Form 0920-0530 Telephone Interviews and Intro Letters

Energy Employees Occupational Illness Compensation Program Act Dose Reconstruction Interviews and Forms (EEOICPA)

Attachment C CATI form_ICRO edits

EEOICPA Dose Reconstruction Introductory Letters & Telephone Interview

OMB: 0920-0530

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ATTACHMENT C

Telephone Interviews with Claimants/Coworkers and Introductory Letters

I am writing on behalf of the ORAU Team, the contractor assisting the National Institute for Occupational Safety and Health (NIOSH) with your dose reconstruction. We would like to speak with you on the phone to ask you some questions about work history and radiation exposure. We expect the call to take about an hour.

So that you know what to expect during the call, I have enclosed a list of the questions that we would like to discuss. Some things to keep in mind:

 Your participation is voluntary. If you decide to talk with us, the information collected will be treated in a secure manner and will not be disclosed, unless otherwise compelled by law.

 If you have any special needs for the call we will make arrangements to meet those special needs.

When you have looked over the enclosed questions and are ready to schedule your call, please contact the ORAU Team toll-free at 1-800-790-6728 (1-800-790-ORAU). Our hours are from 8:00 a.m. to 4:30 p.m. Eastern time. Keep in mind that this initial call is simply to schedule a future time to discuss the questions about your work history and radiation exposure.

Please feel free to call our toll-free number if you have any questions about this letter. You can also find more information about the ORAU Team on the internet at www.oraucoc.org <http://www.oraucoc.org>.

Form Approved:

OMB No. 0920-0530

Exp. Date xx/xx/20xx

EEOICPA Dose Reconstruction Phone Call Questions

Claimant is Covered Employee

As you may know, NIOSH is responsible for estimating the occupational radiation doses received by persons with cancer applying for compensation under the Energy Employees Occupational Illness Compensation Program.

The attached questions will provide you with the chance to let us know any additional information about your work history that might not be found in the exposure monitoring information we receive from the Department of Energy (DOE) or Atomic Weapons Employer (AWE). While we encourage all claimants to talk to us about their work history, your participation is voluntary.

Some things to keep in mind with these questions:

You are not expected to know all of the information for the questions being asked and we do not want or expect you to search for any of this information. Please keep in mind that the technical documents we use to complete the dose reconstruction may already include some or all of the information you give us during the call.

You do not need to return the questionnaire to us as we will take the information from you over the phone.

We rarely need to consult other individuals for information on your claim, but this call gives you the opportunity to identify supervisors, co-workers, or others who might know relevant information so that we can contact them if we need to.

When the call is complete we will send you a summary of the information discussed and ask you to review it. Once your review is complete and we make any needed changes, we will continue the dose reconstruction process.

This should take no more than an hour. If we need to, we can divide this into a couple of shorter phone calls. If you have any special needs for the call we will make arrangements to meet those special needs.

Public Burden Statement

Public reporting burden for this collection of information is estimated to average 60 minutes per response, including time for reviewing instructions, gathering the information needed, and completing the interview. 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-D-74, Atlanta, GA 30333; ATTN:PRA 0920-0530. Do not send the completed phone call form to this address. Please do not complete and return this form; you will be contacted by telephone to collect this information. Persons are not required to respond to the work history questions unless a currently valid OMB number is displayed.

Privacy Act Advisement

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. § 552a), you are hereby notified of the following:

The Energy Employees Occupational Illness Compensation Program Act (42 U.S.C. §§ 7384-7385) (EEOICPA) requires the promulgation of methods, in the form of regulations, for estimating the dose levels of ionizing radiation incurred by workers in the performance of duty for nuclear weapons production programs for the Department of Energy and its predecessor agencies. These methods are applied by the National Institute for Occupational Safety and Health (NIOSH), an Institute of the Centers for Disease Control and Prevention, for producing radiation dose estimates that the U.S. Department of Labor uses in adjudicating certain claims under EEOICPA.

