DTRA Form 150-A Nuclear Test Personnel Review Program: Questionnaire for

	DEFENSE THREAT REDUCTION AGENCY
	Nuclear Test Personnel Review Program Questionnaire for Continental United States Test Participants
AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information is estimated to average 60 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.
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.
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].
SECTION I: Please use a separate questionnaire for each operation in which you participated. Check the operation for which these answers apply:
TRINITY (1945) RANGER (1951) BUSTER-JANGLE (1951)		TUMBLER-SNAPPER (1952) UPSHOT-KNOTHOLE (1953) TEAPOT (1955)	PLUMBBOB (1957) HARDTACK II (1958) DOMINIC II (1962)

OMB No. 0704-0447

Expiration:

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:
	Unit of assignment:
	Rank (at time of participation):
	Specialty:
2.	List names of other personnel (up to four) with similar participation experience:
3.	Where were you billeted? (check all that apply) (a) Camp Desert Rock/TRINITY Base Camp (b) Camp Mercury (c) Indian Springs AFB (d) None of the above; visited test site from another location (specify): (e) Other (specify):
4.	If (a), (b) or (c) were checked above, about when did you arrive and depart?
	Arrival date:		Departure date:
	Did you leave the area (temporary duty, emergency leave, etc.) at any time during your deployment? Yes (provide reason and approximate dates) No

5.		Which of the following describes your participation in the test series? (check all that apply) (a) Participated in a troop maneuver in conjunction with a detonation(s). Provide details in Question 6 (page 3). (b) Participated as an observer at a detonation(s). Provide details in Question 7 (page 3). (c) Participated in a scientific project. Provide details in Question 8 (page 4). (d) Supported operations from location specified in Question 3. Provide details in Question 9 (page 5). (e) Was a crew member of an aircraft that participated in or supported the operation. Provide details in Question 10 (page 5). (f) Other (specify below). Provide details in Question 11 (page 7).
SECTION III: The following questions are intended to assess your potential for exposure to radiation during your participation as indicated in Question 5. Please provide details for answers to the 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.”
6.	If you participated in a troop maneuver(s), provide details by event:
	(a) Shot/date:
	(b) Maneuver unit designation:
	(c) Your location at shot time: In open area In trench/foxhole In vehicle (specify) Other (specify) Distance from ground zero:
	(d) Description of maneuver and your activities: Time (minutes after shot) maneuver began: Duration of maneuver:
	(e) At the end of the maneuver, were you monitored for radiological contamination? Yes No If yes, were you found to be contaminated? Yes No If yes, where? Were you decontaminated? Yes No If yes, how?
	(f) Other comments:

7.	Other than in conjunction with a troop maneuver (Question 6), if you observed a test detonation from a location other than the base camp, provide details by event:
	(a) Shot/date:
	(b) Your location at shot time: In open area In trench/foxhole In vehicle (specify) Other (specify) Distance from ground zero:
	(c) Post-shot activity (e.g., toured equipment display area):
	Other than in conjunction with a troop maneuver (Question 6), if you observed a test detonation from a location other than the base camp, provide details by event (Continued):
	(d) Location of activity with respect to ground zero:
	(e) Time (minutes after shot) activity began: Total time in shot area:
	(f) At the end of the activity, were you monitored for radiological contamination? Yes No If yes, were you found to be contaminated? Yes No If yes, where? Were you decontaminated? Yes No If yes, how?
	(g) Other comments:
8.	If you participated in a scientific project, provide details by event:
	(a) Shot/date:
	(b) Project number/title:
	(c) Description of activity: Location of activity with respect to ground zero: Time (before/after shot) activity began: Total time in shot area:
8.	(d) At the end of the activity, were you monitored for radiological contamination? Yes No If yes, were you found to be contaminated? Yes No If yes, where? Were you decontaminated? Yes No If yes, how?
	(e) Other comments:
9.	If you supported the operation from a base camp or other location (e.g., Camp Desert Rock, Indian Springs AFB), provide details:
	(a) Location:
	(b) Description of duties:
	(c) Did these duties involve contaminated material? Yes (provide details below) No Contaminated item(s): Your associated duties: Duration of association (hours): Proximity to item (feet):
	(d) Other comments relative to possible radiation exposure:
10.	If you supported the operation as an air crew member, provide details:
	(a) Flight duty (pilot, engineer, etc.):
	(b) Type of aircraft: Operating from (airfield):
	(c) Were you airborne during any detonation? Yes (provide details by event) No (see 10.d) Shot/date: Altitude at shot time: Distance and direction from detonation: Purpose and route of mission:

10.	(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:
	If you supported the operation as an air crew member, provide details (Continued):
	(e) Did your aircraft penetrate the nuclear cloud or encounter fallout? Yes (provide details below) No Time after shot of penetration/fallout encounter: Duration of penetration/fallout encounter: Altitude of aircraft at the time: Total duration of flight: Radiation levels encountered: Precautionary measures taken (e.g., breathed 100% oxygen, sealed/filtered air intakes, wore leaded vest, flew through rain showers):
	(f) Were you contaminated during any mission? Yes (provide details by shot/mission) No Shot/date: Purpose of mission: Activity that resulted in contamination: Location of contamination (e.g., gloves, pant leg, face): Method of decontamination: Other comments:
	(g) Did your aircraft land in a contaminated area? Yes (provide details below) No Shot, location, and time: Radiation levels and duration: Reason for landing:

10.	(h) 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:
	(i) Do you have flight logs for the period that you supported the operation? Yes (please submit copies with this questionnaire) No
11.	If your participation is not covered in Questions 6-10, provide details regarding any potential exposure to radiation (date, location, activities, exposure conditions, etc.):
12.	Did you perform any RADSAFE activity (e.g., serve as radiation monitor, decontaminate personnel/ equipment)? Yes (provide details below) No
13.	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: Frequency of use: Other comments:
14.	Were you issued a film badge (radiation dosimeter) during the operation? Yes (check all statements below that apply) No (a) Issued badge upon arrival at test site, wore same badge during entire stay. (b) Issued badge upon arrival, wore until replaced with another badge. (c) Issued badge(s) for a specific activity/mission, turned in afterwards. (d) Wore more than one badge at a time. (e) Lost or failed to turn in at least one badge during the operation. (f) None of the above (please explain):
15.	During the tests, did you eat your meals at (check all that apply): (a) Mess Hall / Tent (b) In the field; circumstances: ____________________________________________________ (c) Other (specify): _____________________________________________________ If you ate your meals in the field, did you use (check all that apply): (a) Plates, cups, cutlery (b) Box lunches (c) Canteens (d) C-rations (e) Other (specify): _____________________________________________________

15.	Additional comments: ______________________________________________________________ _________________________________________________________________________________
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

DTRA Form 150-A (August 2017)