Special Exposure Cohort Petition-Form B

Special Exposure Cohort Petition

U.S. Department of Health and Human Services

under the Energy Employees Occupational
Illness Compensation Program Act

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

Special Exposure Cohort Petition — Form B

OMB Number: 0920-0639

Expires: 10/31/2019
Page 1 of 7

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.
General Instructions on Completing this Form (complete instructions are available in a separate packet):
Except for signatures, please PRINT all information clearly and neatly on the form.
Please read each of Parts A – G in this form and complete the sections appropriate to you. If there is more
than one petitioner, then each petitioner should complete those sections of Parts A – C of the form that apply
to them. Additional copies of the first two pages of this form are provided at the end of the form for this
purpose. A maximum of three petitioners is allowed.
If you need more space to provide additional information, use the continuation page provided at the end of
the form and attach the completed continuation page(s) to Form B.
For Further Information: If you have questions about the use of this form, please call the following NIOSH
toll-free phone number and request to speak to someone in the Division of Compensation Analysis and
Support about an SEC petition: 1-877-222-7570.
Start at D
☐ A Labor Organization,
Start at C
☐ An Energy Employee (current or former),
If you
are:
Start at B
☐ A Survivor (of a former Energy Employee),
☐ A Representative (of a current or former Energy Employee);
Start at A
A.
Representative Information — Complete Part A if you are authorized by an Energy Employee or
Survivor(s) to petition on behalf of a class.
A.1

Are you a contact person for an organization? ☐ Yes (Go to A.2) ☐ No (Go to A.3)

A.2

Organization Information:
_______________________________________________________________________________
Name of Organization
______________________________________________________________________________
Position of Contact Person

A.3

Name of Petition Representative:
______________________________________________________________________________
Mr./Mrs./Ms. First Name
Middle Initial
Last Name

A.4

Address of Petition Representative:
______________________________________________________________________________
Street
Apt #
P.O. Box
___________________________________________________________________________________________________

City

State

Zip Code

A.5

Telephone Number of Petition Representative: (________)____________________________

A.6

Email Address of Petition Representative:

A.7

☐ Check the box at left to indicate you have attached to the back of this form written authorization to
petition by the survivor(s) or energy employee(s) indicated in Parts B or C of this form.
If you are representing a Survivor, go to Part B;
if you are representing an Energy Employee, go to Part C.

_____________________________________

Special Exposure Cohort Petition

U.S. Department of Health and Human Services

under the Energy Employees Occupational
Illness Compensation Program Act

Centers for Disease Control and Prevention
National Institute for Occupational Safety and Health
OMB Number: 0920-0639

Expires: 10/31/2019

Special Exposure Cohort Petition — Form B
Page 2 of 7
B.
Survivor Information — Complete Part B if you are a Survivor or representing a Survivor.
B.1

Name of Survivor:
______________________________________________________________________________
Mr./Mrs./Ms. First Name
Middle Initial
Last Name

B.2

Address of Survivor:
______________________________________________________________________________
Street
Apt #
P.O. Box
______________________________________________________________________________
Zip Code
City
State

B.3

Telephone Number of Survivor: (________)____________________________

B.4

Email Address of Survivor:

B.5

C.

Relationship to Energy Employee: ☐ Spouse
☐Son/Daughter
☐Parent
☐Grandparent
☐Grandchild
Go to Part C.
Energy Employee Information — Complete Part C UNLESS you are a labor organization.

C.1

Name of Energy Employee:

_____________________________________

______________________________________________________________________________
Last Name
Mr./Mrs./Ms. First Name
Middle Initial
C.2

Former Name of Energy Employee (e.g., maiden name/legal name change/other):
______________________________________________________________________________
Last Name
Middle Initial
Mr./Mrs./Ms. First Name

C.3

Address of Energy Employee (if living):
______________________________________________________________________________
P.O. Box
Street
Apt #
______________________________________________________________________________
City
State
Zip Code

C.4

Telephone Number of Energy Employee: (________)____________________________

C.5

Email Address of Energy Employee:

C.6

Employment Information Related to Petition:

_____________________________________

C.6a Energy Employee Number (if known): ______________________________________________
C.6b Dates of Employment:
C.6c Employer Name:

Start ____________________

End

_____________________

_____________________________________________________________

C.6d Work Site Location: _____________________________________________________________
_____________________________________________________________
C.6e Supervisor’s Name: _____________________________________________________________
Go to Part E.