Records containing identifiable information become part of an existing NIOSH system of records under the Privacy Act, 09-20-147 “Occupational Health Epidemiological Studies EEOICPA Program Records, and WTC Health Program Records. HHS/CDC/NIOSH.” These records are treated in a confidential manner, unless otherwise compelled by law. Disclosures that NIOSH may need to make to complete a radiation dose reconstruction for your claim are listed below.

NIOSH may need to disclose personal identifying information to: (a) the Department of Energy, other federal agencies, other government or private entities and to private sector employers to permit these entities to retrieve records required by NIOSH; (b) identified witnesses as designated by NIOSH so that these individuals can provide information relevant to completing a radiation dose reconstruction for your claim; (c) contractors assisting NIOSH; (d) collaborating researchers, under certain limited circumstances to conduct further investigations; (e) Federal, state and local agencies for law enforcement purposes; and (f) a Member of Congress or a Congressional staff member in response to a verified inquiry.

This notice applies to all work history phone calls and forms that you may receive from NIOSH in connection with completing a radiation dose reconstruction for your claim.

Your participation in this phone call is voluntary.

Section 1: “Introductory Questions”

Did you receive a letter about the call from NIOSH?
Do you wish to discuss your work history?
Do you have any questions about the process?
Do you have any questions or concerns before we get started?

Section 2: “Employment History”

From what you remember or information readily available to you, what jobs have you held working for DOE, DOE contractors, or AWEs?

a. Facility	b. Job Title	c. Start Date
d. End Date	e. Supervisor Name

Start with the most recent job and ask the following questions in sections. Repeat these for each DOE/AWE job included in the employment history.

Section 3: “Detailed Work History”

How many hours per week did you work on this job?
Did you work any overtime hours? (If yes, how many hours of overtime, on average, did you work per week?)
Did you work any shift work?
How many hours per week did your job involve potential exposure to radiation and/or radioactive materials?
Which buildings or locations did you work in, for each of your routine duties, and during what time periods did you work in each of the buildings or locations?
Describe what you did on the job, as routine duties.

What types of radioactive materials were present or processed, and in what form(s) (solid, liquid, or gas)? Review the list below individually, as necessary

Radionuclide
Isotope(s) if known

Form of the material (solid / liquid / gas)

· Tritium	· Polonium	· Uranium (enriched)
· Cobalt	· Radon (progeny)	· Neptunium
· Strontium/Yttrium	· Radium	· Plutonium
· Technetium	· Actinium	· Americium
· Iodine	· Europium	· Curium
· Cesium	· Thorium (natural)	· Californium
· Thallium	· Protactinium	· Others (describe)
· Lead	· Uranium (natural)

What quantities of radioactive materials were present or processed (ounces, pounds, kilograms, drums) over what time periods?
What types of production processes involving radioactive materials occurred in areas where you worked?
What types of radiation-generating equipment were present or used? (example: neutron devices, radiography equipment/sources, portable x ray units, electron beam welders).
What specific tasks did you perform, using what types of radioactive materials (in what quantities), and/or radiation generating equipment?

What exposure/contamination control measures did you use to protect you? (Frequency of use: Always, Sometimes, Never)

· Fume Hoods	· Glove boxes	· Local ventilation
· Shielding	· Other enclosures (explain)	· Respirators
· Showers	· Anti-contamination clothing	· Other personal protective equipment (specify)

Did you conduct your work under a Special Work Permit, Radiological Work Permit, or other work control document that specified safety & health requirements? (If Yes, during what time periods?)

Section 4: “Radiation Monitoring”

Did you or your co-workers (working in the same area as you) routinely wear radiation dosimetry badges?
1. For which duties or in which buildings or locations, and during what time periods (e.g., which years) did you or your co-workers (working in the same areas as you) routinely wear radiation dosimetry badges?
  
