The information below appears in the Defense Nuclear Agency Data Base. it and supply missing information or correct data if it is incorrect. PARTICIPANT'S NAME: REFERENCE NUMBER: SOCIAL SECURITY NUMBER: TELEPHONE: ( Please check SEX: ) DATE OF BIRTH: ADDRESS: PLACE OF BIRTH: Month City . CAUSE OF DEATH: DECEASED? Day a , Year State YEAR: CALLER'S NAME: SEX: CALLER'S RELATIONSHIP TO PARTICIPANT: PARTICIPATION NAME OF TEST SERIES: NAME OF TEST EVENT: DATE OF TEST EVENT: TEST LOCATION (State or Area): WAS DOSIMETER ISSUED? MILITARY SERVICE: WAS IT WORN? RANK: (Or Civilian) SERVICE NUMBER: (Or Civilian Grade) MILITARY UNIT DURING TEST: (Or Civilian Company) (Unusual health problems, distance from GZ, protective clothing worn, etc.) REMARKS: e Privacy Act Statement pursuant to P.L. 93-579, Privacy Act of 1974. The purpose of this form is to obtain information on personnel who participated in the Departwent of Defense Atmospheric Nuclear Weapons Testing Program. The information will be used as part of a data collection program being conducted to provide information for detailed research on the correlation, if any, between exposure to low-level external ionizing radiation and subsequent incidence of certain diseases. The authority for obtaining the data is the Atomic Energy Act of 1954. Disclosure of the requested information is voluntary. DNA FORM 10 REVISED 1 July 1979 FL ER Ee oe ~ ‘ EF EF Previous editions obsolete B&B «£ . fF Oe Re F&F i eee i IESER ee i peta ah te 4 - bi. fh hm lll eof yc Uk . . ” * t UYU UOUEDULUUE