Special Exposure Cohort Petition

U.S. Department of Health and Human Services

under the Energy Employees Occupational
Illness Compensation Program Act

Centers for Disease Control and Prevention
National Institute for Occupational Safety and Health
OMB Number: 0920-0639

Expires: 10/31/2019

Special Exposure Cohort Petition — Form B
Page 3 of 7
D.
Labor Organization Information — Complete Part D ONLY if you are a labor organization.
D.1

Labor Organization Information:
_______________________________________________________________________________
Name of Organization
______________________________________________________________________________
Position of Contact Person

D.2

Name of Petition Representative:
______________________________________________________________________________
Mr./Mrs./Ms. First Name
Middle Initial
Last Name

D.3

Address of Petition Representative:
______________________________________________________________________________
Street
Apt #
P.O. Box
__________________________________________________________________________________________________

City

State

Zip Code

D.4

Telephone Number of Petition Representative: (________)_____________________________

D.5

Email Address of Petition Representative:

D.6

Period during which labor organization represented energy employees covered by this petition
(please attach documentation):
Start ________________
End ________________

D.7

Identity of other labor organizations that may represent or have represented this class
of energy employees (if known):

______________________________________

___________________________________________________________________________________________________

Go to Part E.

Special Exposure Cohort Petition

U.S. Department of Health and Human Services

under the Energy Employees Occupational
Illness Compensation Program Act

Centers for Disease Control and Prevention
National Institute for Occupational Safety and Health
OMB Number: 0920-0639

Expires: 10/31/2019

Special Exposure Cohort Petition — Form B
Page 4 of 7
E.
Proposed Definition of Energy Employee Class Covered by Petition — Complete Part E.
E.1

Name of DOE or AWE Facility: _____________________________________________________

E.2.

Locations at the Facility relevant to this petition:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________

E.3

List job titles and/or job duties of energy employees included in the class. In addition, you can
list by name any individuals other than petitioners identified on this form who you believe
should be included in this class:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________

E.4

E.5

Employment Dates relevant to this petition:
Start

__________________

End

__________________

Start

__________________

End

__________________

Start

__________________

End

__________________

Is the petition based on one or more unmonitored, unrecorded, or inadequately monitored or
recorded exposure incidents?: ☐ Yes
☐ No
If yes, provide the date(s) of the incident(s) and a complete description (attach additional pages as
necessary):
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________

Go to Part F.

Special Exposure Cohort Petition
under the Energy Employees Occupational
Illness Compensation Program Act

U.S. Department of Health and Human Services
Centers for Disease Control and Prevention
National Institute for Occupational Safety and Health
OMB Number: 0920-0639

Expires: 10/31/2019

Special Exposure Cohort Petition — Form B
Page 5 of 7
F.
Basis for Proposing that Records and Information are Inadequate for Individual Dose
Reconstruction — Complete Part F.
Complete at least one of the following entries in this section by checking the appropriate box and providing
the required information related to the selection. You are not required to complete more than one entry.
F.1

☐ I/We have attached either documents or statements provided by affidavit that indicate that
radiation exposures and radiation doses potentially incurred by members of the proposed class,
that relate to this petition, were not monitored, either through personal monitoring or through area
monitoring.
(Attach documents and/or affidavits to the back of the petition form.)
Describe as completely as possible, to the extent it might be unclear, how the attached
documentation and/or affidavit(s) indicate that potential radiation exposures were not monitored.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

F.2

☐ I/ We have attached either documents or statements provided by affidavit that indicate that
radiation monitoring records for members of the proposed class have been lost, falsified, or
destroyed; or that there is no information regarding monitoring, source, source term, or process
from the site where the energy employees worked.
(Attach documents and/or affidavits to the back of the petition form.)
Describe as completely as possible, to the extent it might be unclear, how the attached
documentation and/or affidavit(s) indicate that radiation monitoring records for members of the
proposed class have been lost, altered illegally, or destroyed.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

Part F is continued on the following page.