  · Building/Location
  
  · Time Period
  
  · Duties
  
  · Employee Wore badge
  
  · Only Co-worker wore badge
2. For the time periods identified above, under what situations did you wear your badge?

How often did you wear your badge? (Time Period / Situations (e.g. always, upon entry to certain areas, when provided by Health and Safety, supervisor, etc.))
How often was your badge exchanged? (Time Period / Frequency (e.g. weekly, monthly, annually, don’t know))
Where on your body was your badge worn? (Time Period / Body Location)

Did you participate in a biological radiation monitoring program? (if yes, at what frequency)

· urine

· fecal

· in-vivo/whole body count

· breath
Do you have copies of your dosimeter badge or biological monitoring records, or annual reports of your monitoring results? (If Yes, Would you be willing to provide copies to us if we need the records?
Were you routinely surveyed (frisked) for external contamination? (If Yes, Were you surveyed before or after showering?)
Was air monitoring for radiation performed in the work environment?
1. When (over what time periods) did this occur?
2. What type of air monitoring was performed?
  
  · Job-specific
  
  · Lapel (employee breathing zone)
  
  · General area
  
  · Environmental
  
  · Other (Describe)
Were there any radiation surveys taken to characterize potential for external exposure? (If Yes, When did these occur?)
Was there monitoring in any of the buildings or areas you worked for exposure to radon? (If Yes, Which buildings or areas)
Were you ever restricted from the workplace or certain job duties because you had reached a radiation dose limit? (If Yes, Please explain)
Did you ever not turn in your dosimeter badge because you were approaching a radiation dose limit? (If Yes, How many times did this occur and during what periods?)

Section 5: “Required Medical Screening”

Were you ever required to have medical x rays for this job, as a condition of employment (upon hire, as part of an annual physical, etc.)
1. How often were you x-rayed, and over what time period(s)?
  
  · Time Period
  
  · Frequency of x rays
2. Do you have records of these x rays? (If Yes, Would you be willing to provide copies to us, if we need these records?)

Section 6: “Radiation Incidents”

Were you ever involved in any incidents involving radiation exposure or contamination? (If Yes, Please provide the following information for each incident)
1. What happened and when?
2. Which radioactive materials were involved, and in what form and quantity?
3. Was radiation-generating equipment involved? (If yes, what type?)
4. Where did it take place?
5. Who was involved?
6. What actions were taken to remedy the exposure or contamination?
7. What were your location and activities during the incident?
8. What precautions were taken to protect you?
9. What types of personal protective equipment, if any, did you use?
10. How long were you exposed during the incident?
11. Did you receive chelating therapy or other medical treatment as a result of radiation exposure from this incident?
  1. Please describe the medical treatment you received (example: Chelating Therapy)
12. Did you receive biological monitoring after the incident?

What type of biological monitoring and do you have records of this monitoring?

· urine

· in-vivo / whole body measurement

· breath

· fecal

· nasal swab
Are you willing to provide copies of these records to NIOSH?

Section 7: “Other relevant information”

Have we missed asking you about any conditions, situations, or practices that occurred during this job which you think may be useful to us in estimating your radiation doses?
1. Describe this with as much detail as possible, in terms of what occurred, where, when, for how long, and who was involved:
Are you aware of any records related to the information you have provided that may help us estimate your doses? (If Yes, please provide the following information)

· Log Books	· Personal Physician	· Site Medical Records
· Incident Reports	· Safety Meeting Notes	· Other (describe)

Section 8: “Final Questions Identifying co-workers and other witnesses”

NIOSH is confident it will obtain enough information to complete your dose reconstruction without receiving information from other individuals. However, in the event NIOSH does wish to speak to others who might provide information about your work conditions or exposures, can you readily provide names and contact information for co-workers, supervisors, industrial hygienists, radiation safety specialists, or anyone else who might be able to provide such information? (If “Yes” Obtain up to five names and any contact information available.)

