j;J/';c! ~+ :26.=a. . S?" .... . ,~ ~ ~ . ~ 

A? Are you a contact person for an organizati 

IA.~ Organization Information: I 

I Name of Organization I 

Position of Contact Person 

A.3 Name of Petition Representative: 

Mr.lMrs.lMs. First Name Middle Initial Last Name 

A.4 Address: 

I Street Apt # P.0. Box I 

City State Zip Code 

A.5 Telephone Number: 1 

A.6 Email Address: 

A.7 0 Check the box at left to indicate you have attached to the back of this form written authorization to 

petition by the suwivor(s) or employee(s) indicated in Parts B or C of this form. An authorization 

form for this purpose is provided. 

you ard representing a survivk'; go to Part B; if you are repreieAting an ~mpioyee, go to Part C. 

a---~ 

Name or Social Security Number of First Petitioner: 4 1 
Special Exposure Cohort Petition 

underthe Energy Employees Occupational 

Illness Compensation Act 

U.S. DeDarhnent of Health and Human Services I 

Centen for D:sease Control and Prevention 

National InsltJte for Occdpatona Safely and Hea.th 

.... ... , .. I BI Name of Survivor: - "I 1 Mr.lMrs.lMs. First Name Middle Initial Last Name 1 

8.2 Social Security Number of Survivor: 

8.3 Address of Survivor: 

I Street Apt # P.O. Box I I city State Zip Code I 

I 

8.4 Telephone Number of Survivor: ( 

8.5 Email Address of Survivor: 

8.6 Relationship to Employee: 0 Spouse 0 ~6nl~au~hter 0 Parent 

U Grandparent U, Grandchild ... ........ ...... ., . . . . . 

GO to Part C. 

I C.l Name of Employee; ( An - 

I Mr/Mrs.Ns. ~irsf N& Middle Initial Last Name 

) C.2 Former Name of Employee (e.g., maiden namefleqal name changelother): . - 

I d 

Mr./Mrs.lMs. First Name 

/1 

Middlk Initial J Last Name 

C.3 Social Security Number of Employe-. . - - -, 

C.4 Address of Employee (if living): 3 . ,.- fl A 

Street ,A .A 81 Apt # .f d P.O. Box 

City State I~-~ . Zip Code 

C.5 Telephone Number of Etnploye=. , . - , , - ~* - *. 

C.6 Email Address of Employee: ddC.7 Employment Information Related to Petition: 

C.7a Employee Number (if known): 

C.7b Dates of Employment: Start Ann'/ ?c! fl.7 

c.7~ Employer Name: sewck 

C.7d Work Site Location: a1~/1d hb 

l"/jl ~~.WIIS bl*fu, Oh/.$ -1 . ! /<I 

U~34oZ 

C.7e Supewiso<s Name: 

I I 

si$n ~a'i'~ of the oiginal - petition. ' 

Name or Social Security Number of First petitioner: . - I-- 

I Snecial Exnosure Cohort Petition U.S. Denartment of Health and Human Services I 

un'der the ~n&~ Employees Ocarpational 

Illness Compensation Ad 

Centers for Disease Control and Prevention 

National Institute lor Occupational Safety and Health 

Labor Organization Information: 

Name of Organization 

Position of Contact Person 

Name of Petitlon Representative: 

Address of Petitlon Representative: 

Street Apt # P.0 Box 

C~ty State Zip Code 

Telephone Number of Petitlon Representatlve: 1 

Email Address of Petition Representative: I D6 Pe"od during which labor organization represented employem covered by hls petition 

(please attach documentation): Start End I 

D.7 Identity of other labor organizations that may represent or have represented this class of 

trmpioyws (if known): 

Name or Social Security Number of First Petitioner: -