DTRA Form 150-A Questionnaire for Continental United States Test Partici

Defense Threat Reduction Agency
Nuclear Test Personnel Review Program

OMB No. xxxx-xxxx
Expiration: Xxx 20XX

Questionnaire for Continental United States Test Participants
SECTION I: Please use a separate questionnaire for each operation in which you participated.
Check the operation for which these answers apply:
TRINITY (1945)
RANGER (1951)
BUSTER-JANGLE (1951)

TUMBLER-SNAPPER (1952)
UPSHOT-KNOTHOLE (1953)
TEAPOT (1955)

PLUMBBOB (1957)
HARDTACK II (1958)
DOMINIC II (1962)

Participant Information
Name:

Branch of Service/Service Number:

Address:
Telephone:
If this questionnaire is completed by someone other than the participant, please provide:
Name:
Relationship to veteran:

SECTION II: Participation Summary
1. Home station:
Unit of assignment:
Rank (at time of participation):
Code/Specialty:
2. List names of other personnel (up to four) with similar participation experience:

3. Where were you billeted? (check all that apply)
(a)
(b)
(c)
(d)
(e)

Camp Desert Rock/TRINITY Base Camp
Camp Mercury
Indian Springs AFB
None of the above; visited test site from another location (specify):
Other (specify):

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SECTION II (Continued)
4. If (a), (b) or (c) were checked above, about when did you arrive and depart?
Arrival date:
Departure date:
Did you leave the area (temporary duty, emergency leave, etc.) at any time during your deployment?
Yes (provide reason and approximate dates)
No

5. Which of the following describes your participation in the test series? (check all that apply)
(a)

Participated in a troop maneuver in conjunction with a detonation(s). Provide details in
Question 6 (page 2).
Participated as an observer at a detonation(s). Provide details in Question 7 (page 3).
Participated in a scientific project. Provide details in Question 8 (page 4).
Supported operations from location specified in Question 3. Provide details in Question 9
(page 4).
Was a crew member of an aircraft that participated in or supported the operation. Provide details
in Question 10 (page 5).
Other (specify below). Provide details in Question 11 (page 6).

(b)
(c)
(d)
(e)
(f)

SECTION III: The following questions are intended to assess your potential for exposure to radiation during
your participation as indicated in Question 5. Please provide details for answers to best of your recollection
(qualify as “approximate” as necessary). Use back or a separate page with reference to question number if
more space is needed. If you are unable to answer a question or provide details, state “Unknown.”

6.

If you participated in a troop maneuver(s), provide details by event:
(a) Shot/date:
(b) Maneuver unit designation:
(c) Your location at shot time (distance from ground zero):
In open area
In trench
In vehicle (specify):
Other:
(d) Description of maneuver and your activities:
Time (minutes after shot) maneuver began:
Duration of maneuver:

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SECTION III (Continued)
6. If you participated in a troop maneuver (continued):
(e) At the end of the maneuver, were you monitored for radiological contamination?
If yes, were you found to be contaminated?
If yes, where?
Were you decontaminated?
If yes, how?

Yes

Yes

Yes

No

No

No

(f) Other comments:

7. Other than in conjunction with a troop maneuver (Question 6), if you observed a test detonation from a
location other than the base camp, provide details by event:
(a) Shot/date:

(b) Your location at shot time (distance from ground zero):
In open area
In trench
In vehicle (specify):
Other (specify):
(c) Post-shot activity (e.g., toured equipment display area):

(d) Location of activity with respect to ground zero:

(e) Time (minutes after shot) activity began:
Total time in shot area:
(f) At the end of the activity, were you monitored for radiological contamination?
If yes, were you found to be contaminated?
If yes, where?
Were you decontaminated?
If yes, how?

Yes

Yes

Yes

No

No

No

(g) Other comments:

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SECTION III (Continued)
8. If you participated in a scientific project, provide details by event:
(a) Shot/date:
(b) Project number/title:
(c) Description of activity:
Location of activity with respect to ground zero:
Time (before/after shot) activity began:
Total time in shot area:
(d) At the end of the activity, were you monitored for radiological contamination?
If yes, were you found to be contaminated?
If yes, where?
Were you decontaminated?
If yes, how?

Yes

Yes

Yes

No

No

No

(e) Other comments:

9. If you supported the operation from a base camp or other location (e.g., Camp Desert Rock, Indian Springs
AFB), provide details:
(a) Location:
(b) Description of duties:

(c) Did these duties involve contaminated material?

Yes (provide details below)

No

Contaminated item(s):
Your associated duties:
Duration of association (hours):
Proximity to item (feet):
(d) Other comments relative to possible radiation exposure:

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SECTION III (Continued)
10. If you supported the operation as an air crew member, provide details:
(a) Flight duty (pilot, engineer, etc.):
(b) Type of aircraft:
Operating from (airfield):
(c) Were you airborne during any detonation?

Yes (provide details by event)

No (see 10.d)

Shot/date:
Altitude at shot time:
Distance and direction from detonation:
Purpose and route of mission:
(d) If your answer to (c) was No, were you airborne subsequent to any test detonation (within 12 hours)?
Yes (provide details by event)
No
Shot/date:
Altitude:
Purpose and route of mission:
(e) Did your aircraft penetrate the nuclear cloud or encounter fallout?
Yes (provide details below)
No
Time after shot of penetration/fallout encounter:
Duration of penetration/fallout encounter:
Altitude of aircraft at the time:
Total duration of flight:
Radiation levels encountered:
Precautionary measures taken (e.g., breathed 100% oxygen, sealed/filtered air intakes, wore leaded
vest, flew through rain showers):

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SECTION III (Continued)
10. If you supported the operation as an air crew member (continued):
(f) Were you contaminated during any mission?
Yes (provide details by shot/mission)

No

Shot/date:
Purpose of mission:
Activity that resulted in contamination:
Location of contamination (e.g., gloves, pant leg, face):
Method of decontamination:
Other comments:

(g) Did your aircraft land in a contaminated area?

Yes (provide details below)

No

Shot, location, and time:
Radiation levels and duration:
Reason for landing:
(h) Was your aircraft involved in a special project(s)?

Yes (provide details below)

No

Identify project(s) and describe your role in different than normal air crew duty:

11. If your participation is not covered in Questions 6-10, provide details regarding any potential exposure to
radiation (date, location, activities, exposure conditions, etc.):

12. Did you perform any RADSAFE activity (e.g., serve as radiation monitor, decontaminate personnel/
Yes (provide details below)
No
equipment)?

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SECTION III (Continued)
13. Did you wear any special clothing/equipment (e.g., coveralls, gloves, respirators) during the operation?
Yes (provide details below)
No
Type of clothing/equipment worn:
Activity that required such clothing/equipment:
Frequency of use:
Other comments:

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Were you issued a film badge (radiation dosimeter) during the operation?
Yes (check all statements below that apply)
No
(a)
(b)
(c)
(d)
(e)
(f)

Issued badge upon arrival at test site, wore same badge during entire stay.
Issued badge upon arrival, wore until replaced with another badge.
Issued badge(s) for a specific activity/mission, turned in afterwards.
Wore more than one badge at a time.
Lost or failed to turn in at least one badge during the operation.
None of the above (please explain):

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SECTION IV: SIGNATURE
I certify under penalty of perjury under the laws of the United States of America that the information provided on this
form is true and correct.

Signature: _________________________________________________

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 DoD 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: The information on this form is necessary to facilitate location of record(s) or information,
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 may delay or preclude DTRA from
producing your radiation dose assessment.
SECTION VI: AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information is estimated to be less than one hour. If you have any
questions regarding this form, please call the NTPR toll-free helpline (800-462-3683), e-mail us at [email protected], or
write to: Defense Threat Reduction Agency, Attn: NTDN/NTPR, 8725 John J. Kingman Road, Stop 6201, Fort Belvoir,
VA 22060-6201.

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