(SV) CATI Introduction Letter (Letter 3) – Cover Page

So that you know what to expect during the call, I have enclosed a list of the questions that we would like to discuss. Some things to keep in mind:

 Your participation is voluntary. If you decide to talk with us, the information collected will be treated in a secure manner and will not be disclosed, unless otherwise compelled by law.

 If you have any special needs for the call we will make arrangements to meet those special needs.

Form Approved:

OMB No. 0920-0530

Exp. Date xx/xx/20xx

EEOICPA Dose Reconstruction Phone Call Questions

Claimant is a Family Member

The attached questions will provide you with the chance to let us know any additional information about the energy employees work history that might not be found in the exposure monitoring information we receive from the Department of Energy (DOE) or Atomic Weapons Employer (AWE). While we encourage all claimants to talk to us about the energy employee’s work history, participation is voluntary.

Some things to keep in mind with these questions:

You are not expected to know all of the information for the questions being asked and we do not want or expect you to search for any of this information. Please keep in mind that the technical documents we use to complete the dose reconstruction may already include some or all of the information you give us during the call.

You do not need to return the questionnaire to us as we will take the information from you over the phone.

We rarely need to consult other individuals for information on your claim, but this call gives you the opportunity to identify supervisors, co-workers, or others who might know relevant information so that we can contact them if we need to.

When the call is complete we will send you a summary of the information discussed and ask you to review it. Once your review is complete and we make any needed changes, we will continue the dose reconstruction process.

Public Burden Statement

Privacy Act Advisement

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. § 552a), you are hereby notified of the following:

Records containing identifiable information become part of an existing NIOSH system of records under the Privacy Act, 09-20-147 “Occupational Health Epidemiological Studies, EEOICPA Program Records and WTC Health Program Records. HHS/CDC/NIOSH.” These records are treated in a confidential manner, unless otherwise compelled by law. Disclosures that NIOSH may need to make to complete a radiation dose reconstruction for your claim are listed below.

This notice applies to all work history phone calls and forms that you may receive from NIOSH in connection with completing a radiation dose reconstruction for your claim.

Your participation in this phone call is voluntary.

Section 1: “Introductory Questions”

Did you receive a letter about the call from NIOSH?
Do you wish to discuss energy employee’s work history?
Do you have any questions about the process?
Do you have any questions or concerns before we get started?

Section 2: “Employment History”

From what you remember or information readily available to you, what jobs did the {Covered Employee} hold, working for DOE, DOE contractors, or AWEs?

a. Facility	b. Job Title	c. Start Date
d. End Date	e. Supervisor’s Name

answer the following questions. Repeat these questions for each DOE/AWE job included in the employment history

Section 3: “Detailed Work History”

How many hours per week did the {Covered Employee} work on this job?
Did the {Covered Employee} work any overtime hours? (If Yes, How many hours of overtime, on average, did the {Covered Employee} work per week?)
Did the {Covered Employee} work any shift work?
Do you know which buildings or locations (s)he worked in, routinely?

· Building

· Location
Describe whatever you know about the {Covered Employee(s)} duties.

Section 4: “Radiation Monitoring”

Did the {Covered Employee} routinely wear radiation dosimetry badges?
Did the {Covered Employee} participate in a biological radiation monitoring program? (If Yes, at what frequency?)

· urine

· fecal

· in-vivo/whole body count

· breath
Do you have copies of the {Covered Employee’s} dosimeter badge or biological monitoring records or annual reports? (If Yes, Would you provide copies to us?)
Was the {Covered Employee} ever restricted from the workplace or certain job duties because (s)he had reached a radiation dose limit?

Section 5: “Required Medical Screening”

Was the {Covered Employee} ever required to have medical x rays for this job, as a condition of employment (upon hire, as part of an annual physical, etc.)? (If Yes, Please provide the following information)
1. How often was (s)he x-rayed, and over what time period(s)? (e.g. upon hire, as part of an annual physical, etc.)
  
  · Time Period
  
  · Frequency of x rays
2. Do you have records of these x rays? (If Yes, Would you provide us with copies to us, if we need these records?)

