DTRA Form 150 B Questionnaire for Oceanic Test Participants

DEFENSE THREAT REDUCTION AGENCY Nuclear Test Personnel Review Program
Questionnaire for Oceanic Test Participants
PLEASE RETURN YOUR RESPONSE TO THE ADDRESS BELOW.
Responses should be sent to: Defense Threat Reduction Agency, Attn: RD-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), email us at [email protected], or write us at the address above.
SECTION I. Please use a separate questionnaire for each operation in which you participated. Check the operation for which these answers apply:
SANDSTONE (1948) GREENHOUSE (1951) IVY (1952)	CASTLE (1954) WIGWAM (1955) REDWING (1956)		HARDTACK I (1958) ARGUS (1958) DOMINIC I (1962)
PARTICIPANT INFORMATION (please print)
Name:		Branch of Service/Service Number:
Address:
Telephone:
If this questionnaire is completed by someone other than the participant, please provide (please print):
Name:		Relationship to veteran:
Address:
Telephone:

OMB No. 0704-0447 Expiration:

SECTION II. PARTICIPATION SUMMARY
1.	Home station/port:
	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) Enewetak Island of Enewetak Atoll (b) Parry Island of Enewetak Atoll (c) Japtan Island of Enewetak Atoll (d) Eneu Island of Bikini Atoll (e) Bikini Island of Bikini Atoll (f) Christmas Island (g) Johnston Island (h) Aboard ship (provide name and hull number of ship): (i) None of the above; visited test site from another location (specify): (j) Other (specify):
4.	If you checked any of (a) through (g) above, about when did you arrive and depart?
	Arrival date:	Departure date:
	Mode of transportation:
	Did you leave the area (temporary duty, emergency leave, etc.) at any time during your deployment? Yes (provide reason and approximate dates) No

SECTION II. PARTICIPATION SUMMARY (Continued)
5.	Which of the following describes your participation in the test series? (check all that apply) (a) Supported operations from a location specified in 3a through 3g. Provide details in Question 6 . (b) Supported operations aboard a ship. Provide details in Question 7 (page 4). (c) Participated as an official observer at a detonation(s). Provide details in Question 8 (page 6). (d) Participated in a scientific project. Provide details in Question 9 (page 7). (e) Was a crew member of an aircraft that participated in or supported the operation. Provide details in Question 10 (page 7). (f) Other (specify below). Provide details in Question 11 (page 9).
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 supported the operation from one of the residence islands specified in Question 3, provide details:
	(a) General nature of duties (e.g., administrative support):
	(b) Where were you located during each test detonation (e.g., inside building, in open area, evacuated aboard ship)? What precautions were taken (e.g., wore goggles)?
	(c) Did your residence island receive any fallout during the operation? Yes (provide details by event) No Shot/date: Your location during fallout: Indoors Outdoors What precautions were taken to minimize exposure to fallout?
	(d) Did your duties involve contact with radioactive material other than general fallout on the island? Yes (provide details below) No

SECTION III (Continued)
6.	If you supported the operation from one of the residence islands specified in Question 3, provide details (Continued):
	(e) Did you visit non-residence islands or other locations? Yes (provide details below) No Name of island/location: Date and duration of visit(s): Purpose of visit: Was the island/location contaminated? Yes No If yes, were any precautions taken to minimize exposure to radiation? Yes (provide details below) No Other activities:
	(f) Were you ever found to be contaminated during the operation? Yes (provide details) No If yes, describe the event(s) that resulted in this contamination:
7.	If you supported the operation aboard a ship, provide details:
	(a) Name, hull number, and type of ship: General nature of duties (e.g., maintained electronic equipment): Average time spent topside: hours per day
	(b) Where were you located during each test detonation (e.g., at duty station below decks)? What precautions were taken (e.g., wore goggles)?
	(c) Did your ship receive any fallout during the operation? Yes (provide details by event) No Shot/date: Your location during fallout: Topside Below decks What precautions were taken to minimize exposure to the fallout (e.g., set gas-tight envelope, energized washdown system)?

SECTION III (Continued)
7.	If you supported the operation aboard a ship, provide details (Continued):
	(d) Did your duties involve contact with radioactive material other than general fallout on the ship? Yes (provide details below) No
	(e) Was your ship involved in a special project (e.g., recovery of missile pods)? Yes (provide details below) No
	(f) Did you visit or were you assigned to another ship? Yes (provide details below) No Name and hull number of ship: Frequency and duration of visit/assignment: Purpose of visit/assignment:
	(g) Did you perform activities aboard target ships? Yes (provide details below) No Name and hull number of ship: Frequency and duration of visit: Activities during visit:
	(h) Did you participate in small boat operations? Yes (provide details below) No Frequency of operations (daily, once a week, etc.): Duration of operations (in hours): Activities aboard small boats:
	(i) Were you granted shore liberty during the operation? Yes (provide details/location) No Frequency and duration of liberty:

SECTION III (Continued)
7.	If you supported the operation aboard a ship, provide details (Continued):
	(j) Did you perform activities that involved potential exposure to radiation/radioactive material on other ships/boats/islands? Yes (provide details below) No Activity, location, duration, etc.:
	(k) Did you leave the ship for any other reasons? Yes (provide details below) No
	(l) Were you ever found to be contaminated during the operation? Yes (provide details) No Describe the event(s) that resulted in this contamination: Where were you contaminated (hands, clothes, etc.)? Were you decontaminated? Yes No If yes, how?
8.	If you participated as an official observer, provide details:
	(a) Shot/date:
	(b) Location at shot time: On island (specify): On ship (name and hull number): In aircraft (type): Altitude and distance from detonation:
	(c) Post-shot activity:
	(d) Length of time in test area:
	(e) Billet location:

SECTION III (Continued)
9.	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:
	(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?
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 test 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:
	(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:

SECTION III (Continued)
10.	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:
	(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:
	(g) Do you have flight logs for the period that you supported the operation? Yes (please submit copies with this questionnaire) No

SECTION III (Continued)
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.	Where did you eat your meals? (a) Mess hall / tent (b) Aboard ship – crew mess / wardroom (c) Aboard ship – topside (d) Island – outside (e) Other (specify): _____________________________________________________ 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

SECTION V. AGENCY DISCLOSURE NOTICE

The public reporting burden for this collection of information should 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 [email protected]. 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.

SECTION VI. 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-B (Dec 2019) 8