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EEOICPA Dose Reconstruction Interviews and Form

Attachment C Telephone Interviews

EEOICPA Dose Reconstruction Interviews and Form

OMB: 0920-0530

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-0530 can be found here:

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Attachment C - Telephone Interviews with Claimants/Coworkers and Introductory Letters

ORAU Team

Dose Reconstruction Project for NIOSH

ORAU Team

Dose Reconstruction Project for NIOSH

NIOSH Tracking Number:

Date:

Name

Address

City, ST Zip

Dear Name:

Oak Ridge Associated Universities (ORAU) requests your help in reconstructing the radiation dose for your claim. ORAU, the contractor assisting the National Institute for Occupational Safety and Health (NIOSH) with the dose reconstruction process, will be conducting a telephone interview with you shortly to gather information concerning radiation exposure information for your claim. The interview takes about an hour on average to complete. If we need additional information that may only be available from supervisors, co-workers or others, the interview is also an opportunity for you to help us identify and locate these persons.

Your participation in this interview is voluntary. If you choose to be interviewed, the information you provide will be treated in a confidential manner unless otherwise compelled by law. The information you provide to ORAU will be shared with staff working for NIOSH and the Department of Labor (DOL), both of whom have roles in administering this program. Please note that if you have any special needs for the interview (for example, hearing impairments, Spanish-speaking interview, etc.) ORAU will make arrangements to meet those special needs. After the telephone interview has been completed, a summary report will be prepared and sent to you for your review. Once the report is complete and you have had time to review and comment on it, we will proceed with the dose reconstruction process.

To help you prepare for the interview, we have enclosed a list of the questions that will be covered. Please DO NOT send this questionnaire back to us; we will take this information by telephone. When you have reviewed the enclosed questions and feel that you are ready to schedule your telephone interview, please call ORAU toll-free at 1-800-790-6728 (1-800-790-ORAU) and ask to speak to the telephone interview scheduler. Keep in mind that this initial call is simply to SCHEDULE your interview, not to actually perform the interview. Our hours are from 8:00 a.m. to 4:30 p.m. Eastern time, but we have found that calls placed between 8:30 a.m. and 11:00 a.m. may experience a shorter wait time for you in scheduling the interview.

Feel free to call our toll-free number if you have any questions about the interview process. You may also get more information on ORAU at www.oraucoc.org.

Sincerely,

Claimant Communications

ORAU Team

Dose Reconstruction Project for NIOSH

Enclosure

Form Approved: OMB No. 0920-0530 Exp. Date x/xx/xx

EEOICPA Dose Reconstruction Telephone Interview

Claimant is Covered Employee

This interview provides you with the opportunity to inform NIOSH of any additional information regarding your work history that might not be contained in the exposure monitoring information we receive from the Department of Energy (DOE) or Atomic Weapons Employer (AWE). While we encourage all claimants to participate in the interview process, participation is voluntary. Even though some claimants may not be able to answer all of the questions during the interview or have limited answers to the questions, any information provided during the interview may be useful in the dose reconstruction process.

Interviews with survivors will seek more general information while the interviews with energy employees will contain more detailed questions. This interview should take no more than an hour, although we may have to call you back for additional information. If we need to divide this interview into a couple of shorter calls, we can do that as well. While we believe that most dose reconstructions can be completed without discussing classified information, we will arrange for a secure interview for those claimants who believe such an arrangement is necessary to complete the interview.

Public Burden Statement

Public reporting burden for this collection of information is estimated to average 60 minutes per response, including time for reviewing instructions, gathering the information needed, and completing the interview. 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-D-74, Atlanta, GA 30333; ATTN:PRA 0920-0530. Do not send the completed interview form to this address. Please do not complete and return this form; you will be contacted by telephone to collect this information. Persons are not required to respond to the interview questions unless a currently valid OMB number is displayed.

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) requires the promulgation of methods, in the form of regulations, for estimating the dose levels of ionizing radiation incurred by workers in the performance of duty for nuclear weapons production programs for the Department of Energy and its predecessor agencies. These methods are applied by the National Institute for Occupational Safety and Health (NIOSH), an Institute of the Centers for Disease Control and Prevention, for producing radiation dose estimates that the U.S. Department of Labor uses in adjudicating certain claims under EEOICPA.