Section 6: “Radiation Incidents”

Was the {Covered Employee} ever involved in an incident involving radiation exposure or contamination? (If Yes, Please provide the following information for each incident)
1. What happened, where and when?
2. Did the {Covered Employee} receive chelation therapy or other medical treatment as a result of radiation exposure from this incident?
  
  · chelation therapy
  
  · other medical treatment
3. Did the {Covered Employee} receive biological monitoring after the incident?
  
  · urine
  
  · fecal
  
  · breath
  
  · nasal swab
  
  · in-vivo / whole body measurement
4. Do you have records of this monitoring? (If Yes, Would you be willing to provide copies to us if we need the records?

Section 7: “Other relevant information”

Have we missed asking you about any conditions, situations, or practices that occurred during this job which you think may be useful to us in estimating the {Covered Employee’s} radiation doses? (If Yes, Describe with as much detail as possible, in terms of what occurred, where, when, for how long, and who was involved.)
Are you aware of any records related to the information you have provided that may help us estimate the {Covered Employee’s} radiation doses? (If Yes, please provide the following information)

· Log Books	· Personal Physician	· Site Medical Records
· Incident Reports	· Safety Meeting Notes	· Other (describe)

Section 8: “Final Questions Identifying co-workers and other witnesses”

NIOSH is confident it will obtain enough information to complete your dose reconstruction without receiving information from other individuals. However, in the event NIOSH does wish to speak to others who might provide information about the work conditions or exposures, can you readily provide names and contact information for co-workers, industrial hygienists, or radiation safety specialists, or anyone else who might be able to provide such information? (If “Yes” Obtain up to five names and any contact information available.)

(Co-worker / Supervisor) CATI Introduction Letter (Letter 3) – Cover Page

I am writing on behalf of the ORAU Team, the contractor assisting the National Institute for Occupational Safety and Health (NIOSH). We are requesting your help in reconstructing the radiation dose for [name of covered employee] on behalf of [survivor claimant’s name, if appropriate]. We would like to speak with you on the phone to ask some questions concerning radiation exposure information for [covered employee’s or survivor claimant’s name, as appropriate]. We expect the call to take about an hour.

So that you know what to expect during the call, I have enclosed a list of the questions that we would like to discuss. Some things to keep in mind:

 Your participation is voluntary. If you decide to talk with us, the information collected will be treated in a secure manner and will not be disclosed, unless otherwise compelled by law.

 If you have any special needs for the call we will make arrangements to meet those special needs.

Form Approved:

OMB No. 0920-0530

Exp. Date xx/xx/20xx

EEOICPA Dose Reconstruction Phone Call Questions

Co-Worker or Supervisor

The attached questions will provide you with the chance to let us know any additional information that might not be found in the exposure monitoring information we receive from the Department of Energy (DOE) or Atomic Weapons Employer (AWE). While we encourage you to talk to us, your participation is voluntary.

Some things to keep in mind with these questions:

You are not expected to know all of the information for the questions being asked and we do not want or expect you to search for any of this information. Please keep in mind that the technical documents we use to complete the dose reconstruction may already include some or all of the information you give us during the call.

You do not need to return the questionnaire to us as we will take the information from you over the phone

When the call is complete we will send you a summary of the information discussed and ask you to review it. Once your review is complete and we make any needed changes, we will continue the dose reconstruction process.

This should take no more than an hour, although we may have to call you back for additional information. If we need to divide this into a couple of shorter calls, we can do that as well.

Public Burden Statement

Public reporting burden for this collection of information is estimated to average 60 minutes per response, including time for reviewing instructions, gathering the information needed, and completing the work history phone call. 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-D-74, Atlanta, GA 30333; ATTN:PRA 0920-0530. Do not send the completed phone call form to this address. Please do not complete and return this form; you will be contacted by phone to collect this information. Persons are not required to respond to the work history phone call questions unless a currently valid OMB number is displayed.

