Proposed changes to interview forms

Phone Interview with Proposed Revisions.doc

EEOICPA Dose Reconstruction Interviews and Form

Proposed changes to interview forms

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⚠️ Notice: This form may be outdated.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. We rarely need to consult other individuals for information on your claim, but this interview gives you the opportunity to identify supervisors, co-workers, or others who might know relevant information so we can contact them if needed. 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. Also, do not expend effort researching answers. We are only interested in information you can remember or find easily. 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 3/31/2012

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. From what you remember or information readily available to you, Wwhat jobs have you held working for DOE, DOE contractors, or AWEs?

Employer Facility

Supervisor’s Name

Job Title

Start Date

(mm/yyyy)

End Date

(mm/yyyy)

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

3 Did you work any overtime hours?

_____Yes

_____No

4. If yes, how many hours of overtime, on average, did you work per week?

_____hours per week

5. Did you work any shift work?

_____Yes

_____No

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

47. Which buildings or locations did you work in, for each of your routine duties, and during what time periods did you work in each of the buildings or locations?

Building/Location	Time Period Worked	Duties

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

________________________________________________________________________

Obtain additional details on duties, as necessary:

58.1 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

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

________________________________________________________________________

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

58.4 What types of radiation-generating equipment were present or used (e.g., neutron devices, radiography equipment/sources, portable x ray units, electron beam welders)?_____________________________________________________

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

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

Measure Frequency of use

___Fume Hhoods __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

58.7 Did you conduct your work under a Special Work Permit or a Radiological Work Permit or other work control document that specified safety and health requirementsradiation work permitting system?

___Yes

___No

___Don’t know

If “No” or “Don’t know”, go to Question 69, if “Yes”:

58.8 During what time period(s)?___________________________________________

Radiation Monitoring

9. 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 710, if “Yes”:

69.1 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 107, 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:

96.2 For the time periods identified above, under what situations How often did you wear your badge?

Time Period Situations (Frequencye.g. always, upon entry to certain areas, when provided by Health and Safety, supervisor, etc.)

__________ _________

69.3 How often was your badge exchanged?

Time Period Frequency (e.g. weekly, monthly, annually, don’t know)

__________ _________

69.4 Where on your body was your badge worn?

Time Period Body Location

__________ ____________

10. Did you participate in a biological radiation monitoring program (urine/, fecal/, breath, or in-vivo/whole body count)?

___Yes, urine Frequency_____________

___Yes, fecal Frequency_____________

___Yes, breath Frequency_____________

___Yes, in-vivo/whole body count Frequency_____________

___No

___Don’t know

811. Do you have copies of your dosimeter badge or biological monitoring records, or annual reports of your monitoring results?

___Yes, badge ___Yes, biological

___Yes, annual report(s)

___No

If “No” go to Question 912, if “yes”:

11.1 Would you be willing to provide copies to us, if we need those records?

____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? _________________________________________________________

12. Did Were you routinely surveyed yourself (frisked) for external contamination?

If “No” go to Question 103, if “Yes”:

12.1 When did Were you surveyed yourself, before or after showering?

___ Before

___After

13. 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 114, if “Yes”:

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

13.2 What type of air monitoring was performed?

___Job-specific

___Lapel (employee breathing zone)

___General area

___Environmental

___Other (Describe)___________________________________________________

14. 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 125, if “Yes”:

14.1 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:

125. 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 136, if “Yes”:

125.1 Which buildings or areas? ____________________________________________

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

___Yes

___No

If “No” go to Question 17, if “Yes”:

Please explain._______________________________________________________

17. 1Did you ever not turn in your dosimeter badge because you were approaching a radiation dose limit?

___Yes

___No

If “No” go to Question 18, if “Yes”:

How many times did this occur and during what periods?__________________

Required medical screening x rays

158. Were you ever required to have medical x rays for this job, as a condition of employment (upon hire, as part of an annual physical, etc.)?

