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Special Exposure Cohort Petition U*S* Department of Health and Human Services under the Energy Employees Occupational Illness Compensation Act Centers for Disease Control and Prevention National Institute for Occupational Safety and Health OMB Number 0920-0639 Expires 09/20/2013 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...

How to fill out special exposure cohort petition

How to fill out Special Exposure Cohort Petition — Form A

1. Obtain the Special Exposure Cohort Petition — Form A from the official website or relevant authority.
2. Fill in your personal details, including your name, address, and contact information.
3. Provide details of your employment history, including the names of facilities you worked at, positions held, and dates of employment.
4. Specify the types of exposures you believe you experienced, such as nuclear materials, and provide supporting documentation if available.
5. Include any medical records or evidence that support your claims of exposure leading to health issues.
6. Review the completed form for accuracy and completeness.
7. Submit the form as instructed, either through mail or online submission, along with any required fees or additional documentation.

Who needs Special Exposure Cohort Petition — Form A?

1. Individuals who worked at designated atomic weapons facilities or in jobs with significant exposure to radioactive materials.
2. Workers who believe their health problems are related to exposure during their employment.
3. Survivors or dependents of those who have passed away due to illnesses believed to be caused by exposure.

People Also Ask about

What cancers are covered under EEOICPA?

EEOICPA: The 22 Specified Cancers Leukemia; Primary or secondary cancer of the lungs; Primary or secondary bone cancer; Primary or secondary renal cancer; Primary thyroid cancer; Primary cancer; Primary esophagus cancer; Primary stomach cancer;

What cancers are covered under EEOICPA?

EEOICPA: The 22 Specified Cancers Leukemia; Primary or secondary cancer of the lungs; Primary or secondary bone cancer; Primary or secondary renal cancer; Primary thyroid cancer; Primary cancer; Primary esophagus cancer; Primary stomach cancer;

What is an exposure based cohort?

Cohort studies are observational studies that follow groups of patients with different exposures forward in time and determine outcomes of interest in each exposure group or that investigate the effect of one or more participant characteristics on prognostic outcomes [1].

What is special exposure cohort?

The Special Exposure Cohort (SEC) is a uniquely defined category of employees established under The Act. The SEC is comprised of classes of employees who: have at least one of the 22 SEC cancers and. have worked for a specific period of time at one of the SEC Work Sites.

For pdfFiller’s FAQs

What is Special Exposure Cohort Petition — Form A?

The Special Exposure Cohort Petition — Form A is a formal request submitted to the Department of Energy (DOE) to designate a group of workers as part of the Special Exposure Cohort. This designation allows the workers to be eligible for compensation related to illnesses caused by exposure to toxic substances.

Who is required to file Special Exposure Cohort Petition — Form A?

Individuals or groups of former employees of the Department of Energy, its contractors, or subcontractors who believe they were exposed to harmful levels of radiation or other toxic substances while performing their duties may be required to file Special Exposure Cohort Petition — Form A. This typically includes workers at various DOE facilities.

How to fill out Special Exposure Cohort Petition — Form A?

To fill out Special Exposure Cohort Petition — Form A, applicants need to provide detailed information about the affected cohort, including the type of work performed, the location and dates of employment, and specific details about the exposure to hazardous materials. It's important to complete all sections accurately and provide any available supporting documentation.

What is the purpose of Special Exposure Cohort Petition — Form A?

The purpose of Special Exposure Cohort Petition — Form A is to enable affected individuals to seek recognition of their exposure to harmful substances during their work, which can lead to eligibility for compensation under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA).

What information must be reported on Special Exposure Cohort Petition — Form A?

Information that must be reported on Special Exposure Cohort Petition — Form A includes details about the working group (such as job titles, work locations, and employment dates), the nature of the exposure (including types of radiation or toxic substances), and the health effects resulting from that exposure. Additional supporting documentation may also be required.