Form B

Appendix D- SEC Petition Form B

Form Approved

OMB No. 0920-0639

Expiration Date: XX/XX/20xx

Special Exposure Cohort Petition U.S. Department of Health and

under the Energy Employees Occupational Human Services

Illness Compensation Program Act

Centers for Disease Control and

Prevention

National Institute for Occupational

Safety and Health

Special Exposure Cohort Petition - Form B

Use of this form is voluntary. Failure to use this form will not result in the denial of any right, benefit, or privilege to which you may be entitled.

General Instructions on Completing this Form (complete instructions are available in a separate packet):

Except for signatures, please PRINT all information clearly and neatly on the form.

Please read each of Parts A-G in this form and complete the parts appropriate to you. If there is more than one petitioner, then each petitioner should complete those sections of Parts A-C of the form that apply to them. Additional copies of the first two pages of this form are provided at the end of the form for this purpose. A maximum of three petitioners is allowed.

If you need more space to provide additional information, use the continuation page provided at the end of the form and attach the completed continuation page(s) to Form B.

Public reporting burden of this collection of information is estimated to average 5 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D­74, Atlanta, Georgia 30333; ATTN: PRA (0920­0639).

For Further Information: If you have questions about these instructions, please call the following toll-free phone number and ask to speak to someone in the Division of Compensation Analysis and Support about an SEC petition: 1-877-222-8570.

If you are:

A Labor Organization, start at Part D.

An Energy Employee (current or former), start at Part C.

A Survivor (of a former Energy Employee), start at Part B.

A Representative (of a current or former Energy Employee or Survivor), start at Part A.

Part A Representative Information – Complete Part A if you are authorized by an Employee or Survivor(s) to petition on behalf of a class.

A.1. Are you a contact person for an organization? ___ Yes (Go to A.2.) ___ No (Go to A.3.)

A.2. Organization Information:

___________________________________________________________________________

Name of Organization

___________________________________________________________________________

Position of Contact Person

A.3. Name of Petition Representative:

___________________________________________________________________________

Mr./Mrs./Ms. First Name Middle Initial Last Name

A.4. Address of Petition Representative:

___________________________________________________________________________

Street Apt. # P.O. Box

___________________________________________________________________________

City State Zip Code

A.5. Telephone Number of Petition Representative: (______)_______-__________________

A.6. Email Address of Petition Representative: _________________________________

A.7. ____ Check the space at left to indicate you have attached to the back of this form written authorization to petition by the survivor(s) or energy employee(s) indicated in Parts B or C of this form.

If you are representing a Survivor, go to Part B; if you are representing an Employee, go to Part C

Part B Survivor Information – Complete Section B if you are a Survivor or representing a Survivor

B.1. Name of Survivor:

___________________________________________________________________________

Mr./Mrs./Ms. First Name Middle Initial Last Name

B.2. Address of Survivor:

___________________________________________________________________________

Street Apt. # P.O. Box

___________________________________________________________________________

City State Zip Code

B.3. Telephone Number of Survivor: (______)_______-__________________

B.4. Email Address of Survivor: _________________________________

B.5. Relationship to Employee: ___ Spouse ___ Son/Daughter ___ Parent

___ Grandparent ___Grandchild

Go to Part C.

Part C Employee Information – Complete Section C UNLESS you are a labor organization

C.1. Name of Employee:

___________________________________________________________________________

Mr./Mrs./Ms. First Name Middle Initial Last Name

C.2. Former Name of Employee (e.g., maiden name/legal name change/other):

___________________________________________________________________________

Mr./Mrs./Ms. First Name Middle Initial Last Name

C.3. Address of Employee (if living):

___________________________________________________________________________

Street Apt. # P.O. Box

___________________________________________________________________________

City State Zip Code

C.4. Telephone Number of Employee: (______)_______-__________________

C.5. Email Address of Employee: _________________________________

C.6. Employment Information Related to Petition:

C.6.a. Employee Number (if known): ________________________________________

C.6.b. Dates of Employment: Start _________________ End ____________________

C.6.c. Employer Name: _________________________________________________________

C.6.d. Work Site Location: _________________________________________________________

_________________________________________________________

C.6.e. Supervisor’s Name: _________________________________________________________

Go to Part E.

Part D Labor Organization Information – Complete Part D ONLY if you are a labor organization.

