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\ Special Exposure Cohort Petition under the Energy Employees Occupational illness Compensation Act U.S. Department of Health and Human Services -- 1 A,-??,.- Centers for Disease Control and Prevention National Institute for Occupational Safety and Health 37":: q r tn 9 3 ' &B Expires: 05/31/2007 Page 1 of 2 Use of this form and disclosure of Social Security Number are voluntary. Failure to use this form or disclose this number will not result in the denial of any right, benefit, or privilege to which you may be entitled. Special Exposure Cohort Petition - Form A I Number 0920-0639 I I Instructions on Completing this Form: II You should use this petition form oniy if NIOSH has reported to you in writing that it cannot complete the dose reconstruction needed for your cancer claim. All other petitioners should u w Petition Form B to submit a petition to NOSH. For Further Information: if you have questions about these instructions, please call the following NlOSH toll-free phone number and request to speak to someone in the O cf e if of Compensation Analysis and Support about an SEC petition: 1-800-356-4674. A.l I A.2 NlOSH Trackina Number (indicated on ail NIOSH correspondence): I / ~ r . l ~ r s . 1 First .Name ~~ A.3 . Print Name offinergy Employee for whom t y s claim was filed: Middle Initial />---, G s t Name /-1 Social Security Number of Energy Employee for whom this claim was flled: I Print and sign yolir riame below to indicate that you are petitioning for HtIS to consider adding a class of employees to the Special Exposure Cohort that would include the employee indicated by the tracking number or name under entry 1 above. Print your name below: I . , . , .. First ~ a m e Middle initial Last Name ' , Sign your name below: i ; First Name n~ ~ . jJ ,/) f Middie Initial 'Last Name Once NIOSH receives this form. the U.S. Department of Health and Human Services will consider adding a class of employees to the Special Exposure Cohort. Your contact at NlOSH will be available to inform you of the progress of your petition. Send this form to: SEC Petition Office of Compensation Analysis and Support NlOSH 4676 Columbia Parkway, MSC-47 Cincinnati, OH 45226 Name or Social Security Number of First Petiiioner: Public reporting burden for this collection of information is estimated to average 3 minutes 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 NlOSH at the address provided in these instructions. Persons are not required to respond to the information collected on this form unless Rdisplays a currently valid OMB number. Prlvacy Act Advisement In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 5 552a), you are hereby notified of the The Energy Employees Occupational Illness Compensation Program Act (42 U.S.C. 53 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 responsibilitieswith the assistance of the National lnstitute for Occupational Safety (NIOSH), an Institute of the Centers for Disease Control and Prevention. Information obtained by NlOSH in connection with petitions for inciuding 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 NlOSH system of records underthe Privacy Act, 09-20-147 "Occupational Health EpidemiologicalStudies and EEOICPA Program Records. HHSICDCINIOSH." These records are treated in a confidential manner, unless othedse compelled by law. Disclosures that NlOSH may need to make for the processing of your petition or other purposes are listed NlOSH 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 w'besses as designated by NlOSH so that these ' individuals can provide information to assist with the evaluation of SEC petitions; (c) contractors aSSi~ting NIOSH; (d) collaborating researchers, under certain limited circumstances to conduct further investigations; (e) Federal, state and local agencies for law enforcement purposes; and (9 a Member of Congress or a Congressional staff member in response to a veriied 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 NlOSH 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. Name or Social Sewrily Number of First Petitioner: - Special Exposure Cohort Petltlon U.S. Department of Health and Human Sewlces under the Energy Employees Occupational Illness Compensation Act Centers for Disease Control and Preenson National Institute fw Occupational Safety and Health OMB Number. 0920-0639 Petitloner Authorization Form Expires: 05/31/2007 Page 2 of 2 Public Burden Statement Public reporting burden for this collectionof informationis estimated to average 3 minutes per response. including time for reviewing instwctions, 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 Clion Road, MS-E-11, Atlanta GA. 30333; AlTN: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. Use of this form is voluntary. Fallure to use this form will not result in the denial of any right, benefit, or privilege to which you may be entitled. Name o Social Security Number of First Petltiir: r