Form DTRA Form 150 DTRA Form 150 Nuclear Test Personnel Review Information Request and Re

OMB No. xxxx-xxxx
Expiration: Xxx 20XX

DEFENSE THREAT REDUCTION AGENCY
Nuclear Test Personnel Review Information Request and Release
1. Last Name

SECTION I: PARTICIPANT PERSONAL DATA (please print)
2. First Name
3. Middle Name

4. Sex
M

5. SSN

6. Branch of Service

7. Rank

F

8. Service Number

9. Address

10. Telephone

___________________________________________________________

Home (

) ____________________

City____________________________ State ___________Zip___________ Other (
) ____________________
14. Date of Death (mm/dd/yy)
11. Date of Birth (mm/dd/yy) 12. Place of Birth
13. Deceased
Yes

No

SECTION II: PARTICIPATION DATA (please print)
15. Name(s) of Test Series / Occupation of Hiroshima or Nagasaki, Japan

16. Test Location(s) or Occupation Area

17. Test or Occupation Date(s) (mm/dd/yy)

18. Participating Unit Assigned During Test or Occupation

19. Permanent Home Unit Assigned During Test or Occupation (to lowest level, e.g., company, squadron, if known)

20. Remarks

SECTION III: IDENTITY OF THE REQUESTER
21. Requester is (check one):
Participant identified in Section I, above
Next of kin, if participant is deceased (specify relationship) ________________________________________
Legal guardian (must submit copy of court appointment)
Other (specify relationship AND obtain signed authorization from participant per Authorization Statement below)
Relationship: ___________________________

If you have any questions regarding this form, please call the NTPR toll-free helpline:
800-462-3683

DTRA Form 150 (September 2006)

SECTION IV: SIGNATURE AND AUTHORIZATION
I certify under penalty of perjury under the laws of the United States of America that the information in Section III is true
and correct. Violations of the provisions of the Privacy Act are enforceable through legal action, and criminal and civil
penalties may apply. It is a crime to knowingly and willfully request or obtain records concerning an individual from a
Government agency under false pretenses.

Signature of Requester

______________________________________

Date _____________________

AUTHORIZATION STATEMENT
(Must be completed if requester is not the participant, next of kin of a deceased participant, or legal guardian)

Pursuant to the Privacy Act of 1974, I authorize the Defense Threat Reduction Agency to release information to:

____________________________________________________
(Print name of authorized individual)

Signature of Participant ______________________________________

Date _____________________

SECTION V: PRIVACY ACT STATEMENT
AUTHORITY: 38 U.S.C. 1154 and 1112 (Veterans Benefits) assigns Defense Nuclear Agency (now Defense Threat
Reduction Agency (DTRA)) as executive agent for the Nuclear Test Personnel Review Program and delineates
Department of Veterans Affairs presumptive and non-presumptive radiogenic disease compensation. 42 U.S.C. 2210
describes the Department of Justice radiogenic disease compensation program that DTRA also supports.
PRINCIPAL PURPOSES: To certify the identity of the requesting party as a participant, verify participant
information, obtain permission to release information to a third party, and/or serve as a record of disclosure. The
information on this form is necessary to facilitate location of the correct record(s) or information. Additionally, this
information may be used to provide participation and dose information, prepare histories of nuclear test programs,
support scientific studies or medical follow-up programs, and provide data or documentation relevant to the processing
of administrative claims or litigation. For use by Agency officials and employees, authorized contractors, and other
DoD components.
ROUTINE USES: Disclosures are permitted under 5 U.S.C. 552a(b) of the Privacy Act, to Department of Veterans
Affairs, Department of Justice, Department of Labor, Department of Energy, Department of Health and Human Services,
National Research Council, Veterans’ Advisory Board on Dose Reconstruction and under the ‘Blanket Routine Uses’
published at the beginning of DTRA’s compilation of systems of records notices.
DISCLOSURE: Voluntary. However, failure to provide the requested information and authorization may delay or
preclude DTRA from providing or releasing information.
SECTION VI: AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information is estimated to be 15 minutes. If you have any questions
regarding this form, please call the NTPR toll-free helpline: (800-462-3683) for assistance, email us at [email protected],
or write us at: Defense Threat Reduction Agency, Attn: NTDN/NTPR, 8725 John J. Kingman Road, Stop 6201, Fort
Belvoir, VA 22060-6201.
DTRA Form 150 (September 2006)