D.1. Labor Organization Information:

___________________________________________________________________________

Name of Organization

___________________________________________________________________________

Position of Contact Person

D.2. Name of Petition Representative:

___________________________________________________________________________

Mr./Mrs./Ms. First Name Middle Initial Last Name

D.3. Address of Petition Representation:

___________________________________________________________________________

Street Apt. # P.O. Box

___________________________________________________________________________

City State Zip Code

D.4. Telephone Number of Petition Representative: (______)_______-__________________

D.5. Email Address of Petition Representative: _________________________________

D.6. Period during which labor organization represented employees covered by this petition

(please attach documentation): Start __________ End __________

D.7. Identity of other labor organizations that may represent or have represented this class of employees (if known):

Go to Part E.

Part E Proposed Definition of Employee Class Covered by Petition – Complete Part E..

E.1. Name of DOE or AWE Facility: _____________________________________________

E.2. Locations at the Facility relevant to the petition:

____________________________________________________________________________________

____________________________________________________________________________________

E.3. List job titles and/or job duties of employees included in the class. In addition, you can list by name any individuals other than petitioners identified on this form who you believe should be included in the class:

____________________________________________________________________________________

____________________________________________________________________________________

E.4. Employment Dates relevant to this petition:

Start __________________________ End _____________________________

Start __________________________ End _____________________________

Start __________________________ End _____________________________

E.5 Is the petition based on one or more unmonitored, unrecorded, or inadequately monitored or recorded exposure incidents? ____ Yes ____ No

If yes, provide the date(s) of the incident(s) and a complete description (attach additional pages as necessary):

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

Go to Part F.

Part F Basis for Proposing that Records and Information are Inadequate for Individual Dose Reconstructions – Complete Part F.

Complete at least one of the following entries in this section by checking the appropriate box and providing the required information related to the selection. You are not required to complete more than one entry.

F.1. ___ I/We have attached either documents or statements provided by affidavit that indicate that radiation exposures and radiation doses potentially incurred by members of the proposed class, that relate to this petition, were not monitored, either through personal monitoring or through area monitoring.

(Attach documents and/or affidavits to the back of the petition form.)

Describe as completely as possible, to the extent it might be unclear, how the attached documentation and/or affidavit(s) indicate that potential radiation exposures were not monitored.

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

F.2. ___ I/We have attached either documents or statements provided by affidavit that indicate that radiation monitoring records for members of the proposed class have been lost, falsified, or destroyed; or that there is no information regarding monitoring, source, source term, or process from the site where the employees worked.

(Attach documents and/or affidavits to the back of the petition form.)

Describe as completely as possible, to the extent it might be unclear, how the attached documentation and/or affidavit(s) indicate that radiation monitoring records for members of the proposed class have been lost, altered illegally, or destroyed.

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Part F is continued on the following page.

F.3. ___ I/We have attached a report from a health physicist or other individual with expertise in radiation dose reconstruction documenting the limitations of existing DOE or AWE records on radiation exposures at the facility, as relevant to the petition. The report specifies the basis for believing these documented limitations might prevent the completion of dose reconstructions for members of the class under 42 CFR Part 82 and related NIOSH technical implementation guidelines.

(Attach report to the back of the petition form.)

F.4. ___ I/We have attached a scientific or technical report, issued by a government agency of the Executive Branch of Government or the General Accounting Office, the Nuclear Regulatory Commission, or the Defense Nuclear Facilities Safety Board, or published in a peer-reviewed journal, that identifies dosimetry and related information that are unavailable (due to either a lack of monitoring or the destruction or loss of records) for estimating the radiation doses of employees covered by the petition.

(Attach report to the back of the petition form.)

Go to Part G.

Part G Signature of Person(s) Submitting this Petition – Complete Section G.

All Petitioners should sign and date the petition. A maximum of three persons may sign the petition.

___________________________________________ ___________________

Signature Date

___________________________________________ ___________________

Signature Date

___________________________________________ ___________________

Signature Date

Notice: Any person who knowingly makes any false statement, misrepresentation, concealment of fact or any other act of fraud to obtain compensation as provided under EEOICPA or who knowingly accepts compensation to which that person is not entitled is subject to civil or administrative remedies as well as felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment or both. I affirm that the information provided on this form is accurate and true.

Send this form to: SEC Petition

Division of Compensation Analysis and Support

NIOSH

4676 Columbia Parkway, MS-C-47

Cincinnati, OH 45226

If there are additional petitioners, they must complete the Appendix Forms for additional petitioners. The Appendix forms are located at the end of this document.