Privacy Act Advisement

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. § 552a), you are hereby notified of the following:

Records containing identifiable information become part of an existing NIOSH system of records under the Privacy Act, 09-20-147 “Occupational Health Epidemiological Studies, EEOICPA Program Records and WTC Health Program Records. HHS/CDC/NIOSH.” These records are treated in a confidential manner, unless otherwise compelled by law. Disclosures that NIOSH may need to make to complete a radiation dose reconstruction for your claim are listed below.

This notice applies to all work history phone calls and forms that you may receive from NIOSH in connection with completing a radiation dose reconstruction for your claim.

Your participation in this phone call is voluntary.

Section 1: “Introductory Questions”

Did you receive a letter about the call from NIOSH?
Do you wish to discuss energy employee’s work history?
Do you have any questions about the process?
Do you have any questions or concerns before we get started?

Section 2: “Employment History”

From what you remember or information readily available to you, when and where did you and the {Covered Employee} work together, what was your job title, and who was his/her supervisor at the time?

a. Facility	b. Job Title	c. Start Date
d. End Date	e. Supervisor Name

answer the following questions. Repeat these questions for each DOE/AWE job included in the employment history

Section 3: “Detailed Work History”

How many hours per week did (s)he work on this job?
Did (s)he work any overtime hours? (If yes, how many hours of overtime, on average, did (s)he work per week?)
Did (s)he work any shift work?
How many hours per week did his/her job involve potential exposure to radiation and/or radioactive materials?
Which buildings or locations did (s)he work in, what were his/her routine duties, and during what time periods did (s)he work in each of the buildings or locations?
Describe his/her duties.
What types of radioactive materials were present or processed, and in what form(s) (solid, liquid, or gas)? Review the list below individually, as necessary
1. Radionuclide
2. Isotope(s) if known
3. Form of the material (solid / liquid / gas)

· Tritium	· Polonium	· Uranium (enriched)
· Cobalt	· Radon (progeny)	· Neptunium
· Strontium/Yttrium	· Radium	· Plutonium
· Technetium	· Actinium	· Americium
· Iodine	· Europium	· Curium
· Cesium	· Thorium (natural)	· Californium
· Thallium	· Protactinium	· Others (describe)
· Lead	· Uranium (natural)

What quantities of radioactive materials were present or processed (ounces, pounds, kilograms, drums) over what time periods
What types of production processes involving radioactive materials occurred in

areas where (s)he worked?

What types of radiation-generating equipment were present or used (example: neutron devices, radiography equipment/sources, portable x-ray units, electron beam welders).
What specific tasks did (s)he perform, using what types of radioactive materials (in what quantities), and/or radiation generating equipment?

What exposure/contamination control measures did you use to protect him/her? (Frequency of use: Always, Sometimes, Never)

· Fume Hoods	· Glove boxes	· Local ventilation
· Shielding	· Other enclosures (explain)	· Respirators
· Showers	· Anti-contamination clothing
· Other personal protective equipment (specify)

Did (s)he conduct your work under a Special Work Permit, Radiological Work Permit, or other work control document that specified safety & health requirements? (If Yes, during what time periods?)

Section 4: “Radiation Monitoring”

Did the {Covered Employee} routinely wear radiation dosimetry badges?
1. For which duties or in which buildings or locations, and during what time periods (e.g., which years) did the {Covered Employee} routinely wear radiation dosimetry badges?
  
  ·         Building/Location
  
  ·         Time Period
  
  ·         Duties
  
  ·         Employee Wore badge
Did the {Covered Employee} participate in a biological radiation monitoring program (urine, fecal, breath, or in-vivo/whole body count)? (if yes, at what frequency)

·         urine

·         fecal

·         in-vivo/whole body count

·         breath
If the caller is a co-worker who may have had comparable exposures.
1. For the time periods identified above, under what situations did you wear your badge?