Special Exposure Cohort Petition

U.S. Department of Health and Human Services

under the Energy Employees Occupational
Illness Compensation Program Act

Special Exposure Cohort Petition — Form B
F.3

Centers for Disease Control and Prevention
National Institute for Occupational Safety and Health
OMB Number: 0920-0639

Expires: 10/31/2019
Page 6 of 7

☐ I/We have attached a report from a health physicist or other individual with expertise in
radiation dose reconstruction documenting the limitations of existing DOE or AWE records on
radiation exposures at the facility, as relevant to the petition. The report specifies the basis for
believing these documented limitations might prevent the completion of dose reconstructions for
members of the class under 42 CFR Part 82 and related NIOSH technical implementation
guidelines.
(Attach report to the back of the petition form.)

F.4

☐ I/We have attached a scientific or technical report, issued by a government agency of the
Executive Branch of Government or the General Accounting Office, the Nuclear Regulatory
Commission, or the Defense Nuclear Facilities Safety Board, or published in a peer-reviewed
journal, that identifies dosimetry and related information that are unavailable (due to either a lack
of monitoring or the destruction or loss of records) for estimating the radiation doses of energy
employees covered by the petition.
(Attach report to the back of the petition form.)

G.

Go to Part G.
Signature of Person(s) Submitting this Petition — Complete Part G.

All Petitioners should sign and date the petition. A maximum of three persons may sign the petition.
_____________________________________________________
Signature

_____________________
Date

_____________________________________________________
Signature

_____________________
Date

_____________________________________________________
Signature

_____________________
Date

Notice:

Any person who knowingly makes any false statement, misrepresentation, concealment of
fact or any other act of fraud to obtain compensation as provided under EEOICPA or who
knowingly accepts compensation to which that person is not entitled is subject to civil or
administrative remedies as well as felony criminal prosecution and may, under appropriate
criminal provisions, be punished by a fine or imprisonment or both. I affirm that the information
provided on this form is accurate and true.

Send this form to:

SEC Petition
Division of Compensation Analysis and Support
NIOSH
1090 Tusculum Ave, MS-C-47
Cincinnati, OH 45226

If there are additional petitioners, they must complete the Appendix Forms for additional petitioners.
The Appendix forms are located at the end of this document.

Special Exposure Cohort Petition

U.S. Department of Health and Human Services

under the Energy Employees Occupational
Illness Compensation Program Act

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

Special Exposure Cohort Petition — Form B

OMB Number: 0920-0639

Expires: 10/31/2019
Page 7 of 7

Public Burden Statement
Public reporting burden for this collection of information is estimated to average 5 hours 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.
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) authorizes the President to designate additional classes of employees to be included in the
Special Exposure Cohort (SEC). EEOICPA authorizes HHS to implement its responsibilities with the
assistance of the National Institute for Occupational Safety (NIOSH), an Institute of the Centers for Disease
Control and Prevention. Information obtained by NIOSH in connection with petitions for including additional
classes of employees in the SEC will be used to evaluate the petition and report findings to the Advisory
Board on Radiation and Worker Health and HHS.
Records containing identifiable information become part of an existing NIOSH system of records under the
Privacy Act, 09-20-147 “Occupational Health Epidemiological Studies and 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 for the processing of your
petition or other purposes 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 to assist with the evaluation of SEC petitions; (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 forms and informational requests that you may receive from NIOSH in connection
with the evaluation of an SEC petition.
Use of the NIOSH petition forms (A and B) is voluntary but your provision of information required by these
forms is mandatory for the consideration of a petition, as specified under 42 CFR Part 83. Petitions that fail to
provide required information may not be considered by HHS.

This page intentionally left blank.

Special Exposure Cohort Petition

U.S. Department of Health and Human Services

under the Energy Employees Occupational
Illness Compensation Program Act

Centers for Disease Control and Prevention
National Institute for Occupational Safety and Health
OMB Number: 0920-0639

Expires: 10/31/2019

Special Exposure Cohort Petition — Form B
Appendix — Petitioner 2
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.
Use this Appendix for Petitioner 2.
This appendix form is to be used as needed. Petitioner 2, or his or her representative, should complete the
sections applicable to him or her.
Refer to the General Instructions on completing petitioner information for Parts A, B, or C.
If you need more space to provide additional information, use the continuation page provided at the end of
the form and attach the completed continuation page(s) to Form B.
Except for signatures, please PRINT all information clearly and neatly on the form.
Start at C
☐ An Energy Employee (current or former),
Start at B
☐ A Survivor (of a former Energy Employee),
Start at A
☐ A Representative (of a current or former Energy Employee or Survivor);
Representative Information — Complete Part A if you are authorized by an Energy Employee or
Survivor(s) to petition on behalf of a class.

If you
are:
A.
A.1

Are you a contact person for an organization?

A.2

Organization Information:

☐ Yes (Go to A.2)

☐ No (Go to A.3)

_______________________________________________________________________________
Name of Organization
______________________________________________________________________________
Position of Contact Person
A.3

Name of Petition Representative:
______________________________________________________________________________
Last Name
Mr./Mrs./Ms. First Name
Middle Initial

A.4

Address of Petition Representative:
______________________________________________________________________________
P.O. Box
Street
Apt #
___________________________________________________________________________________________________

City

State

Zip Code

A.5

Telephone Number of Petition Representative: (________)____________________________

A.6

Email Address of Petition Representative:

A.7

☐ Check the box at left to indicate you have attached to the back of this form written authorization to
petition by the survivor(s) or energy employee(s) indicated in Parts B or C of this form. An
authorization form for this purpose is provided.

_____________________________________

If you are representing a Survivor, go to Part B;
if you are representing an Energy Employee, go to Part C.

Special Exposure Cohort Petition

U.S. Department of Health and Human Services

under the Energy Employees Occupational
Illness Compensation Program Act

Centers for Disease Control and Prevention
National Institute for Occupational Safety and Health
OMB Number: 0920-0639

Expires: 10/31/2019

Special Exposure Cohort Petition — Form B
Appendix — Petitioner 2
B.
Survivor Information — Complete Part B if you are a Survivor or representing a Survivor.
B.1

Name of Survivor:
______________________________________________________________________________
Mr./Mrs./Ms. First Name
Middle Initial
Last Name

B.2

Address of Survivor:
______________________________________________________________________________
Street
Apt #
P.O. Box
______________________________________________________________________________
State
Zip Code
City

B.3

Telephone Number of Survivor: (________)____________________________

B.4

Email Address of Survivor:

B.5

C.

Relationship to Energy Employee: ☐ Spouse
☐Grandparent
Go to Part C.
Energy Employee Information — Complete Part C.

C.1

Name of Energy Employee:

_____________________________________
☐Son/Daughter
☐Grandchild

☐Parent

______________________________________________________________________________
Mr./Mrs./Ms. First Name
Middle Initial
Last Name
C.2

Former Name of Energy Employee (e.g., maiden name/legal name change/other):
______________________________________________________________________________
Middle Initial
Mr./Mrs./Ms. First Name
Last Name

C.3

Address of Energy Employee (if living):
______________________________________________________________________________
Street
Apt #
P.O. Box
______________________________________________________________________________
Zip Code
City
State

C.4

Telephone Number of Energy Employee: (________)____________________________

C.5

Email Address of Energy Employee:

C.6

Employment Information Related to Petition:

_____________________________________

C.6a Energy Employee Number (if known): ______________________________________________
C.6b Dates of Employment:
C.6c Employer Name:

Start ____________________

End

_____________________

_____________________________________________________________

C.6d Work Site Location: _____________________________________________________________
_____________________________________________________________
C.6e Supervisor’s Name: _____________________________________________________________
Sign Part G of the original petition.