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 to complete a radiation dose reconstruction for your claim 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 relevant to completing a radiation dose reconstruction for your claim; (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 interviews and forms that you may receive from NIOSH in connection with completing a radiation dose reconstruction for your claim.

Your participation in this interview is voluntary.

Employment History

1. What jobs have you held working for DOE, DOE contractors, or AWEs?

Employer

Supervisor’s Name

Job Title

Start Date

(mm/yyyy)

End Date

Start with the most recent job and ask the following questions in sections. Repeat these for each DOE/AWE job included in the employment history.

Detailed Work History:

2. How many hours per week did you work on this job? ______hrs/week

How many hours per week did your job involve potential exposure to radiation and/or radioactive materials? _____hrs/week

4. Which buildings or locations did you work in, for each of your routine duties?

Building/Location

Duties

5. Describe what you did on the job, as routine duties.

________________________________________________________________________

Obtain additional details on duties, as necessary:

5.1 What types of radioactive materials were present or processed, and in what form(s) (solid, liquid, or gas)? Review the list below individually, as necessary.

Radionuclide Response Isotope(s) if known Form

Tritium __Y __N __DK _____ __S __L __G

Cobalt __Y __N __DK _____ __S __L __G

Strontium/Yttrium __Y __N __DK _____ __S __L __G

Technetium __Y __N __DK _____ __S __L __G

Iodine __Y __N __DK _____ __S __L __G

Cesium __Y __N __DK _____ __S __L __G

Thallium __Y __N __DK _____ __S __L __G

Lead __Y __N __DK _____ __S __L __G

Polonium __Y __N __DK _____ __S __L __G

Radon (progeny) __Y __N __DK _____ __S __L __G

Radium __Y __N __DK _____ __S __L __G

Actinium __Y __N __DK _____ __S __L __G

Europium __Y __N __DK _____ __S __L __G

Thorium (natural) __Y __N __DK _____ __S __L __G

Protactinium __Y __N __DK _____ __S __L __G

Uranium (natural) __Y __N __DK _____ __S __L __G

Uranium(enriched) __Y __N __DK _____ __S __L __G

Neptunium __Y __N __DK _____ __S __L __G

Plutonium __Y __N __DK _____ __S __L __G

Americium __Y __N __DK _____ __S __L __G

Curium __Y __N __DK _____ __S __L __G

Californium __Y __N __DK _____ __S __L __G

Others

___(1) _____ __S __L __G

___(2) _____ __S __L __G

___(3) _____ __S __L __G

5.2 What quantities of radioactive materials were present or processed (ounces, pounds, kilograms, drums) over what time periods? ________________________

________________________________________________________________________

5.3 What types of production processes involving radioactive materials occurred in areas where you worked?_____________________________________________

5.4 What types of radiation-generating equipment were present or used (e.g., neutron devices, radiography equipment)?____________________________________

5.5 What specific tasks did you perform, using what types of radioactive materials (in what quantities), and/or radiation generating equipment?____________________

5.6 What exposure/contamination control measures were used to protect you?

Measure Frequency of use

___Hoods __Always __ Sometimes __ Never

___Glove boxes __Always __ Sometimes __ Never

___Shielding __Always __ Sometimes __ Never

___Other enclosures (explain) __Always __ Sometimes __ Never

___Local ventilation __Always __ Sometimes __ Never

___Anti-contamination clothing __Always __ Sometimes __ Never

___ Respirators __Always __ Sometimes __ Never

___Other personal protective __Always __ Sometimes __ Never

equipment (specify)

___Showers __Always __ Sometimes __ Never

5.7 Did you conduct your work under a radiation work permitting system?

___Yes

___No

___Don’t know

If “No” or “Don’t know”, go to question 6, if “Yes”:

5.8 During what time period(s)?___________________________________________

Radiation Monitoring

Did you or your co-workers (working in the same area as you) routinely wear radiation dosimetry badges?

___Yes

___No

___Don’t know

If “No” or “Don’t know”, go to question 7, if “Yes”:

6.1 For which duties or in which buildings or locations, and during what time periods (e.g., which years) did you or your co-workers (working in the same areas as you) routinely wear radiation dosimetry badges?

