ISpecial ExposureCohort Petition Iunderthe EnergyEmpb~ OcaJpational
I IDness
U.S.Departmentof Healtil and HumanServices
Centers Dis888e for Control Prevention aOO
~on
Ad:
National \nstin&for~~tia1aI
safely HeaIU\ arK!
Special ExposureCohort Petition
- Form A
OMBNumber: 0920-0639
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expires:05/31/2007 Page of 2 1
:~~.~~.."~: : Instructions Completing Form: on this
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You should use this petition form only If NIOSH has reportedto you in writing that it cannot completethe dose reconstnx:tionneeded for your cancer claim.
I All other petitionersshould use PetitionForm B to submita petition to NIOSH.
!For Further Information: If you have questionsabout these instrudions, please call the following NIOSH
toll-free phone numberand request to speak to someoneIn the OffIce of Compensation Analysis and
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Support aboutanSECpetition:1-800-356-4674.
!A.1
NIOSH Tracking Number (indicatedon all NIOSH oon'e8pondence):
IA.2
1A.3
Print Name Energy Employee whom this claim was filed: of for ~/Mrs.IMs. First Name Middle Initial LastName
Social Sec~rityN~ber of Ene~ Employee whom this claim was filed: for
Print and sign your name belowto Indicate that Youare petitioningfor HHS to consider adding a class of employeesto the Special ExPOsure Cohortthat would Include the employee Indicatedby the b'ackir\g number or name under entry 1 above.
Printyour'name below:
FirstName Middle Initial LastNam6
.- .
First Name
~-
':, .
.
Middle Initial LaStName
Once NIOSH receivesthis form, the U.S. Departmentof HeaJthand Human Services will consider adding a class of employeesto the Special ExposureCohort. Your contad at NIOSHwill be available to infoml you of the progress of your petition.
Send tt1is fonn to:
SEC Petition Office of CompensationAnalysis and Support NIOSH 4676 COlumbiaParkway.MS-C47 Cincinnati.OH 45226
Nameor SocialSecurity NumbercI FirstPetitioner
Special Exposure Cohort Petition Iu" u. Ensvy ~ ~~ Illness~on Ad;
u.s. Deparbnent Healthand HumanServices' of b' . Cen8r8 Di888M Coi1U'd ~ end
Nationalinelu. b ~patkX\8I Safety8I1d HeeIh OMS Number: 092~ ExpIr8l: 05/31f1.007 Paaa2of2
IS~eclal Ex~O8Ure_Cohort ~etition
-:: Fonn A
Public BurdenStatement
IPublic reporting burdenfor this conectionof informaUon
i Including time for
Is estimated to average 3 minutes per response,
. nave any comments regarding the burden estimate or any other aspect of this collection of infocmatlon.
reviewingInstructions.gatheringthe informationneeded,and completingthe fonn. If you
Iincluding
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suggestions for reducing this burden, send them to CDC ReportsCIearan~ Officer, 1600 Clifton Road. MS-E-11 , Atlanta GA, 30333: A TTN:PRA 0920-0639. Do not send the completed petition fonn to this address. Completedpetitions are to be submittedto NIOSH at the addrss provided in these Instructions. IPersons are not requiredto respond to the Informationcollected 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:
IThe Energy EmployeesOccupational Illness CompensationProgramAct (42 U.S.C. §§ 7384-7385) (EEOICPA) authorizes tie President to designate additional classes of employees to be included In the
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Speaal ExposureCohort (SEC). EEOICPAauthorizesHHS to implement its responsibilitieswith 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
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ctasses of employeesIn the SEC will be used to evaluate tie petition and report findings to the Advisory Board on Radiationand Worker Health and HHS. Records containing identifiable informationbecome part of an existing NIOSH system of records underthe
PrIvacy Ad,'O9-2Q-147 80caJpationai Health Eprdemlological StOOiesat1d EEOICPA Program Records.
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HHS/CDC/NIOSH,8These records are treated In a confidentialmanner, unless otherwise OOfnpeiled law. by
Disclosures that NIOSH may need to make for the processing of your petition or other purposes are listed lbebw.
',NIOSH may need to disclose personal identifyinginfonT1ation (a) the Deparbnentof Energy, other federal to: Iagencies, other governmentor private entities and to private sector employersto penT1it these entities to 'retrieve r8c:0"i"ds i'eqUtiedby NIOSR;'(b) identifiedWIttIesties designatedby NIOS~ so.that these . 88 Ijndlviduals can provideinfonnation to assist with the evaluation of SEC petitions; (c) contractorsassisting NIOSH; (d) collaboratingresearchers, under certain limited circumstancesto conduct further investigations; (e) Federal, state and local agencies for law enforcementpurposes;and (f) a Member of Congress or a I Congressional staff member in responseto a verified Inquiry.
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This notice appliesto all forms and Informationalrequeststhat you may receive from NIOSH in connection with the evaluationof an SEC petition.
Use of the NIOSH petition considerationof a petition. as specified under42 infonnation required by these forms Is maooatoryfor the fonns (A and B) is voluntary but your provisionof CFR Part 83. .
iprovide required informationmay not be consideredby HHS.
Name or Sodal SecurityNumber of First Petitioner:
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