DTRA Form 150-C Nuclear Test Personnel Review Program: Questionnaire for

OMB No. 0704-0447 Expiration:

D EFENSE THREAT REDUCTION AGENCY

Nuclear Test Personnel Review Program

Questionnaire for CROSSROADS Test Participants

AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 4800 Mark Center Drive, East Tower, Suite 02G09, Alexandria, VA 22350-3100 (0704-0447). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.
PRIVACY ACT STATEMENT
AUTHORITY: 42 U.S.C. 2013 (AEC), 38 U.S.C. 1154 and 1112 (Veterans Benefits), 42 U.S.C. 2210 (DOJ compensation program), Pub. L. 108-183 section 601 (Veterans Benefits Act of 2003), Pub. L. 94-367, Pub. L. 100-426 (Radiation Exposure Compensation Act) amended by Pub. L. 100-510; and E.O. 9397 (SSN), as amended. PURPOSE(S): To provide data or documentation relevant to the processing of administrative claims or litigation; to conduct scientific studies or medical follow-up programs; and in the preparation of the histories of nuclear test programs. ROUTINE USES: Disclosure of records permitted outside DoD under 5 U.S.C. 552a(b) (Privacy Act) to the Department of Veterans Affairs, Department of Justice, and Department of Labor for identifying and processing claims by individuals who allege job-related disabilities as a result of participation in nuclear test programs and for litigation actions, Veterans Advisory Board on Dose Reconstruction for the purpose of reviewing and overseeing the DoD Radiation Dose Reconstruction Program audits of dose reconstructions; and to the Department of Health and Human Services, and Vanderbilt University for the purpose of conducting epidemiological studies on the effects of ionizing radiation on participants of nuclear test programs. Additional routines are listed in the applicable system of records notice HDTRA 010, Nuclear Test Participants, located at: http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570291/hdtra-010/ DISCLOSURE: Voluntary; however, failure to provide the requested information and authorization may delay or preclude DTRA from providing or releasing information.
PLEASE RETURN YOUR RESPONSE TO THE ADDRESS BELOW.
Responses should be sent to: Defense Threat Reduction Agency, Attn: J9NTS (NTPR), 8725 John J. Kingman Road, Stop 6201, Fort Belvoir, VA 22060-6201. For assistance, please either call the NTPR toll-free helpline: (1-800-462-3683), write us at the provided NTPR address, or email us at dtra-ntpr@mail.mil.
SECTION I: Participant Information
Name:				Branch of Service/Service Number:
Address:
Telephone:
If this questionnaire is completed by someone other than the participant, please provide:
Name:			Relationship to veteran:
SECTION II: Participation Summary
1.	Home station/port:
	Unit of assignment:
	Rank/specialty (at time of participation):
2.	Where you were billeted? (check all that apply): (a) Aboard ship (name and hull number of ship): (b) Bikini Island of Bikini Atoll (c) Eneu Island of Bikini Atoll (d) Other (specify):
3.	If you checked any of (a) through (d) above, about when did you arrive and depart?
	Arrival date:
4.	Which of the following describes your participation? (check all that apply) (a) Supported operations aboard ship. Provide details in Question 5. (b) Supported operations from location specified in 2b or 2c. Provide details in Question 6 (page 4). (c) Participated in a scientific project. Provide details in Question 7 (page 4). (d) Was a crew member of an aircraft that participated in or supported the operation. Provide Details in Question 8 (page 5). (e) Other (specify): Provide details in Question 9 (page 5).
SECTION III: The following questions are intended to assess your potential for exposure to radiation during your participation as indicated in Question 4. Please provide details for answers to the best of your recollection (qualify as “approximate” as necessary). Use back or a separate page with reference to question number if more space is needed. If you are unable to answer a question or provide details, state “Unknown.”
5.		If you supported the operation aboard a ship, provide details:
		(a) Name, hull number, and type of ship: General nature of duties (e.g., maintained electronic equipment): Average time spent topside: hours per day