Building/

Location

Time Period

Duties

Wore badge

(check = yes)

Only co-worker wore badge

If the claimant did not wear a badge, go to Question 7, if claimant wore a badge: I’ll ask you several questions about badge practices. I realize that badge practices changed over time, so please recall to the best of your ability any changes and the time period that they cover:

6.2 How often did you wear your badge?

Time Period Frequency

__________ _________

6.3 How often was your badge exchanged?

Time Period Frequency

__________ _________

6.4 Where on your body was your badge worn?

Time Period Body Location

__________ ____________

7. Did you participate in a biological radiation monitoring program (urine/fecal/breath)?

___Yes, urine

___Yes, fecal

___Yes, breath

___No

___Don’t know

8. Do you have copies of your dosimeter badge or biological monitoring records?

___Yes, badge ___Yes, biological

___No

If “No” go to question 9, if “yes”:

Would you provide copies to us?

____Yes

____No

If “Yes” go to question 9, if “No” explain the importance of this information and address any concerns, as feasible. If the answer remains “No”:

8.2 Why not? _________________________________________________________

Did you routinely survey yourself (frisk) for external contamination?

If “No” go to question 10, if “Yes”:

When did you survey yourself, before or after showering?

___ Before

___After

Was there general area air monitoring for radiation performed in the work environment?

___Yes

___No

___Don’t know

If “No” or “Don’t know” go to question 11, if “Yes”:

When (over what time periods) did this occur?_________________________________

Were there any radiation surveys taken to characterize potential for external exposure?

___Yes

___No

___Don’t know

If “No” or “Don’t know” go to question 12, if “Yes”:

When did these occur?_________________________________

If claimant worked at Fernald, Mallinckrodt, or FUSRAP, or if the claimant responded in Question 5 that he worked with radium and/or thorium, ask the following question; if not, go to question 13:

12. Was there monitoring in any of the buildings or areas you worked for exposure to radon?

____Yes

____No

____Don’t know

If “No” or “Don’t know” go to question 13, if “Yes”:

12.1 Which buildings or areas? ____________________________________________

13. Were you ever restricted from the workplace or certain job duties because you had reached a radiation dose limit?

___Yes

___No

Radiation Incidents

14. Were you ever involved in an incident involving radiation exposure or contamination?

___Yes

___No

If “No” go to question 15, if “Yes” ask the following questions for each incident identified:

14.1 What happened and when?___________________________________________

14.2 Which radioactive materials were involved, and in what form and quantity?___________________________________________________

14.3 Which radiation-generating equipment was involved?________________

14.4 Where did it take place? _______________________________________

14.5 Who was involved? ___________________________________________

14.6 What actions were taken to remedy the exposure or contamination?_______________________________________________

14.7 What were your location and activities during the incident?____________________________________________________

14.8 What precautions were taken to protect you?_______________________________________________________

14.9 What types of personal protective equipment, if any, did you use?_______________________________________________________

How long were you exposed during the incident?____________________________________________________

Did you receive chelation therapy or other medical treatment as a result of radiation exposure from this incident?

___Yes

___No

___Don’t Know

If “No” or “Don’t know” go to question 14.12, if “Yes”:

Please describe the medical treatment you received:

_____ Chelation Therapy

__________________________________________Other Medical Treatment

Did you receive biological monitoring after the incident?

___Yes

___No

If “No” go to question 15, if “Yes”:

What type of biological monitoring?

___whole body measurement

___urine

___fecal

___breath

Do you have records of this monitoring?

___Yes

___No

If “No” go to question 15, if “Yes”:

Are you willing to provide copies of these records to NIOSH?

___Yes

___No

If “Yes” go to Question 15, if “No” explain the importance of this information and address any concerns, as feasible. If the answer remains no:

14.16 Why not?________________________________________

Required medical screening x rays

15. Were you ever required to have medical x rays for this job, as a condition of employment?

___Yes

___No

If “No” go to question 16, if “Yes” :

15.1 How often were you x-rayed, and over what time period(s)?

Time Period

Frequency of x rays

Do you have records of these x rays?

___Yes, for all x rays

___Yes, for some x rays

___No

If “No” go to question 16, if “Yes”:

Would you provide us with copies of these records?

___Yes

___No

Other relevant information

Have we missed asking you about any conditions, situations, or practices that occurred during this job which you think may be useful to us in estimating your radiation doses?

___Yes

___No

If “No”, go to Question 17, if “Yes”:

16.1 Describe this with as much detail as possible, in terms of what occurred, where, when, for how long, and who was involved:

______________________________________________________________________________________________________________________________________________________________________________________________________

Are you aware of any records related to the information you have provided that may help us estimate your doses?

