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

D OMB No. 0704-0447 Expiration: EFENSE 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 (0704-0447). 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: NTS (NTPR), 8725 John J. Kingman Road, Stop 6201, Fort Belvoir, VA 22060-6201. For assistance, please either call the NTPR toll-free helpline: (1-800-462-3683), write us at the provided NTPR address, or email us at [email protected].
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), as amended. PURPOSE(S): 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, and Vanderbilt University for the purpose of conducting epidemiological studies on the effects of ionizing radiation on participants of nuclear test programs. Additional routines are listed in the applicable system of records notice HDTRA 010, Nuclear Test Participants, located at: http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570291/hdtra-010/ DISCLOSURE: Voluntary; however, failure to provide the requested information and authorization may delay or preclude DTRA from providing or releasing information.
SECTION I: PARTICIPANT PERSONAL DATA (please print)
1. Last Name			2. First Name				3. Middle Name				4. Sex M F
5. SSN		6. Branch of Service		7. Rank						8. Service Number
9. Address City State Zip								10. Telephone Home (        ) Other (        )
11. Date of Birth (mm/dd/yy)	12. Place of Birth				13. Deceased Yes No				14. Date of Death (mm/dd/yy)
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)
SECTION III: PARTICIPATION DATA (please print) (continued):
20. Remarks
SECTION IV: 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 V: 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 Date

DTRA Form 150 (August 2017) 3