DTRA Form 150-C Questionnaire for Crossroads Test Participants

Defense Threat Reduction Agency
Nuclear Test Personnel Review Program

OMB No. xxxx-xxxx
Expiration: Xxx 20XX

Questionnaire for CROSSROADS Test Participants
SECTION I: 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/port:
Unit of assignment:
Rank/specialty (at time of participation):
Height at time of the operation (e.g., 5’ 10”):
2. Where you were billeted? (check all that apply):
(a)
(b)
(c)
(d)

Aboard ship (name and hull number of ship):
Bikini Island of Bikini Atoll
Eneu Island of Bikini Atoll
Other (specify):

3. If you checked any of (a) through (d) above, about when did you arrive and depart?
Arrival date:
Departure date:
Mode of transportation:
Did you leave the area (temporary duty, emergency leave, etc.) at any time during your deployment?
Yes (provide reason and approximate dates)
No

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SECTION II (Continued)
4. Which of the following describes your participation? (check all that apply)
(a)
(b)
(c)
(d)
(e)

Supported operations aboard ship. Provide details in Question 5 (page 2).
Supported operations from location specified in 2b or 2c. Provide details in Question 6 (page 4).
Participated in a scientific project. Provide details in Question 7 (page 4).
Was a crew member of an aircraft that participated in or supported the operation. Provide details
in Question 8 (page 5).
Other (specify): Provide details in Question 9 (page 5).

SECTION III: The following questions are intended to assess your potential for exposure to radiation during
your participation as indicated in Question 4. 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.”

5. If you supported the operation aboard a ship, provide details:
(a) Name, hull number, and type of ship:
General nature of duties (e.g., maintained electronic equipment):

Average time spent topside:
hours per day
(b) Where were you located during each test detonation (e.g., at duty station below decks)?

(c) 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:

(d) Did your ship receive any fallout during the operation?

Yes (provide details by event)

No

Shot/date:
Your location during fallout:

Topside

Below decks

What precautions were taken to minimize exposure to the fallout (e.g., wash down ship)?

(e) Did your duties involve contact with radioactive material other than general fallout on the ship?
Yes (provide details below)
No

DTRA Form 150-C (Nov 2006)

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SECTION III (Continued)
5. If you supported the operation aboard a ship (continued):
(f) Was your ship involved in a special project?
Yes (provide details below)

(g) Did you visit or were you assigned to another ship?

No

Yes (provide details below)

No

Name and hull number of ship:
Frequency and duration of visit/assignment:
Purpose of visit/assignment:

(h) Did you perform activities aboard target ships?

Yes (provide details below)

No

Name and hull number of ship:
Frequency and duration of visit:
Activities during visit:

(i) Did you participate in small boat operations?

Yes (provide details below)

No

Frequency of operations (daily, once a week, etc.):
Duration of operations (in hours):
Activities aboard small boats:

(j) Were you granted shore liberty during the operation?

Yes (provide details)

No

Where and how long?
(k) Were you ever found to be contaminated during the operation?

Yes (provide details)

No

Describe the event(s) that resulted in this contamination:

Where were you contaminated (hands, clothes, etc.)?
Were you decontaminated?
If yes, how?

Yes

No

(l) How frequently did you shower during the operation?

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SECTION III (Continued)
6. If you supported the operation from Bikini Atoll, provide details:
(a) General nature of duties (e.g., administrative support):

(b) Did you visit or support the operation from other island locations?

Yes (provide details)

No

Name of island/location:
Date and duration of visit(s):
Purpose of visit(s):

7. If you participated in a scientific project, provide details:
(a) Shot/date:
(b) Project number/title:
(c) Description of activity:

(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

8. If you supported the operation as an air crew member, provide details:
(a) Flight duty (pilot, engineer, etc.):

(b) Type of aircraft:

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SECTION III (Continued)
8.

If you supported the operation as an air crew member (continued):
(c) Were you airborne during any test detonation?
Yes (provide details by event)

No (see 8.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) Was your aircraft involved in a special project(s)?

Yes (provide details below)

No

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

9.

If your participation is not covered in Questions 5-8, provide details regarding any potential exposure to
radiation (date, location, activities, exposure conditions, etc.):

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

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SECTION III (Continued)
11. 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):

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 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.

DTRA Form 150-C (Nov 2006)

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