DTRA Form 150 D Atomic Veterans Service Certificate Application and Nucl

OMB No. 0704-0447 Expiration: D EFENSE THREAT REDUCTION AGENCY Atomic Veterans Service Certificate Application and Nuclear Test Personnel Review Information Request and Release
PLEASE RETURN YOUR RESPONSE TO THE ADDRESS BELOW.
Responses should be sent to: Defense Threat Reduction Agency, Attn: RD-NTS (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), email us at dtra-ntpr@mail.mil, or write us at the address above.
SECTION I. PARTICIPANT PERSONAL DATA (please print)
1. Last Name			2. First Name				3. Middle Name			4. Sex M F
5. SSN		6. Branch of Service		7. Rank					8. Service Number
9. Date of Birth (mm/dd/yy)	10. Place of Birth				11. Deceased Yes No			12. Date of Death (mm/dd/yy)
SECTION II. PARTICIPATION DATA (please print)
13. Name(s) of Test Series / Occupation of Hiroshima or Nagasaki, Japan
14. Test Location(s) or Occupation Area						15. Test or Occupation Date(s) (mm/dd/yy)
16. Participating Unit Assigned During Test or Occupation
17. Permanent Home Unit Assigned During Test or Occupation (to lowest level, e.g., company, squadron, if known)
18. Remarks

SECTION III. IDENTITY OF THE REQUESTER (please print)
19. Requester is (check one): Participant identified in Section I, above Next of kin, if participant is deceased (specify name/relationship) Legal guardian (must submit copy of court appointment) Other (specify relationship AND obtain signed authorization from participant per Authorization Statement below) Relationship: 20. How did you hear of the NTPR Program: _________________________________________________________ _______________________________________________________________________________________________
21. Address City State Zip	22. Telephone Home (        ) Other (        )
If you have any questions regarding this form, please call the NTPR toll-free helpline: 1-800-462-3683
SECTION IV. SIGNATURE AND AUTHORIZATION
I certify under penalty of perjury under the laws of the United States of America that the information in Section III is true and correct. Violations of the provisions of the Privacy Act are enforceable through legal action, and criminal and civil penalties may apply. It is a crime to knowingly and willfully request or obtain records concerning an individual from a Government agency under false pretenses. Signature of Requester Date AUTHORIZATION STATEMENT (Must be completed if requester is not the participant, next of kin of a deceased participant, or legal guardian) Pursuant to the Privacy Act of 1974, I authorize the Defense Threat Reduction Agency to release information to, and mail any resulting Atomic Veterans Service Certificate to: ________________________________________ (Print name of authorized individual) Signature of Participant Date

SECTION V. AGENCY DISCLOSURE NOTICE

The public reporting burden for this collection of information is estimated to average 15 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 whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil. 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.

SECTION VI. 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).

PURPOSE(S): For use by agency officials and employees, or authorized contractors, and other DOD components 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, National Council on Radiation Protection & Measurements, and Vanderbilt University for the purpose of conducting epidemiological studies on the effects of ionizing radiation on participants of nuclear test programs. The DoD 'Blanket Routine Uses' also apply.

DISCLOSURE: Voluntary. However, failure to provide the requested information and authorization may delay or preclude DTRA from providing or releasing information.

DTRA Form 150-D (Dec 2019) 3