___Yes: Source/Type

___Personal Physician

___Site Medical Records

___Incident Reports

___Safety Meeting Notes

______________________Other (describe)

___No

If “No” and this is the last job to review, go to Question 18.

If “Yes” and the records are from a personal physician, ask the claimant to obtain and provide the relevant medical records to NIOSH.

Final Questions – Identifying co-workers and other witnesses

Can you name co-workers or other witnesses, such as consulting industrial hygienists or radiation safety specialists, who can confirm or expand upon the information you have provided us?

___Yes

___No

If “Yes”, obtain up to five names and any contact information available:

1.____________________________

2.____________________________

3.____________________________

4.____________________________

5.____________________________

Form Approved : OMB No. 0920-0530 Exp. Date x/xx/xx

EEOICPA Dose Reconstruction Telephone Interview

Claimant is a Family Member

This interview provides claimants with the opportunity to inform NIOSH of any additional information regarding the work history of the energy employee that might not be contained in the exposure monitoring information we receive from the Department of Energy (DOE) or Atomic Weapons Employer (AWE). While we encourage all claimants to participate in the interview process, participation is voluntary. Even though some claimants may not be able to answer all of the questions during the interview or have limited answers to the questions, any information provided during the interview may be useful in the dose reconstruction process.

Public Burden Statement

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:

This notice applies to all interviews and forms that you may receive from NIOSH in connection with completing a radiation dose reconstruction for your claim.

Your participation in this interview is voluntary.

Employment History

1. What jobs did ___{Covered Employee}___ hold, working for DOE, DOE contractors, or AWEs?

Employer

Supervisor’s Name

Job Title

Start Date

(mm/yyyy)

End Date

For each job listed in question 1, answer the following questions. Repeat these questions for each DOE/AWE job included in the employment history.

Detailed Work History:

2. How many hours per week did___{Covered Employee}___ work on this job?

______hrs/week

3. Do you know which buildings or locations (s)he worked in, routinely?

Building/Location

4. Describe whatever you know about ___{Covered Employee’s}___ duties.

________________________________________________________________________

Radiation Monitoring

5. Did ___{Covered Employee}___ routinely wear radiation dosimetry badges?

___Yes

___No

___Don’t know

6. Did __{Covered Employee}___ participate in a biological radiation monitoring program (urine/fecal/breath)?

___Yes, urine

___Yes, fecal

___Yes, breath

___No

___Don’t know

7. Do you have copies of ___{Covered Employee’s}___ dosimeter badge or biological monitoring records?

___Yes, badge ___Yes, biological

___No

If “No” go to question 8, if “yes”:

Would you provide copies to us?

____Yes

____No

If “Yes” go to question 8, if “No” explain the importance of this information and address any concerns, as feasible. If the answer remains “No”:

7.2 Why not? _________________________________________________________

Was ___{Covered Employee}___ ever restricted from the workplace or certain job duties because (s)he had reached a radiation dose limit?

___Yes

___No

___Don’t know

Radiation Incidents

9. Was ___{Covered Employee}___ ever involved in an incident involving radiation exposure or contamination?

___Yes

___No

___Don’t know

If “No” or “Don’t know” go to question 10, if “Yes” ask the following questions for each incident identified:

9.1 What happened, and when?__________________________________________

9.2 Did ___{Covered Employee}___ receive chelation therapy or other medical treatment as a result of radiation exposure from this incident?

___Yes

___No

___Don’t know

If “No” or “Don’t know” go to question 9.4, if “Yes”:

9.3 Please describe the medical treatment (s)he received:

_____ Chelation Therapy

_____________________________________________Other Medical Treatment

9.4 Did ___{Covered Employee}___ receive biological monitoring after the incident?

___Yes

___No

___Don’t know

If “No” or ‘Don’t know” go to question 10, if “Yes”:

Do you have records of this monitoring?

___Yes

___No

If “No” go to question 10, if “Yes”:

9.4 Are you willing to provide copies of these records to NIOSH?

___Yes

___No

If “Yes” go to Question 10, if “No” explain the importance of this information and address any concerns, as feasible. If the answer remains no:

9.5 Why not?________________________________________

Required medical screening x rays

10. Was ___{Covered Employee}___ ever required to have medical x rays for this job, as a condition of employment?

___Yes

___No

___Don’t know

If “No” go to question 11, if “Yes” :

10.1 Do you know how often (s)he was x-rayed, and over what time period(s)?

Time Period

Frequency of x rays

Do you have records of these x rays?