How often did you wear your badge? (Time Period / Frequency
How often was your badge exchanged? (Time Period / Frequency
Where on your body was your badge worn? (Time Period / Body Location)

Did you also participate in a biological radiation monitoring program (urine/fecal/breath)

·         urine

·         fecal

·         breath
Do you have copies of your dosimeter badge or biological monitoring records, or annual reports of your monitoring results? (If Yes, Would you be willing to provide copies to us if we need the records?

Was the {Covered Employee} routinely surveyed (frisked) for external contamination? (If Yes, Was the {Covered Employee} surveyed before or after showering?)

Was air monitoring for radiation performed in the work environment?
1. When (over what time periods) did this occur?
2. What type of air monitoring was performed?
  
  · Job-specific
  
  · Lapel (employee breathing zone)
  
  · General area
  
  · Environmental
  
  · Other (Describe)
Were there any radiation surveys taken to characterize potential for external exposure? (If Yes, When did these occur?)

Was there monitoring in any of the buildings or areas where the {Covered Employee} worked for exposure to radon? (If Yes, Which buildings or areas)

Was the {Covered Employee} ever restricted from the workplace or certain job duties because (s)he had reached a radiation dose limit? (If Yes, Please explain)

Did the {Covered Employee} ever not turn in his/her dosimeter badge because (s)he was approaching a radiation dose limit? (If Yes, How many times did this occur and during what periods?)

Section 5: “Required Medical Screening”

Was the {Covered Employee} ever required to have medical x rays for this job, as a condition of employment (upon hire, as part of an annual physical, etc.)
1. Do you know how often (s)he was x-rayed, and over what time period(s)?

· Time Period

· Frequency of x rays

Section 6: “Radiation Incidents”

Was the {Covered Employee} ever involved in any incidents involving radiation exposure or contamination? (If Yes, Please provide the following information for each incident)
1. What happened and when?
2. Which radioactive materials were involved, and in what form and quantity?
3. Was radiation-generating equipment involved? (If yes, what type?)
4. Where did it take place?
5. Who was involved?
6. What actions were taken to remedy the exposure or contamination?
7. What were the {Covered Employee’s} location and activities during the incident?
8. What precautions were taken to protect him/her?
9. What types of personal protective equipment, if any, did (s)he use?
10. How long were (s)he exposed during the incident?
11. Did the {Covered Employee} receive biological monitoring after the incident?
12. Were you similarly involved and exposed in the incident?
  1. Did you receive biological monitoring after the incident?
  2. What type of biological monitoring?
    
    · urine
    
    · whole body measurement
    
    · breath
    
    · fecal
    
    · nasal swab
  3. Do you have records of this monitoring? (If Yes, Would you be willing to provide copies to us, if we need those records?)

Section 7: “Other relevant information”

Have we missed asking you about any conditions, situations, or practices that occurred during this job which you think may be useful to us in estimating the {Covered Employee’s} radiation doses?
1. Describe this with as much detail as possible, in terms of what occurred, where, when, for how long, and who was involved:

Section 8: “Final Questions Identifying co-workers and other witnesses”

NIOSH is confident it will obtain enough information to complete the {Covered Employee’s} dose reconstruction without receiving information from other individuals. However, in the event NIOSH does wish to speak to others who might provide information about his/her work conditions or exposures, can you readily provide names and contact information for co-workers, supervisors, industrial hygienists, radiation safety specialists, or anyone else who might be able to provide such information)

File Type	application/msword
Author	dshatto
Last Modified By	SYSTEM
File Modified	2018-06-25
File Created	2018-06-25

· Building/Location	· Time Period		· Duties
· Employee Wore badge		· Only Co-worker wore badge

· Job-specific	· Lapel (employee breathing zone)	· General area
· Environmental	· Other (Describe)

· urine	· in-vivo / whole body measurement	· breath
· fecal	· nasal swab

· urine	· whole body measurement	· breath
· fecal	· nasal swab