Public Burden Statement

Public reporting burden for this collection of information is estimated to average 300 minutes per response, including time for reviewing instructions, gathering the information needed, and completing the form. 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-E-11, Atlanta GA, 30333; ATTN:PRA 0920-0639. Do not send the completed petition form to this address. Completed petitions are to be submitted to NIOSH at the address provided in these instructions. Persons are not required to respond to the information collected on this form unless it displays a currently valid OMB number.

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) authorizes the President to designate additional classes of employees to be included in the Special Exposure Cohort (SEC). EEOICPA authorizes HHS to implement its responsibilities with the assistance of the National Institute for Occupational Safety (NIOSH), an Institute of the Centers for Disease Control and Prevention. Information obtained by NIOSH in connection with petitions for including additional classes of employees in the SEC will be used to evaluate the petition and report findings to the Advisory Board on Radiation and Worker Health and HHS.

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 and WTC Health 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 for the processing of your petition or other purposes 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 to assist with the evaluation of SEC petitions; (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 forms and informational requests that you may receive from NIOSH in connection with the evaluation of an SEC petition.

Use of the NIOSH petition forms (A and B) is voluntary but your provision of information required by these forms is mandatory for the consideration of a petition, as specified under 42 CFR Part 83. Petitions that fail to provide required information may not be considered by HHS.

Special Exposure Cohort Petition - Form B Appendix – Petitioner 2

Use of this form is voluntary. Failure to use this form will not result in the denial of any right, benefit, or privilege to which you may be entitled.

OMB No.: 0920-0639 Expires:

Use this Appendix for Petitioner 2

This appendix form is to be used as needed. Petitioner 2, or his or her representative, should complete the parts applicable to him or her.

Refer to the General Instructions on completing petitioner information for Parts A, B, or C.

If you need more space to provide additional information, use the continuation page provided at the end of the form and attach completed continuation page(s) to Form B.

Except for signatures, please PRINT all information clearly and neatly on the form.

If you are:

An Energy Employee (current or former), start at Part C.

A Survivor (of a former Energy Employee), start at Part B.

A Representative (of a current or former Energy Employee or Survivor), start at Part A.

Part A Representative Information – Complete Part A if you are authorized by an Energy Employee or Survivor(s) to petition on behalf of a class.

A.1. Are you a contact person for an organization? ___ Yes (Go to A.2.) ___ No (Go to A.3.)

A.2. Organization Information:

___________________________________________________________________________

Name of Organization

___________________________________________________________________________

Position of Contact Person

A.3. Name of Petition Representative:

___________________________________________________________________________

Mr./Mrs./Ms. First Name Middle Initial Last Name

A.4. Address of Petition Representative:

___________________________________________________________________________

Street Apt. # P.O. Box

___________________________________________________________________________

City State Zip Code

A.5. Telephone Number of Petition Representative: (______)_______-__________________

A.6. Email Address of Petition Representative: _________________________________

A.7. ____ Check the space at left to indicate you have attached to the back of this form written authorization to petition by the survivor(s) or energy employee(s) indicated in Parts B or C of this form.

If you are representing a Survivor, go to Part B; if you are representing an Energy Employee, go to Part C

Part B Survivor Information – Complete Section B if you are a Survivor or representing a Survivor

B.1. Name of Survivor:

___________________________________________________________________________

Mr./Mrs./Ms. First Name Middle Initial Last Name

B.2. Address of Survivor:

___________________________________________________________________________

Street Apt. # P.O. Box

___________________________________________________________________________

City State Zip Code

B.3. Telephone Number of Survivor: (______)_______-__________________

B.4. Email Address of Survivor: _________________________________

B.5. Relationship to Energy Employee: ___ Spouse ___ Son/Daughter ___ Parent

___ Grandparent ___Grandchild

Go to Part C.

