Get the free Special Exposure Cohort Petition Form B - cdc

O N*s. c Cfarmant10 I SpecIal Exposure Cohort Petition DOLD o. under the Energy Employees IJ1I1es Compensation Act Occupational and HUman Services NIOC Centers for Disease Control and Pf9VentJon NatJonailnstitute for Occupational Safety and Health OMS Number 09 Special Ex sure Coh rt Petition - Form B expires 05/31/2007 f2 Use of this-form-and disclosure-of Social Security Number are voluntary. Failure to-use this fonn or- isclose this number will not result in the denial of any right...

How to fill out special exposure cohort petition

How to fill out Special Exposure Cohort Petition Form B

1. Download the Special Exposure Cohort Petition Form B from the official website.
2. Read the instructions carefully to understand what information is required.
3. Provide personal identification details, including your name, address, and contact information.
4. Fill out the section regarding your exposure history, detailing specific locations and dates.
5. Include any relevant medical records or documentation that supports your claim.
6. Review the form to ensure all information is accurate and complete.
7. Sign and date the form at the designated area.
8. Submit the completed form to the specified address or through the designated online portal.

Who needs Special Exposure Cohort Petition Form B?

1. Individuals who worked at specific sites and were potentially exposed to radiation or harmful substances.
2. Former employees of the Department of Energy or related agencies who believe their health is affected due to workplace exposure.
3. Survivors or family members of deceased workers seeking compensation or recognition of exposure.

People Also Ask about

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.

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;

For pdfFiller’s FAQs

What is Special Exposure Cohort Petition Form B?

Special Exposure Cohort Petition Form B is a form used by individuals or groups seeking to establish that they have been exposed to radiation or toxic substances during specific time periods and locations, potentially qualifying them for benefits under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA).

Who is required to file Special Exposure Cohort Petition Form B?

Individuals who believe they were exposed to radiation or toxic substances while working for certain employers, such as those in the Department of Energy (DOE) or its contractors, are required to file Special Exposure Cohort Petition Form B to seek inclusion in the Special Exposure Cohort.

How to fill out Special Exposure Cohort Petition Form B?

To fill out Special Exposure Cohort Petition Form B, the petitioner must provide personal information, details about their employment, specific exposure circumstances, and any relevant medical evidence. It is important to follow the instructions provided with the form carefully and gather supporting documentation.

What is the purpose of Special Exposure Cohort Petition Form B?

The purpose of Special Exposure Cohort Petition Form B is to allow individuals to formally request recognition of their radiation or toxic substance exposure, which may qualify them for compensation and benefits under the EEOICPA.

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

The information that must be reported on Special Exposure Cohort Petition Form B includes the petitioner's name, contact information, details of the employment history, specific sites and dates of exposure, medical conditions, and any other relevant details or documentation that support the claim.