	(b) Where were you located during each test detonation (e.g., at duty station below decks)?
	(c) Did you wear any special clothing/equipment (e.g., coveralls, gloves, respirators) during the operation? Yes (provide details below) No Type of clothing/equipment worn: Activity that required such clothing/equipment:
5.	If you supported the operation aboard a ship, provide details: (Continued)
	(d) Did your ship receive any fallout during the operation? Yes (provide details by event) No –If no, go to 5(e). Shot/date: Your location during fallout: Topside Below decks What precautions were taken to minimize exposure to the fallout (e.g., wash down ship)?
	(e) Did your duties involve contact with radioactive material other than general fallout on the ship? Yes (provide details below) No
	(f) Was your ship involved in a special project? Yes (provide details below) No
	(g) Did you visit or were you assigned to another ship? Yes (provide details below) No Name and hull number of ship: Frequency and duration of visit/assignment: Purpose of visit/assignment:
	(h) Did you perform activities aboard target ships? Yes (provide details below) No Name and hull number of ship: Frequency and duration of visit: Activities during visit:
	(i) Did you participate in small boat operations? Yes (provide details below) No Frequency of operations (daily, once a week, etc.): Duration of operations (in hours): Activities aboard small boats:

	5.		(j) Were you granted shore liberty during the operation? Yes (provide details) No Where and how long?
			(k) Were you ever found to be contaminated during the operation? Yes (provide details) No Describe the event(s) that resulted in this contamination: Where were you contaminated (hands, clothes, etc.)? Were you decontaminated? Yes No If yes, how?
			(l) How frequently did you shower during the operation?
	6.		If you supported the operation from Bikini Atoll, provide details:
			(a) General nature of duties (e.g., administrative ):
			(b) Did you visit or support the operation from other island locations? Yes (provide details) No Name of island/location: Date and duration of visit(s): Purpose of visit(s):
	7.		If you participated in a scientific project, provide details:
			(a) Shot/date:
			(b) Project number/title:
			(c) Description of activity:
			(d) At the end of the activity, were you monitored for radiological contamination? Yes No If yes, were you found to be contaminated? Yes No If yes, where? Were you decontaminated? Yes No If yes, how?
			If you supported the operation as an air crew member, provide details:
			(a) Flight duty (pilot, engineer, etc.): (b) Type of aircraft:
	8.		If you supported the operation as an air crew member:
			(c) Were you airborne during any test detonation? Yes (provide details by event) No (see 8.d.) Shot/date: Altitude at shot time: Distance and direction from detonation: Purpose and route of mission:
			(d) If your answer to (c) was No, were you airborne subsequent to any test detonation (within 12 hours)? Yes (provide details by event) No Shot/date: Altitude: Purpose and route of mission:
			(e) Was your aircraft involved in a special project(s)? Yes (provide details below) No Identify project(s) and describe your role if different than normal air crew duty:
			(f) Do you have flight logs for the period that you supported the operation? Yes (please submit copies with this questionnaire) No
	9.		If your participation is not covered in Questions 5-8, provide details regarding any potential exposure to radiation (date, location, activities, exposure conditions, etc.):
	10.		Did you perform any RADSAFE activity (e.g., serve as radiation monitor, decontaminate personnel/ equipment)? Yes (provide details below) No
	11.		Were you issued a film badge (radiation dosimeter) during the operation? Yes (check all statements below that apply) No (a) Issued badge upon arrival at test site, wore same badge during entire stay. (b) Issued badge upon arrival, wore until replaced with another badge. (c) Issued badge(s) for a specific activity/mission, turned in afterwards. (d) Wore more than one badge at a time. (e) Lost or failed to turn in at least one badge during the operation. (f) None of the above (please explain):
12.		Where did you eat your meals? (a) Mess hall / tent (b) Aboard ship – crew mess / wardroom (c) Aboard ship – topside (d) Other (specify): _____________________________________________________ Additional comments: ______________________________________________________________ _________________________________________________________________________________
SECTION IV: SIGNATURE
I certify under penalty of perjury under the laws of the United States of America that the information provided on this form is true and correct. Signature: Date

DTRA Form 150-C (September 2017)