Questionnaire for the DOE Accident Investigation Resource List

Questionnaire for
DOE Accident Investigation Resource List

DOE maintains a personnel resource list to select technical and professional individuals to serve as a board chairperson, board member, advisor or consultant for Type A & B Accident Investigations. If you wish to be included on this list, please complete this form and press the SUBMIT button.


    First Name: 
Middle Initial: 
     Last Name: 

         Title: 
 Federal Grade:  (if applicable) (i.e., GS/GM 1-15 or SES)

    Work Phone:    
      Work Fax:   
    Home Phone: 
E-Mail Address: 
   
   Immediate Supervisor:    
Supervisor's Work Phone: 

Current DOE Clearance:

Site/Facility: Choose your Site/Facility from under the Operations or Program Office Menus

AL - Albuquerque Operations Office

CH - Chicago Operations Office

DP - Office of the Ass't Secretary for Defense Programs

EE - Office of Energy Efficiency & Renewable Energy

EH - Office of the Ass't Secretary for Environment, Safety, Health

EM - Office of the Ass't Secretary for Environmental Management

ER - Office of Energy Research

FE - Office of the Ass't Secretary for Fossil Energy

HR - Office of the Ass't Secretary for Human Resources and Admin.

ID - Idaho Operations Office

NE - Office of Nuclear Energy

NN - Office of Nonproliferation and National Security

NV - Nevada Operations Office

OC - Office of Civilian Radioactive Waste Management

OH - Ohio Field Office

OK - Oakland Operations Office

OR - Oak Ridge Operations Office

PA - Power Administrations

PNRO - Pittsburgh Naval Reactors Office

RFFO - Rocky Flats Field Office

RL - Richland Operations Office

SNRO - Schenectady Naval Reactors Office

SRO - Savannah River Operations Office

If your office is not listed above, please put office name here:

If your employer is other than DOE, please put employer name here:

Please provide full work mailing address, including appropriate internal mail codes if needed:

Areas of Expertise: Please check the appropriate categories, up to 10, in which you are most proficient. If you have an area of expertise that is not listed, please indicate a category under which your expertise best fits:

Criticality Safety Administrative - Criticality Safety Code Development Codes/Standards/Regulations Critical Experiment-Validation Criticality Audit/Surveillance Criticality Safety Cross Section Generation Technical - Criticality Safety Training/Education Fire Protection Alarm Systems Appraisal Building Codes Codes/Standards/Regulations Construction Emergency Response Fire Ground Safety Flammable Gas Life Safety Code Petroleum Operations Plant/Shop Pyrophoric Materials Research Suppression Systems Training/Education Industrial Hygiene Analytical Services Biological Agents (Hazards) Breathing Air Systems Chemical Agents (Hazards) Codes/Standards/Regulations Engineering Controls HEPA Filter Testing Illumination Inspection Appraisal Instrument Calibration Personnel Protective Equipment Program Development Radiation-Nonionizing Research Respirator Protection Sampling Methodology Sanitation Temperature Extremes Toxicology Training/Education Ventilation Vibration Industrial Safety Appraisal Boiler Chemical Codes/Standards/Regulations Compressed Gases Construction Cranes/Hoists Dams/Hydroelectric./Water Systems Drilling Electrical-High Voltage Electrical-Low Voltage Explosives Fusion Geophysics and Seismic Safety High Explosive Safety Insurance Large Laser Systems Maintenance Material Handling (Manual) Mechanical Metal Working-Cold Metal Working-Hot Nuclear Explosive Safety Nuclear Weapons Technologies Off-the-Job Safety Office Safety Personnel Protective Equipment Petroleum Pressure Vessel and Piping Process Safety Reporting Robotics Safety/Security Interface Satellite & Space Systems Solar Structural Integrity Training/Education Transportation Tunneling/Mining Vacuum Systems Woodworking Work Planning & Controls Medical Asbestosis Berylliosis Chelation Computer Medical Applications Emergency Medical Response Emergency Planning Emergency Treatment Employee Fitness Program Epidemiology Nuclear Medicine Occupational Medicine Radiation Effects Radiation Injury Treatment Records-Medical Toxicology Training/Education
Environmental Protection Air Quality - Ambient Air Air Quality - Source-Specific Air Quality-General Alternate Energy Analytical Services Codes/Standards/Regulations Development/Implementation Ecology-General Ecology-Radiological Engineering & Process Controls Environmental Restoration Geology Hydrology Liquid Effluence Pesticides/Toxic Substances Program Research - Biochemistry Research - Biology Research - Chemistry Research - Ecology Research - Geochemistry Research - Geology Research - Hydrology Research - Meteorology Research - Microbiology Research - Oceanography Research - Water Quality Research - Zoology Research-General Sampling and Analysis Training/Education Waste Management-General Waste Management-Hazardous Waste Management-Mixed Waste Management-Radioactive Waste Management-Solid Water Quality-Drinking Water Water Quality-General Management Systems Audits and Self-Assessments Authorization Basis/Safety Analysis Reporting Command Post Exercises Conduct of Operations DOE Policy and Policy Implementation Emergency Planning Ergonomics Facility Design Config. and Controls Human Resources Line Management Oversight Operational Readiness Quality Assurance Organization, Planning and Management Risk Assessments/Hazards Analysis Safety System Reporting Training and Qualifications Work Planning and Controls Psychological Employee Assistance Human Factors Human Reliability Personnel Assurance Psychological Services Psychological Testing Training/Education Health Physics (Radiation Protection) Accelerators Administration Applied Health Physics Biological Effects Chemical Processing Codes/Standards/Regulations Dosimetry Emergency Planning Epidemiology Fusion Safety Instrumentation Medical Physics Monitoring, Environmental Monitoring, Personnel Nonionizing Radiation Radiation Biology Radiation Safety/Surveys Radiochemistry Radiological Assessment Reactors, Other Reactors, Power Research Training/Education Waste Management Safeguards/Security Firearms Safety Hostage Negotiations Protective Force Operations Protective Force Performance Testing Protective Force Training Work Place Violence/ Threat Assessment Transportation Aviation Safety Highway Safety Industrial/Construction Vehicle Packaging/Loading Safety Pipeline Safety Railroad Safety Water Safety

