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

OMB No. 0704-0447
Expiration:

DEFENSE THREAT REDUCTION AGENCY

Nuclear Test Personnel Review Information Request and Release
AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information is estimated to average 15 minutes 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. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense,
Washington Headquarters Services, Executive Services Directorate, Information Management Division, 4800 Mark
Center Drive, East Tower, Suite 02G09, Alexandria, VA 22350-3100 (XXXX-XXXX). Respondents should be aware
that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a
collection of information if it does not display a currently valid OMB control number.
PLEASE RETURN YOUR RESPONSE TO THE ADDRESS BELOW.
Responses should be sent to: Defense Threat Reduction Agency, Attn: J9NTSN (NTPR), 8725 John J. Kingman
Road, Stop 6201, Fort Belvoir, VA 22060-6201. For assistance, please either call the NTPR toll-free helpline: (1-800462-3683), write us at the provided NTPR address, or email us at [email protected].

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 (
) ____________________
11. Date of Birth (mm/dd/yy) 12. Place of Birth
13. Deceased
14. Date of Death (mm/dd/yy)
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)

DTRA Form 150 (May 2014)

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SECTION II: PARTICIPATION DATA (please print) (continued):
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: ___________________________
22. How did you hear of the NTPR Program: _______________________________________________________

If you have any questions regarding this form, please call the NTPR toll-free helpline:
1-800-462-3683
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 ______________________________________

DTRA Form 150 (May 2014)

Date _____________________

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SECTION V: PRIVACY ACT STATEMENT
AUTHORITY: 42 U.S.C. 2013 (AEC), 38 U.S.C. 1154 and 1112 (Veterans Benefits), 42 U.S.C. 2210 (DOJ
compensation program), Pub. L. 108-183 section 601 (Veterans Benefits Act of 2003), Pub. L. 94-367, Pub. L. 100-426
(Radiation Exposure Compensation Act) amended by Pub. L. 100-510, and E.O. 9397 (SSN).
PURPOSE(S): For use by agency officials and employees, or authorized contractors, and other DoD components to
provide data or documentation relevant to the processing of administrative claims or litigation; to conduct scientific
studies or medical follow-up programs; and in the preparation of the histories of nuclear test programs.
ROUTINE USES: Disclosure of records permitted outside DoD under 5 U.S.C. 552a(b) (Privacy Act) to the Department
of Veterans Affairs, Department of Justice, and Department of Labor for identifying and processing claims by individuals
who allege job-related disabilities as a result of participation in nuclear test programs and for litigation actions, Veterans
Advisory Board on Dose Reconstruction for the purpose of reviewing and overseeing the DoD Radiation Dose
Reconstruction Program audits of dose reconstructions and to the Department of Health and Human Services, National
Council on Radiation Protection & Measurements, and Vanderbilt University for the purpose of conducting
epidemiological studies on the effects of ionizing radiation on participants of nuclear test programs. The DoD 'Blanket
Routine Uses' also apply.
DISCLOSURE: Voluntary. However, failure to provide the requested information and authorization may delay or
preclude DTRA from providing or releasing information.

DTRA Form 150 (May 2014)

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