___Yes

___No

If “No” go to Question 169, if “Yes” :

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

Time Period

Frequency of x rays

18.2 Do you have records of these x rays?

___Yes, for all x rays

___Yes, for some x rays

___No

If “No” go to Question 169, if “Yes”:

18.3 Would you be willing to provide us with copies to us, if we need of these records?

___Yes

___No

Radiation Incidents

149. Were you ever involved in any incidents involving radiation exposure or contamination?

___Yes

___No

If “No” go to Question 1520, if “Yes” ask the following questions for each incident identified:

149.1 What happened and when?___________________________________________

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

149.3 WasWhich radiation-generating equipment was involved? If yes, what type?________________

149.4 Where did it take place? _______________________________________

149.5 Who was involved? ___________________________________________

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

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

149.8 What precautions were taken to protect you?_______________________________________________________

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

19.10 How long were you exposed during the incident?____________________________________________________

19.11 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 149.123, if “Yes”:

19.12 Please describe the medical treatment you received:

_____ Chelation Therapy

_____Other Medical Treatment____________________________________________

19.13 Did you receive biological monitoring after the incident?

___Yes

___No

___Don’t know

If “No” or “Don’t know”go to Question 1520, if “Yes”:

19.14 What type of biological monitoring?

___in-vivo/whole body measurement

___urine

___fecal

___breath

___nasal swab

19.15 Do you have records of this monitoring?

___Yes

___No

If “No” go to Question 1520, if “Yes”:

19.16 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?________________________________________

Other relevant information

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 your radiation doses?

___Yes

___No

If “No”, go to Question 1721, if “Yes”:

2016.1 Describe this with as much detail as possible, in terms of what occurred, where, when, for how long, and who was involved:

______________________________________________________________________________________________________________________________________________________________________________________________________

21. 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

___Log Books

______________________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.

22. NIOSH is confident it will obtain enough information to complete your dose reconstruction without receiving information from other individuals. However, in the event NIOSH does wish to speak to others who might provide information about your work conditions or exposures, Final Questions – Identifying co-workers and other witnesses

Ccan you readily provide names and contact information for co-workers, supervisors, or other witnesses, such as consulting industrial hygienists, or radiation safety specialists, or anyone else who might be able to provide such information? 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 3/31/2012

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. From what you remember or information readily available to you, Wwhat jobs did ___{Covered Employee}___ hold, working for DOE, DOE contractors, or AWEs?

Employer Facility

Supervisor’s Name

Job Title

Start Date

(mm/yyyy)

End Date

(mm/yyyy)

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 Did___{Covered Employee}___ work any overtime hours?

_____Yes

_____No

4. If yes, how many hours of overtime, on average, did___{Covered Employee}___work per week?

_____hours per week

5. Did___{Covered Employee}___ work any shift work?

_____Yes

_____No

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

Building/Location

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

________________________________________________________________________

Radiation Monitoring

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

___Yes

___No

___Don’t know

9. Did___{Covered Employee}___ participate in a biological radiation monitoring program (urine/, fecal/, breath, or in-vivo/whole body count)?

___Yes, urine Frequency__________

___Yes, fecal Frequency__________

___Yes, breath Frequency__________

___Yes, in-vivo/whole body count Frequency__________

___No

___Don’t know

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

___Yes, badge ___Yes, biological

___Yes, annual report

___No

If “No” go to Question 811, if “yes”:

10.1 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?

11. 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

Required medical screening x rays

102. Was ___{Covered Employee}___ ever required to have medical x rays for this job, as a condition of employment (upon hire, as part of an annual physical, etc.)?

