Authorization Form on behalf of Claimant under 42 CFR 83.7

Special Exposure Cohort Petition

U.S. Department of Health and Human Services

under the Energy Employees Occupational
Illness Compensation Act

Centers for Disease Control and Prevention
National Institute for Occupational Safety and Health

OMB Number: 0920-0639

Petitioner Authorization Form

Expires: 07/31/2010
Page 1 of 2

Use of this form is voluntary. Failure to use this form will not result in the denial of any right, benefit,
Instructions:
If you wish to petition HHS to consider adding a class of employees to the Special Exposure Cohort and you
are NOT either a member of that class, a survivor of a member of that class, or a labor organization
representing or having represented members of that class, then 42 CFR Part 83, Section 83.7(c) requires
that you obtain written authorization. You can obtain such authorization from either an employee who is a
member of the class or a survivor of such an employee. You may use this form to obtain such authorization
and submit the completed form to NIOSH with the related petition. Please print legibly.

For Further Information: If you have questions about these instructions, please call the following NIOSH
toll-free phone number and request to speak to someone in the Office of Compensation Analysis and
Support about an SEC petition: 1-800-356-4674.

Authorization for Individual or Entity to Petition HHS on Behalf of a Class of Employees for
Addition to the Special Exposure Cohort
I,
Name of Class Member or Survivor
Street Address of Class Member or Survivor

Apt. #

P.O. Box

Apt. #

P.O. Box

City, State, Zip Code of Class Member or Survivor
do hereby authorize:
Name of Petitioner
Address of Petitioner
City, State and Zip Code of Petitioner
to petition the Department of Health and Human Services on behalf of a class of employees
that includes:
Name of Class Member (employee, not the employee’s survivor)
for the addition of the class to the Special Exposure Cohort, under the Energy Employee’s
Occupational Illness Compensation Program Act (42 U.S.C. §§ 7384-7385).
In providing this authorization, I recognize that the petitioner named above will have all the rights
of a petitioner as provided for under 42 CFR Part 83.
Signature of Class Member or Survivor

Name or Social Security Number of First Petitioner:

Date

Special Exposure Cohort Petition

U.S. Department of Health and Human Services

under the Energy Employees Occupational
Illness Compensation Act

Centers for Disease Control and Prevention
National Institute for Occupational Safety and Health

OMB Number: 0920-0639

Petitioner Authorization Form

Expires: 07/31/2010
Page 2 of 2

Public Burden Statement
Public reporting burden for this collection of information is estimated to average 3 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.
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.

Name or Social Security Number of First Petitioner: