Conflict or Bias Disclosure Form
Identification
Name of Individual or Corporate Entity: Name of Employer: Today's Date: Sites/Facilities addressed on this form: Timothy D. Taulbee NIOSH/OCAS 3/27/2007 See Attached
Questions to Identify a Conflict or Bias
1. Are you 1 currently engaged in any capacity (paid or unpaid) by the U.S. Department of Energy (DOE)? Check Yes or No.
“Site” and “facility” are defined to include DOE, AWE and other federally-owned or -operated sites. For purposes of brevity, the "other federally-owned or -operated sites" category shall be referred to in this document as “other” sites.
Yes ____, a COB exists and the individual with the COB cannot perform any key Program function for any site. If yes, please provide details about each DOE location (specific site or sites) at which you are currently engaged, a description of your activities for DOE, and whether you are paid or unpaid. Stop. _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _________ No __X____ proceed to Question 2.
2. Do you, or did you, work either at or for this DOE or Atomic Weapons Employer (AWE) site? Check Yes or No.
"Work" means employment at or for the site, site contractor or site subcontractor that includes management, direction, or implementation of radiation protection and/or health physics program policies, procedures or practices related to atomic weapons activities at the site.
Yes _____, a COB exists and the individual with the COB cannot perform a key Program function related to this site or sites. Please provide details below about the DOE or AWE site(s) you work/worked at or for. Stop. No _ X___, proceed to Question 3. 3. Do you, or did you, work for any of the past or current operators of this site? Check Yes or No.
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For purposes of completing this form, “you” refers to an individual or an employer (depending on which party is completing the form).
"Operator" refers to the governmental and/or corporate entities responsible for performing and overseeing day-to-day activities at the site, and includes work, as defined above, performed by the operator's (sub)contractors
Yes _______, provide the names of the past or current operators, the name of the site that the operator did or does administer and the specific times (starting and stopping dates) that you worked, or continue to work, for the operator and proceed to Question 4.
________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________
No ___X____, proceed to Question 6.
4. During the time you worked for that operator, was that operator responsible for this site? Check Yes or No. Yes _______, proceed to Question 5. No ________, proceed to Question 6.
5. Did your work for the operator have an impact on this site? Check Yes or No.
"Impact" means that your work involved decision-making authority over management, direction, or implementation of radiation protection and/or health physics program policies, procedures or practices related to atomic weapons activities at the site.
Yes _______, then a COB exists and the individual with the COB cannot perform a key Program function for this site or sites. Please provide details about the nature of the impact your work for the operator had on the site below. Stop.
________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________
No ________, proceed to Question 6. 6. Did you work for DOE in the past? Check Yes or No.
"Work for DOE" does not include work, as defined above, for DOE of less than four months’ continuous duration as a student intern, graduate fellow or in another primarily educational capacity. It also does not include having received a financial stipend from DOE for graduate study, a fellowship in the context of an established DOE fellowship program intended to support graduate-level work, or receipt of a federal government retirement pension for prior DOE service.
Yes _______, please provide details about each DOE location (specific site or sites) you worked for in the past and a description of your work for DOE (you may use a checklist listing DOE/AWE sites) and then proceed to Question 7.
________________________________________________________________ ________________________________________________________________
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________________________________________________________________ ________________________________________________________________
No ____X_____, proceed to Question 8.
7. Did your work for DOE have an impact on this site? Check Yes or No.
"Impact" means that your work involved decision-making authority over management, direction, or implementation of radiation protection and/or health physics program policies, procedures or practices related to atomic weapons activities at the site.
Yes _______, then a COB exists and the individual with the COB cannot perform a key Program function for this site or sites. Please provide details below about the nature of the impact your work for the operator had on the site. Stop.
________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________
No _____, then proceed to Question 8.
8. Do you have a familial relationship, or a supervisory or subordinate work relationship with an EEOICPA claimant whose claim involves this site? Check Yes or No. “Familial relationship” encompasses a current spouse, child, parent, sibling or grandparent that worked at or
for the site; or any survivors a current spouse, child, parent, sibling or grandparent that are eligible to file claims under the Program. “Supervisory or subordinate work relationship” is one where (a) the individuals in question are/were in the same reporting chain and within two organizational levels of one another; and (b) "Work" means employment at or for the site, site contractor or site subcontractor that includes management, direction, or implementation of radiation protection and/or health physics program policies, procedures or practices related to atomic weapons activities at the site.
Yes ______, then a COB exists and the individual with the COB cannot perform a key Program function for this site or sites. Please provide below details about the nature of your relationship with the EEOICPA claimant. Stop.
________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________
No ___X_______, then proceed to Question 9.
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9. Do you have a familial relationship, or supervisory or subordinate work relationship with anyone who has had an impact related to the site? Check Yes or No. Yes ____, then proceed to Question 10. No ___X___, then proceed to Question 11.
10. If you have a subordinate relationship to someone who has (had) an impact on the site, has a different person been designated to review your job performance as it relates to the site? Check Yes or No. Yes _____, a COB does not exist. Proceed to Question 11. No ______, then a COB exists and the individual with the COB cannot perform a key Program function for this site or sites. Please provide more detailed information about your relationship with the person having an impact on the site. Stop.
________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________
11. Do or did you have a familial, financial or non-financial professional (e.g., providing expert advice) relationship with any attorney at the time the attorney represented an EEOICPA claimant, DOE or the operator? Yes _______, then a COB exists and the individual with the COB cannot perform a key Program function for this site or sites. Please provide details about the relationship with the attorney, to include (if applicable) a list of cases for which you assisted the attorney as well as the names of parties on whose behalf you testified or otherwise provided assistance. Stop.
________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________
No __X_____, then a COB does not exist.
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Additional Details for Disclosure Questions 1-11
Please specify the number of the question(s) for which you are giving additional details.
List of non-conflicted Sites
Name: Timothy D. Taulbee Date: 3/27/2007 Mark an "X" each facility evaluated in the multiple site disclosure form
X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X Covered Site AC Spark Plug AMCOT Aeroprojects, Inc. Ajax Magnathermic Corp. Alba Craft Albany Research Center Albuquerque Operations Office Aliquippa Forge Allegheny-Ludlum Steel Allied Chemical Corp. Plant Allied Chemical and Dye Corp. Allis-Chalmers Co. Aluminum Co. of America (Alcoa) 1 Aluminum Co. of America (Alcoa) 2 Amchitka Island Nuclear Explosion Site American Bearing Corp. American Chain and Cable Co. American Machine and Foundry American Machine and Metals, Inc. American Peddinghaus Corp. American Potash & Chemical Ames Laboratory Anaconda Co. Argonne National Laboratory - East Argonne National Laboratory - West Armco-Rustless Iron and Steel Armour Fertilizer Works Armour Research Foundation Arthur D. Little Co. Ashland Oil Associated Aircraft Tool and Manufacturing Co. B & T Metals BONUS Reactor Plant BWXT Baker Brothers Baker and Company Baker and Williams Warehouses Baker-Perkins Co. Battelle Laboratories - King Avenue Battelle Laboratories - West Jefferson Bell Telephone Laboratories Bendix Aviation (Pioneer Division) Beryllium Production Plant (Brush) Besley-Wells Bethlehem Steel Birdsboro Steel & Foundry Bliss & Laughlin Steel City Flint Fort Worth West Chester Youngstown Oxford Albany Albuquerque Aliquippa Watervliet Metropolis North Claymont West Allis, Milwaukee New Kensington Garwood Amchitka Island Indianapolis Bridgeport Brooklyn E. Moline Moonachle West Hanover Ames Waterbury Argonne Scoville Baltimore Bartow Chicago San Francisco Tonawanda Fairfield Columbus Punta Higuera Lynchburg Toledo Newark New York Saginaw Columbus Columbus Murray Hill Davenport Luckey South Beloit Lackawanna Birdsboro Buffalo State MI TX PA OH OH OR NM PA NY IL DE WI PA NJ AK IN CT NY IL NJ MA IA CT IL ID MD FL IL CA NY OH OH PR VA OH NJ NY MI OH OH NJ IA OH WI NY PA NY
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X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X
Blockson Chemical Co. (Building 55 and related activities) Bloomfield Tool Co. Bowen Engineering, Inc. Bridgeport Brass Co., Adrian Bridgeport Brass Co., Havens Lab Brookhaven National Laboratory Brush Beryllium Co. 1 Brush Beryllium Co. 4 C - B Tool Products Co. C. G. Sargent & Sons C. H. Schnorr C. I. Hayes, Inc. California Research Corp. Callite Tungsten Co. Carboloy Co. Carnegie Institute of Technology Carpenter Steel Co. Chambersburg Engineering Co. Chapman Valve Chemical Construction Co. Chupadera Mesa Cincinnati Milling Machine Co. Clarksville Facility Colonie Site (National Lead) SAM Laboratories, Columbia University Combustion Engineering Connecticut Aircraft Nuclear Engine Laboratory Copperweld Steel Crane Co. Crucible Steel Co. Dana Heavy Water Plant Dorr Corp. Dow Chemical Co. Du Pont - Grasselli Research Laboratory Du Pont Deepwater Works ERA Tool and Engineering Co. Edgerton Germeshausen & Grier, Inc. Electro Circuits, Inc. Electro Metallurgical Elk River Reactor Area IV of the Santa Susana Field Laboratory Environmental Measurements Laboratory Extruded Metals Co. Extrusion Plant (Reactive Metals Inc.) Feed Materials Production Center (FMPC) Fenn Machinery Co. Fenwal, Inc. Fermi National Accelerator Laboratory Foote Mineral Co. GSA 39th Street Warehouse Gardinier, Inc. General Atomics General Electric Company General Electric Plant General Electric Vallecitos Grand Junction Operations Office General Steel Industries Great Lakes Carbon Corp.
Joliet Bloomfield North Branch Adrian Bridgeport Upton Detroit Cleveland Chicago Graniteville Springdale Cranston Richmond Union City Detroit Pittsburgh Reading Chambersburg Indian Orchard Linden Chupadera Mesa Cincinnati Clarksville Colonie (Albany) New York City Windsor Middletown Warren Chicago Syracuse Dana Stamford Walnut Creek Cleveland Deepwater Chicago Boston Pasadena Niagara Falls Elk River Santa Susana New York Grand Rapids Ashtabula Fernald Hartford Ashland Batavia East Whiteland Twp. Chicago Tampa La Jolla Cincinnati / Evendale Shelbyville Pleasanton Grand Junction Granite City Chicago
IL NJ NJ MI CT NY MI OH IL MA PA RI CA NJ MI PA PA PA MA NJ NM OH TN NY NY CT CT OH IL NY IN CT CA OH NJ IL MA CA NY MN CA NY MI OH OH CT MA IL PA IL FL CA OH IN CA CO IL IL
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X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X
Gruen Watch Hallam Sodium Graphite Reactor Hanford Harshaw Chemical Co. Heald Machine Co. Heppenstall Co. Herring - Hall Marvin Safe Co. Hooker Electrochemical Horizons, Inc. Hunter Douglas Aluminum Corp. Huntington Pilot Plant Idaho National Laboratory International Minerals and Chemical Corp. International Nickel Co., Bayonne Laboratories International Rare Metals Refinery, Inc. International Register Iowa Ordnance Plant Ithaca Gun Co. J. T. Baker Chemical Co. Jessop Steel Co. Joslyn Manufacturing and Supply Co. Kaiser Aluminum Corp. Kansas City Plant Kauai Test Facility Kellex/Pierpont Kerr - McGee Koppers Co., Inc. La Pointe Machine and Tool Co. LaCrosse Boiling Water Reactor Laboratory for Energy-Related Health Research Laboratory of Biomedical and Environmental Sciences Laboratory of Radiobiology and Environmental Health Lake Ontario Ordnance Works Landis Machine Tool Co. Latty Avenue Properties Lawrence Berkeley National Laboratory Lawrence Livermore National Laboratory Linde Air Products Linde Ceramics Plant Lindsay Light and Chemical Co. Los Alamos Medical Center Los Alamos National Laboratory Lovelace Respiratory Research Institute DOW Chemical Co. (Madison Site) Magnus Brass Co. Mallinckrodt Chemical Co., Destrehan St. Plant Massachusetts Institute of Technology Mathieson Chemical Co. Maywood Chemical Works McKinney Tool and Manufacturing Co. Medart Co. Medina Facility Metals and Controls Corp Middlesex Municipal Landfill Middlesex Sampling Plant Midwest Manufacturing Co. Mitchell Steel Co. Mitts & Merrel Co.
Norwood Hallam Richland Cleveland Worcester Pittsburgh Hamilton Niagara Falls Cleveland Riverside Huntington Scoville Mulberry Bayonne Mt. Kisco Chicago Burlington Ithaca Phillipsburg Washington Ft. Wayne Dalton Kansas City Kauai Jersey City Guthrie Verona Hudson LaCrosse Davis Los Angeles San Francisco Niagara Falls Waynesboro Hazelwood Berkeley Livermore Buffalo Tonawanda W. Chicago Los Alamos Los Alamos Albuquerque Madison Cincinnati St. Louis Cambridge Pasadena Maywood Cleveland St. Louis San Antonio Attleboro Middlesex Middlesex Galesburg Cincinnati Saginaw
OH NE WA OH MA PA OH NY OH CA WV ID FL NJ NY IL IA NY NJ PA IN IL MO HI NJ OK PA MA WI CA CA CA NY PA MO CA CA NY NY IL NM NM NM IL OH MO MA TX NJ OH MO TX MA NJ NJ IL OH MI
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X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X
Monsanto Chemical Co. Mound Plant Museum of Science and Industry National Bureau of Standards, Van Ness Street National Guard Armory National Research Corp. Naval Research Laboratory Nevada Test Site New Brunswick Laboratory New England Lime Co. New York University Norton Co. Nuclear Materials and Equipment (NUMEC) - Parks Township Nuclear Materials and Equipment Corp. (NUMEC) - Apollo Nuclear Metals, Inc. Oak Ridge Gaseous Diffusion Plant (K-25) Oak Ridge Hospital Oak Ridge Institute for Science Education Oak Ridge National Laboratory (X-10) Oliver Corp. Pacific Northwest National Laboratory Pacific Proving Ground Paducah Gaseous Diffusion Plant Painsville Site (Diamond Magnesium Co.) Pantex Plant Peek Street Facility Penn Salt Co. Philadelphia Naval Yard Pinellas Plant Piqua Organic Moderated Reactor Podbeliniac Corp. Portsmouth Gaseous Diffusion Plant Precision Extrusion Co. Princeton Plasma Physics Laboratory Project Chariot Site Project Faultless Nuclear Explosion Site Project Gasbuggy Nuclear Explosion Site Project Gnome Nuclear explosion Site Project Rio Blanco Nuclear Explosion Site Project Rulison Nuclear Explosion Site Project Shoal Nuclear Explosion Site Puerto Rico Nuclear Center Purdue University Quality Hardware and Machine Co. R. Krasburg and Sons Manufacturing Co. R. W. Leblond Machine Tool Co. Radium Chemical Co. Rare Earth/W. R. Grace Reed Rolled Thread Co. Revere Copper and Brass Rocky Flats Plant Roger Iron Co. Sacandaga Facility Salmon Nuclear Explosion Site Sandia Laboratory-Salton Sea Base Sandia National Laboratory Sandia National Laboratories - Livermore Savannah River Site
Dayton Miamisburg Chicago Washington Chicago Cambridge Washington Mercury New Brunswick Canaan New York Worcester Parks Township Apollo Concord Oak Ridge Oak Ridge Oak Ridge Oak Ridge Battle Creek Richland Marshall Islands Paducah Painsville Amarillo Schenectady Philadelphia / Wyndmoor Philadelphia Clearwater Piqua Chicago Piketon Bensenville Princeton Cape Thompson Central Nevada Test Site Farmington Carlsbad Rifle Grand Valley Fallon Mayaguez Lafayette Chicago Chicago Cincinnati New York Wayne Worcester Detroit Golden Joplin Glenville Hattiesburg Imperial County Albuquerque Livermore Aiken
OH OH IL DC IL MA DC NV NJ CT NY MA PA PA MA TN TN TN TN MI WA MH KY OH TX NY PA PA FL OH IL OH IL NJ AK NV NM NM CO CO NV PR IN IL IL OH NY NJ MA MI CO MO NY MS CA NM CA SC
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X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X
Sciaky Brothers, Inc. Seaway Industrial Park Separations Process Research Unit (at Knolls Lab) Seymour Specialty Wire Shattuck Chemical Shippingport Atomic Power Plant Shpack Landfill Simonds Saw and Steel Co. South Albuquerque Works Southern Research Institute Spencer Chemical Co., Jayhawks Works Sperry Products, Inc. St Louis Airport Storage Site (SLAPS) Standard Oil Development Co. of NJ Stanford Linear Accelerator Center Star Cutter Corp. Staten Island Warehouse Stauffer Metals, Inc. Superior Steel Co. Sutton, Steele and Steele Co. Swenson Evaporator Co. Sylvania Corning Nuclear Corp - Bayside Laboratories Sylvania Corning Nuclear Corp - Hicksville Plant Tech-Art, Inc. Tennessee Valley Authority Texas City Chemicals, Inc. Thomas Jefferson National Accelerator Facility Titanium Alloys Manufacturing Titus Metals Tocco Induction Heating Div Torrington Co. Trinity Nuclear Explosion Site Tube Reducing Co. Tyson Valley Powder Farm U.S. Steel Co., National Tube Division United Lead Co. United Nuclear Corp. University of California Metallurgical Laboratory University of Denver Research Institute University of Florida University of Michigan University of Rochester Atomic Energy Project University of Virginia Utica St. Warehouse Ventron Corporation Virginia-Carolina Chemical Corp. Vitro Corp. of America, Chattanooga Vitro Corp. of America, West Orange Vitro Manufacturing Vulcan Tool Co. W. E. Pratt Manufacturing Co. W. R. Grace W. R. Grace Co., Agricultural Chemical Div. W. R. Grace and Company Wah Chang Waste Isolation Pilot Plant Watertown Arsenal
Chicago Tonawanda Schenectady Seymour Denver Shippingport Norton Lockport Albuquerque Birmingham Pittsburg Danbury St. Louis Linden Palo Alto Farmington New York Richmond Carnegie Dallas Harvey Bayside Hicksville Milford Muscle Shoals Texas City Newport News Niagara Falls Waterloo Cleveland Torrington White Sands Missile Range Wallington St. Louis McKeesport Middlesex Hematite Berkeley Chicago Denver Gainesville Ann Arbor Rochester Charlottesville Buffalo Beverly Nichols Chattanooga West Orange Canonsburg Dayton Joliet Erwin Ridgewood Curtis Bay Albany Carlsbad Watertown
IL NY NY CT CO PA MA NY NM AL KS CT MO NJ CA MI NY CA PA TX IL NY NY OH AL TX VA NY IA OH CT NM NJ MO PA NJ MO CA IL CO FL MI NY VA NY MA FL TN NJ PA OH IL TN FL MD OR NM MA
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X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X
Weldon Spring Plant West Valley Demonstration Project Westinghouse Atomic Power Development Plant Westinghouse Electric Corp. Winchester Engineering and Analytical Center Woburn Landfill Wolff - Alport Chemical Corp. Wolverine Tube Division Wyckoff Drawn Steel Co. Wykoff Steel Co. Y-12 Plant Yucca Mountain Site Characterization Project Carborundum Company Oak Ridge Thermal Diffusion Plant (S-50) Westinghouse Nuclear Fuels Division Tonopah Test Site Ore Buying Station at Globe Green Sludge Plant Uranium Mill in Durango Ore Buying Station at Grants Ore Buying Station at Shiprock Ore Buying Station at Edgemont Ore Buying Station at Marysvale Ore Buying Station at Moab Ore Buying Station at Monticello Ore Buying Station at White Canyon Uranium Mill in Monticello Ore Buying Station at Crooks Gap Ore Buying Station at Riverton General Electric X-Ray Division Nevada Site Office High Energy Rate Forging (HERF) Facility Mill at Moab Utah Clinton Engineer Works (CEW) Canoga Avenue Facility (Vanowen Building) De Soto Avenue Facility Downey Facility Kirtland Operations Office Ross Aviation
Weldon Spring West Valley East Pittsburgh Bloomfield Winchester Woburn Brooklyn Detroit Chicago Newark Oak Ridge Yucca Mountain Niagara Falls Oak Ridge Cheswick North Las Vegas Globe Uraven Durango Grants Shiprock Edgemont Marysvale Moab Monticello White Canyon Monticello Crooks Gap Riverton Milwaukee North Las Vegas Oxnard Moab Oak Ridge Los Angeles Los Angeles Los Angeles Albuquerque Albuquerque
MO NY PA NJ MA MA NY MI IL NJ TN NV NY TN PA NV AZ CO CO NM NM SD UT UT UT UT UT WY WY WI NV CA UT TN CA CA CA NM NM
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