___Yes

___No

___Don’t know

If “No” go to Question 113, if “Yes” :

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

Time Period

Frequency of x rays

12.2 Do you have records of these x rays?

___Yes, for all x rays

___Yes, for some x rays

___No

If “No” go to Question 113, if “Yes”:

12.3 Would you provide us with copies to us, if we needof these records?

___Yes

___No

Radiation Incidents

913. 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 104, if “Yes” ask the following questions for each incident identified:

913.1 What happened, where and when?______________________________________

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

___Yes, chelation therapy

___Yes, other medical treatment

___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

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

___Yes

___No

___Don’t know

If “No” or ‘Don’t know” go to Question 105, if “Yes”:

What type of biological monitoring?

___in-vivo/whole body measurement

___urine

___fecal

___breath

___nasal swab

14.2 Do you have records of this monitoring?

___Yes

___No

If “No” go to Question 150, if “Yes”:

14.39.4 Would you be Are you willing to provide copies to us if we needof 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?________________________________________

Other relevant information

115. 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 136, if “Yes”:

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

________________________________________________________________________________________________________________________________________________________________________________________________________________________

16. 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

___Log Books

______________________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

147. NIOSH is confident it will obtain enough information to complete your dose reconstruction without receiving information from other individuals. However, in the event NIOSH does wish to speak to others who might provide information about your work conditions or exposures, can you readily provide names and contact information for co-workers, supervisors, industrial hygienists, radiation safety specialists, or anyone else who might be able to provide such information?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 3/31/2012

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. From what you remember or information readily available to you, Wwhen and where did you and ___{Covered Employee}___ work together, what was your job title, and who was his/her supervisor at the time?

Employer Facility

Supervisor’s Name

Interviewee

Job Title

Start Date

(mm/yyyy)

End Date

(mm/yyyy)

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 (s)he work on this job?

______hrs/week

___Don’t know

3 Did (s)he work any overtime hours?

_____Yes

_____No

_____Don’t know

4. If yes, how many hours of overtime, on average, did (s)he work per week?

_____hours per week

5. Did (s)he work any shift work?

_____Yes

_____No

_____Don’t know

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

_____hrs/week

___Don’t know

47. Which buildings or locations did (s)he work in, and what were his/her routine duties, and during what time periods did (s)he work in each of the buildings or locations?

Building/Location	Time Period Worked	Duties

58. Describe his/her duties.

________________________________________________________________________

Obtain additional details on duties, as necessary:

58.1 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

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

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

________________________________________________________________________

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

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

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

Measure Frequency of use

___Fume Hhoods __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

58.7 Did (s)he work under a Special Work Permit or a Radiological Work Permit or other work control document that specified safety and health requirementsradiation work permitting system?

___Yes

___No

___Don’t know

If “No” or “Don’t know”, go to Question 69, if “Yes”:

58.8 During what time period(s)?___________________________________________

Radiation Monitoring

9. Did ___{Covered Employee}___routinely wear radiation dosimetry badges?

___Yes

___No

___Don’t know

If “No” or “Don’t know”, go to Question 710, if “Yes”:

69.1 For which duties or in which buildings or locations, and during what time periods (e.g., which years) did ___{Covered Employee}___routinely wear radiation dosimetry badges?

Building/

Location

Time Period

Duties

Wore badge

(check = yes)

10. Did ___{Covered Employee}___participate in a biological radiation monitoring program (urine/, fecal/, breath, or in-vivo/whole body count)?

___Yes, urine Frequency_____________

___Yes, fecal Frequency_____________

___Yes, breath Frequency_____________

___Yes, in-vivo/whole body count Frequency_____________

___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 16 :

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:

811. How often did you wear your badge?

Time Period Frequency

__________ _________

12. How often was your badge exchanged?

Time Period Frequency

__________ _________

103. Where on your body was your badge worn?

Time Period Body Location

__________ ____________

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

___Yes, urine

___Yes, fecal

___Yes, breath

___No

___Don’t know

815. Do you have copies of your dosimeter badge or biological monitoring records, or annual reports of your monitoring results?