___Yes, for all x rays

___Yes, for some x rays

___No

If “No” go to question 11, if “Yes”:

Would you provide us with copies of these records?

___Yes

___No

Other relevant information

11. Have we missed asking you about any conditions, situations, or practices that occurred during this job which you think may be useful to us in estimating ___{Covered Employee’s}___ radiation doses?

___Yes

___No

If “No” go to Question 13, if “Yes”:

Describe this with as much detail as possible, in terms of what occurred, where, when, for how long, and who was involved:

________________________________________________________________________________________________________________________________________________________________________________________________________________________

Are you aware of any records related to the information you have provided that may help us estimate your doses?

___Yes: Source/Type

___Personal Physician

___Site Medical Records

______________________Other (describe)

___No

If “No” and this is the last job to review, go to Question 14

If “Yes” and the records are from a personal physician, ask the claimant to obtain and provide the relevant medical records to NIOSH.

Final Questions – Identifying co-workers and other witnesses

14. Can you name supervisors, co-workers or other potential witnesses, who can confirm or expand upon the information you have provided us?

___Yes

___No

If “Yes” Obtain up to five names and any contact information available:

1.____________________________

2.____________________________

3.____________________________

4.____________________________

5.____________________________

ORAU Team

Dose Reconstruction Project for NIOSH

ORAU Team

Dose Reconstruction Project for NIOSH

NIOSH Tracking Number:

Date:

Name

Address

City, ST Zip

Dear Name:

Oak Ridge Associated Universities (ORAU) requests your help in reconstructing the radiation dose for [name of covered employee] on behalf of [survivor claimant’s name, if appropriate]. ORAU, the contractor assisting the National Institute for Occupational Safety and Health (NIOSH) with the dose reconstruction process, will be conducting a telephone interview with you shortly to gather information concerning radiation exposure information for [covered employee’s or survivor claimant’s name, as appropriate] claim. The interview takes about an hour on average to complete.

Feel free to call our toll-free number if you have any questions about the interview process. You may also get more information on ORAU at www.oraucoc.org.

Sincerely,

Claimant Communications

ORAU Team

Dose Reconstruction Project for NIOSH

Enclosure

Form Approved: OMB No. 0920-0530

Exp. Date x/xx/xx

EEOICPA Dose Reconstruction Telephone Interview

Co-Worker or Supervisor

As you may know, NIOSH is responsible for estimating the occupational radiation doses received by persons with cancer applying for compensation under the Energy Employees Occupational Illness Compensation Program. For this purpose, you have a very important role. Our contractor, Oak Ridge Associated Universities (ORAU) will be interviewing you and others to help ensure that the information NIOSH uses to estimate ___{Covered Employee’s}___ radiation doses is as complete and precise as possible. This interview should take no more than an hour, although we may have to call you back for additional information. If we need to divide this interview into a couple of shorter calls, we can do that as well.

First we will review with you the information we already have from the Department of Labor and Department of Energy. Then we will ask a variety of questions to identify any information that may be missing from records.

Public Burden Statement

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:

This notice applies to all interviews and forms that you may receive from NIOSH in connection with completing a radiation dose reconstruction for your claim.

Your participation in this interview is voluntary.

Employment History

1. Where and when did you and ___{Covered Employee}___ work together, what was your job title, and who was his/her supervisor at the time?

Employer

Supervisor’s Name

Interviewee Job Title

Start Date

(mm/yyyy)

End Date

Start with the most recent job and answer the following questions. Repeat these for each DOE/AWE job included in the employment history.

Detailed Work History:

2. How many hours per week did (s)he work on this job?

______hrs/week

___ Don’t know

3. How many hours per week did his/her job involve potential exposure to radiation and/or radioactive materials?

_____hrs/week

___Don’t know

Which buildings or locations did (s)he work in, and what were his/her duties?

Building/Location

Duties

5. Describe his/her duties.

________________________________________________________________________

Obtain additional details on duties, as necessary:

5.1 What types of radioactive materials were present or processed, and in what form(s) (solid, liquid, or gas)? Review the list below individually if necessary and appropriate.