Special Exposure Cohort Petition

U.S. Department of Health and Human Services

under the Energy Employees Occupational
Illness Compensation Program Act

Centers for Disease Control and Prevention
National Institute for Occupational Safety and Health
OMB Number: 0920-0639

Expires: 10/31/2019

Special Exposure Cohort Petition — Form B
Appendix — Petitioner 3
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.
Use this Appendix for Petitioner 3.
This appendix form is to be used as needed. Petitioner 3, or his or her representative, should complete the
sections applicable to him or her.
Refer to the General Instructions on completing petitioner information for Parts A, B, or C.
If you need more space to provide additional information, use the continuation page provided at the end of
the form and attach the completed continuation page(s) to Form B.
Except for signatures, please PRINT all information clearly and neatly on the form.
Start at C
☐ An Energy Employee (current or former),
Start at B
☐ A Survivor (of a former Energy Employee),
Start at A
☐ A Representative (of a current or former Energy Employee);
Representative Information — Complete Part A if you are authorized by an Energy Employee or
Survivor(s) to petition on behalf of a class.

If you
are:
A.
A.1

Are you a contact person for an organization?

A.2

Organization Information:

☐ Yes (Go to A.2)

☐ No (Go to A.3)

_______________________________________________________________________________
Name of Organization
______________________________________________________________________________
Position of Contact Person
A.3

Name of Petition Representative:
______________________________________________________________________________
Mr./Mrs./Ms. First Name
Last Name
Middle Initial

A.4

Address of Petition Representative:
______________________________________________________________________________
Street
Apt #
P.O. Box
___________________________________________________________________________________________________

City

State

Zip Code

A.5

Telephone Number of Petition Representative: (________)____________________________

A.6

Email Address of Petition Representative:

A.7

☐ Check the box at left to indicate you have attached to the back of this form written authorization to
petition by the survivor(s) or energy employee(s) indicated in Parts B or C of this form. An
authorization form for this purpose is provided.

_____________________________________

If you are representing a Survivor, go to Part B;
if you are representing an Energy Employee, go to Part C.

Special Exposure Cohort Petition

U.S. Department of Health and Human Services

under the Energy Employees Occupational
Illness Compensation Program Act

Centers for Disease Control and Prevention
National Institute for Occupational Safety and Health
OMB Number: 0920-0639

Expires: 10/31/2019

Special Exposure Cohort Petition — Form B
Appendix — Petitioner 3
B.
Survivor Information — Complete Part B if you are a Survivor or representing a Survivor.
B.1

Name of Survivor:
______________________________________________________________________________
Mr./Mrs./Ms. First Name
Middle Initial
Last Name

B.2

Address of Survivor:
______________________________________________________________________________
Street
P.O. Box
Apt #
______________________________________________________________________________
City
State
Zip Code

B.3

Telephone Number of Survivor: (________)____________________________

B.4

Email Address of Survivor:

B.5

C.

Relationship to Energy Employee: ☐ Spouse
☐Son/Daughter
☐Grandparent ☐Grandchild
Go to Part C.
Energy Employee Information — Complete Part C.

C.1

Name of Energy Employee:

_____________________________________
☐Parent

______________________________________________________________________________
Middle Initial
Last Name
Mr./Mrs./Ms. First Name
C.2

Former Name of Energy Employee (e.g., maiden name/legal name change/other):
______________________________________________________________________________
Mr./Mrs./Ms. First Name
Middle Initial
Last Name

C.3

Address of Energy Employee (if living):
______________________________________________________________________________
Street
Apt #
P.O. Box
______________________________________________________________________________
State
Zip Code
City

C.4

Telephone Number of Energy Employee: (________)____________________________

C.5

Email Address of Energy Employee:

C.6

Employment Information Related to Petition:

_____________________________________

C.6a Energy Employee Number (if known): ______________________________________________
C.6b Dates of Employment:
C.6c Employer Name:

Start ____________________

End

_____________________

_____________________________________________________________

C.6d Work Site Location: _____________________________________________________________
_____________________________________________________________
C.6e Supervisor’s Name: _____________________________________________________________
Sign Part G of the original petition.

Special Exposure Cohort Petition

U.S. Department of Health and Human Services

under the Energy Employees Occupational
Illness Compensation Program Act

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

Special Exposure Cohort Petition — Form B

OMB Number: 0920-0639
Expires: 10/31/2019
Appendix — Continuation Page

Continuation Page — Photocopy and complete as necessary.
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Attach to Form B if necessary.