___Yes, badge ___Yes, biological

___Yes, annual report(s)

___No

If “No” go to Question 916, if “yes”:

15.1 Would you be willing to provide copies to us, if we need those records?

____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? _________________________________________________________

16. Did Was___{Covered Employee}___routinely surveyed yourself (frisked) for external contamination?

___Yes

___No

___Don’t know

If “No” or “Don’t know” go to Question 107, if “Yes”:

16.1 When did Was___{Covered Employee}___surveyed yourself, before or after showering?

___ Before

___After

17. 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 118, if “Yes”:

17.1 When (over what time periods) did this occur?____________________________

17.2 What type of air monitoring was performed?

___Job-specific

___Lapel (employee breathing zone)

___General area

___Environmental

___Other (Describe)_________________________________________________

18. 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 129, if “Yes”:

18.1 When (over what time periods) did these occur?___________________________

129. 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 320, if “Yes”:

129.1 Which buildings or areas? ____________________________________________

320. 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

If “No” or “Don’t know” go to Question 21, if “Yes”:

Please explain.______________________________________________________

21. Did___{Covered Employee}___ ever not turn in his/her dosimeter badge because (s)he was approaching a radiation dose limit?

___Yes

___No

___Don’t know

If “No” or “Don’t know” go to Question 22, if “Yes”:

21.1 How many times did this occur and during what periods?__________________

Required medical screening x rays

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

522. Was___{Covered Employee}___ ever required to have medical x rays for this job, as a condition of employment (upon hire, as part of an annual physical, etc.)?

___Yes

___No

___Don’t know

If “No” or “Don’t know” go to Question 623, if “Yes” :

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

Time Period

Frequency of x rays

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:

23. Was___{Covered Employee}___ever involved in any incidents involving radiation exposure or contamination?

___Yes

___No

___Don’t know

If “No” or “Don’t know” go to Question 1524, if “Yes” ask the following questions for each incident identified:

23.1 What happened and when?___________________________________________

23.2 Which radioactive materials were involved, and in what form and quantity? _________________________________________________________________

23.3 WasWhich radiation-generating equipment was involved? If yes, what type?_____________

423.4 Where did it take place? _____________________________________________

423.5 Who was involved? _________________________________________________

423.6 What actions were taken to remedy the exposure or contamination?____________

__________________________________________________________________

423.7 What were___{Covered Employee’s}___location and activities during the incident?__________________________________________________________

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

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

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

23.11 Did___{Covered Employee}___receive biological monitoring after the incident?

___Yes

___No

___Don’t Know

Were you similarly involved and exposed in the incident?

___Yes

___No

If “No” go to Question 4224, if “Yes”:

23.13 Did you receive biological monitoring after the incident?

___Yes

___No

___Don’t know

If “No” or “Don’t know”go to Question 1524, if “Yes”:

23.14 What type of biological monitoring?

___in-vivo/whole body measurement

___urine

___fecal

___breath

___nasal swab

23.15 Do you have records of this monitoring?

___Yes

___No

If “No” go to Question 1524, if “Yes”:

23.16 Would you be willing to provide copies to us, if we need those recordsAre 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?________________________________________

Other relevant information

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

24. 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 1725, if “Yes”:

2416.1 Describe this with as much detail as possible, in terms of what occurred, where, when, for how long, and who was involved:

______________________________________________________________________________________________________________________________________________________________________________________________________

Note: Complete Questions 2 through 24 for each job listed in Question 1.

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.

25. NIOSH is confident it will obtain enough information to complete___{Covered Employee’s}___dose reconstruction without receiving information from other individuals. However, in the event NIOSH does wish to speak to others who might provide information about his/her work conditions or exposures, Final Questions – Identifying co-workers and other witnesses

___Yes

___No

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

1.____________________________

2.____________________________

3.____________________________

4.____________________________

5.____________________________

File Type	application/msword
File Title	SUPPORTING STATEMENT
Author	Mary Griffin
Last Modified By	nbr5
File Modified	2009-12-16
File Created	2009-12-16