Radionuclide Response Isotope(s) if known Form

Tritium __Y __N __DK _____ __S __L __G

Co __Y __N __DK _____ __S __L __G

Sr/Y __Y __N __DK _____ __S __L __G

Tc __Y __N __DK _____ __S __L __G

I __Y __N __DK _____ __S __L __G

Cs __Y __N __DK _____ __S __L __G

Tl __Y __N __DK _____ __S __L __G

Pb __Y __N __DK _____ __S __L __G

Po __Y __N __DK _____ __S __L __G

Rn (progeny) __Y __N __DK _____ __S __L __G

Ra __Y __N __DK _____ __S __L __G

Ac __Y __N __DK _____ __S __L __G

Eu __Y __N __DK _____ __S __L __G

Th (natural) __Y __N __DK _____ __S __L __G

Pa __Y __N __DK _____ __S __L __G

U (natural) __Y __N __DK _____ __S __L __G

U (enriched) __Y __N __DK _____ __S __L __G

Np __Y __N __DK _____ __S __L __G

Pu __Y __N __DK _____ __S __L __G

Am __Y __N __DK _____ __S __L __G

Cm __Y __N __DK _____ __S __L __G

Cf __Y __N __DK _____ __S __L __G

Others

___(1) _____ __S __L __G

___(2) _____ __S __L __G

___(3) _____ __S __L __G

5.2 What quantities of radioactive materials were present or processed (ounces, pounds, kilograms, drums) over what time periods? ________________________

5.3 What types of production processes involving radioactive materials occurred in areas where (s)he worked?____________________________________________

5.4 What types of radiation-generating equipment were present or used (e.g., neutron devices, radiography equipment)?____________________________________

5.5 What specific tasks did (s)he perform, using what types of radioactive materials (in what quantities), and/or radiation generating equipment?__________________

5.5 What exposure/contamination control measures were used to protect him/her?

Measure Frequency of use

___Hoods __Always __ Sometimes __ Never

___Glove boxes __Always __ Sometimes __ Never

___Shielding __Always __ Sometimes __ Never

___Other enclosures (explain) __Always __ Sometimes __ Never

___Local ventilation __Always __ Sometimes __ Never

___Anti-contamination clothing __Always __ Sometimes __ Never

___ Respirators __Always __ Sometimes __ Never

___Other personal protective __Always __ Sometimes __ Never

equipment (specify)

___Showers __Always __ Sometimes __ Never

5.6 Did (s)he work under a radiation work permitting system?

___Yes

___No

___Don’t know

If “No” or “Don’t know”, go to question 6, if “Yes”:

5.7 During what time period(s)?___________________________________________

Radiation Monitoring

Did ___{Covered Employee}___ routinely wear radiation dosimetry badges?

___Yes

___No

___Don’t know

If “No” go to question 7, if “Yes”, for which duties or in which buildings/locations and during which time periods?

Building/

Location

Time Period

Duties

Wore badge

(check = yes)

Did ___{Covered Employee}___ participate in a biological radiation monitoring program (urine/fecal/breath)?

___Yes, urine

___Yes, fecal

___Yes, breath

___No

___Don’t know

If the interviewee is a co-worker who may have had comparable exposures ask the following; if not, go to question 10 :

I’ll ask you several questions about badge practices. I realize that badge practices changed over time, so please recall to the best of your ability any changes and the time period that they cover:

8. How often did you wear your badge?

Time Period Frequency

__________ _________

9. How often was your badge exchanged?

Time Period Frequency

__________ _________

10. Where on your body was your badge worn?

Time Period Body Location

__________ ____________

11. Did you also participate in a biological radiation monitoring program (urine/fecal/breath)?

___Yes, urine

___Yes, fecal

___Yes, breath

___No

___Don’t know

12. Do you have copies of your dosimeter badge or biological monitoring records?

___Yes, badge ___Yes, biological

___No

If “No” go to question 13, if “yes” :

12.1 Would you provide copies to us, so we can use these, if necessary?

____Yes

____No

If “Yes” go to question 13, if “No” explain the importance of this information and address any concerns, as feasible. If the answer remains “No”:

12.2 Why not? _________________________________________________________

13. Did __{Covered Employee}___ routinely survey him/herself (frisk) for external contamination?

___Yes

___No

___Don’t know

If “No” or “Don’t know” go to question 14, if “Yes”:

13.1 When, before or after showering?

___ Before

___ After

Was there general area air monitoring for radiation performed in the work environment?