Part C Energy Employee Information – Complete Section C

C.1. Name of Energy Employee:

___________________________________________________________________________

Mr./Mrs./Ms. First Name Middle Initial Last Name

C.2. Former Name of Energy Employee (e.g., maiden name/legal name change/other):

___________________________________________________________________________

Mr./Mrs./Ms. First Name Middle Initial Last Name

C.3. Address of Energy Employee (if living):

___________________________________________________________________________

Street Apt. # P.O. Box

___________________________________________________________________________

City State Zip Code

C.4. Telephone Number of Energy Employee: (______)_______-__________________

C.5. Email Address of Energy Employee: _________________________________

C.6. Employment Information Related to Petition:

C.6.a. Employee Number (if known): ________________________________________

C.6.b. Dates of Employment: Start _________________ End ____________________

C.6.c. Employer Name: _________________________________________________________

C.6.d. Work Site Location: _________________________________________________________

_________________________________________________________

C.6.e. Supervisor’s Name: _________________________________________________________

Special Exposure Cohort Petition - Form B Appendix – Petitioner 3

Use of this form is voluntary. Failure to use this form will not result in the denial of any right, benefit, or privilege to which you may be entitled.

OMB No.: 0920-0639 Expires:

Use this Appendix for Petitioner 3

This appendix form is to be used as needed. Petitioner 3, or his or her representative, should complete the parts applicable to him or her.

Refer to the General Instructions on completing petitioner information for Parts A, B, or C.

If you need more space to provide additional information, use the continuation page provided at the end of the form and attach completed continuation page(s) to Form B.

Except for signatures, please PRINT all information clearly and neatly on the form.

If you are:

An Energy Employee (current or former), start at Part C.

A Survivor (of a former Energy Employee), start at Part B.

A Representative (of a current or former Energy Employee or Survivor), start at Part A.

Part A Representative Information – Complete Part A if you are authorized by an Energy Employee or Survivor(s) to petition on behalf of a class.

A.1. Are you a contact person for an organization? ___ Yes (Go to A.2.) ___ No (Go to A.3.)

A.2. Organization Information:

___________________________________________________________________________

Name of Organization

___________________________________________________________________________

Position of Contact Person

A.3. Name of Petition Representative:

___________________________________________________________________________

Mr./Mrs./Ms. First Name Middle Initial Last Name

A.4. Address of Petition Representative:

___________________________________________________________________________

Street Apt. # P.O. Box

___________________________________________________________________________

City State Zip Code

A.5. Telephone Number of Petition Representative: (______)_______-__________________

A.6. Email Address of Petition Representative: _________________________________

A.7. ____ Check the space at left to indicate you have attached to the back of this form written authorization to petition by the survivor(s) or energy employee(s) indicated in Parts B or C of this form.

If you are representing a Survivor, go to Part B; if you are representing an Energy Employee, go to Part C

Part B Survivor Information – Complete Section B if you are a Survivor or representing a Survivor

B.1. Name of Survivor:

___________________________________________________________________________

Mr./Mrs./Ms. First Name Middle Initial Last Name

B.2. Address of Survivor:

___________________________________________________________________________

Street Apt. # P.O. Box

___________________________________________________________________________

City State Zip Code

B.3. Telephone Number of Survivor: (______)_______-__________________

B.4. Email Address of Survivor: _________________________________

B.5. Relationship to Energy Employee: ___ Spouse ___ Son/Daughter ___ Parent

___ Grandparent ___Grandchild

Go to Part C.

Part C Energy Employee Information – Complete Section C UNLESS you are a labor organization

C.1. Name of Energy Employee:

___________________________________________________________________________

Mr./Mrs./Ms. First Name Middle Initial Last Name

C.2. Former Name of Energy Employee (e.g., maiden name/legal name change/other):

___________________________________________________________________________

Mr./Mrs./Ms. First Name Middle Initial Last Name

C.3. Address of Energy Employee (if living):

___________________________________________________________________________

Street Apt. # P.O. Box

___________________________________________________________________________

City State Zip Code

C.4. Telephone Number of Energy Employee: (______)_______-__________________

C.5. Email Address of Energy Employee: _________________________________

C.6. Employment Information Related to Petition:

C.6.a. Employee Number (if known): ________________________________________

C.6.b. Dates of Employment: Start _________________ End ____________________

C.6.c. Employer Name: _________________________________________________________

C.6.d. Work Site Location: _________________________________________________________

_________________________________________________________

C.6.e. Supervisor’s Name: _________________________________________________________

Special Exposure Cohort Petition - Form B Appendix –Continuation Page

Use of this form is voluntary. Failure to use this form will not result in the denial of any right, benefit, or privilege to which you may be entitled.

OMB No.: 0920-0639 Expires:

Continuation Page – Photocopy and complete as necessary.

Attach to Form B if necessary