___Yes

___No

___Don’t know

If “No” or “Don’t know” go to question 15, if “Yes”:

When (over what time periods) did this occur?_________________________________

Were there any radiation surveys taken to characterize potential for external exposure?

___Yes

___No

___Don’t know

If “No” or “Don’t know” go to question 16, if “Yes”:

When did these occur?_________________________________

If the Covered Employee worked at Fernald, Mallinckrodt, or FUSRAP, or if the Co-worker responded in Question 4 that the Covered Employee worked with radium and/or thorium, ask the following question; if not, go to question 19:

16. Was there monitoring in any of the buildings or areas where ___{Covered Employee}___ worked for exposure to radon?

____Yes

____No

____Don’t know

If “No” or “Don’t know” go to question 17, if “Yes”:

16.1 Which buildings or areas? ____________________________________________

17. Was _{Covered Employee}___ ever restricted from the workplace or certain job duties because (s)he had reached a radiation dose limit?

___Yes

___No

___Don’t know

Radiation Incidents

I need to ask you about any radiation exposure or contamination incidents that may have occurred while ___{Covered Employee}___ was in this job. For each incident you may recall, please answer the following questions:

18. Was ___{Covered Employee}___ ever involved in an incident involving radiation exposure or contamination?

___Yes

___No

___Don’t know

If “No” or “Don’t know” go to question 19, if “Yes”ask the following questions for each incident identified:

18.1 What happened and when?____________________________________________

18.2 Which radioactive materials were involved, and in what form and quantity?___________________________________________________

18.3 Which radiation-generating equipment was involved?________________

18.4 Where did it take place? _______________________________________

18.5 Who was involved? ___________________________________________

18.6 What actions were taken to remedy the exposure or contamination?_______________________________________________

18.7 What were ___{Covered Employee’s}___ location and activities during the incident?____________________________________________________

18.8 What precautions were taken to protect him/her?___________________________

18.9 What types of personal protective equipment, if any, did (s)he use?____________

18.10 How long was (s)he exposed during the incident?__________________________

18.11 Did ___{Covered Employee}___ receive biological monitoring after the incident?

___Yes

___No

___Don’t know

18.12 Were you similarly involved and exposed in the incident?

___Yes

___No

If “No” or ‘Don’t know” go to question 19, if “Yes”:

18.13 Did you receive biological monitoring after the incident?

___Yes

___No

18.14 Do you have records of this monitoring?

___Yes

___No

If “No” go to question 19, if “Yes”:

18.15 Are you willing to provide copies of these records to NIOSH?

___Yes

___No

If “Yes” go to Question 19, if “No” explain the importance of this information and address any concerns, as feasible. If the answer remains no:

18.16 Why not?__________________________________________________________

Required medical screening x rays

Some workers were required to periodically have medical x rays as a condition of employment:

19. Was ___{Covered Employee}___ ever required to have medical x rays for this job, as a condition of employment?

___Yes

___No

___Don’t know

If “No” go to question 20, if “Yes” :

19.1 Do you know how often (s)he was x-rayed, over what period(s) of time?

Time Period

Frequency of x rays

Other relevant information

This is an opportunity for you to identify other relevant information that might help us complete the dose reconstruction:

20. Have we missed asking you about any conditions, situations, or practices that occurred during this job which you think may be useful to us in estimating ___{Covered Employee’s}___ radiation doses?

___Yes

___No

If “No” and this is the last job to review, go to Question 21, if “Yes”:

20.1 Describe this with as much detail as possible, in terms of what occurred, where, when, for how long, and who was involved:

NOTE: Complete Sections 3-7 for each job listed in question 1.

Final Questions–Identifying co-workers and other witnesses

We may speak with others who might help us with the dose reconstruction for ___{Covered Employee}___.

Can you name supervisors, co-workers or other potential witnesses, who can confirm or expand upon the information you have provided us?

___Yes

___No

If “Yes” obtain up to five names for each job listed in Question 1 and any available contact information:

1.____________________________

2.____________________________

3.____________________________

4.____________________________

5.____________________________

File Type	application/msword
File Title	SUPPORTING STATEMENT
Author	Mary Griffin
Last Modified By	Nelda Robinson
File Modified	2009-01-12
File Created	2009-01-12