Accident Investigation Experience: Record prior accident investigation experience, by identifying specific investigations, in chronological order, in the table below (please see example):

Type A or B
(see Table 1a for definitions) Date and
Location of
Accident Accident Type
(see Table 2a for options)
(Fatality, Injury, Damage) Position
(Chairperson, Board Member, Consultant or Advisor)

Example:
DOEA Example:
1/1/01, DOE/HQ Example:
EL01 (Electrical Fatality) Example:
Board Member

Accident Investigation Training: Please check any applicable training completed.

Accident Investigation Training Department of Energy - EH Sponsored DOE AI Analytical Training (12/9-13/96, Las Vegas NV) DOE AI Training - Board Member Session (8/96, Crystal City VA) DOE AI Training - Chairperson Session (8/96, Crystal City VA) DOE AI Training - Point of Contact Session (8/96 Crystal City VA) DOE AI Training - Core Team (12/97, Gaithersburg, MD) DOE AI Training - Board Chairperson (12/97 via CTA ITV) DOE Accident Investigator Training (1/98, Albuquerque, NM) Other Department of Energy Sponsored DOE Principles of Accident Investigation Workshop Events and Causal Factors Training Mini MORT Root Cause Training MORT AI Training MORT AI Training (update/refresher) Other Government Agency Sponsored Accident Investigation Training - Department of Transportation Accident Investigation Training - Environmental Protection Agency Accident Investigation Training - Federal Aviation Administration Accident Investigation Training - NASA Accident Investigation Training - National Safety Accident Investigation Training - National Transportation Safety Board Accident Investigation Training - Nuclear Regulatory Commission Accident Investigation Training - OSHA Institute Accident Investigation Training - State and Local Agencies Military Sponsored Accident Investigation Training - U.S. Army Accident Investigation Training - U.S. Coast Guard Other Training Other Department of Energy Sponsored Conduct of Operations Assessment Training HAZWOPER Training Special Response Team (Advanced) Training I and II Other Government Agency Sponsored Hazardous Materials Incident Response Training (USEPA) Military Sponsored Navy Nuclear Power School If you completed other federal training which is not listed above, please indicate here:

Certification: Please check any applicable certifications that are current.

Other Department of Energy Sponsored Certified DOE Safeguards and Security Instructor Certified EM Operations Assessment Leader Certified Firearms Instructor Certified Quality Auditor Certified Radiation Worker I Certified Radiation Worker II Other Government Agency Sponsored Certified FAA Flight Instructor Military Sponsored Certified Naval Chief Test Engineer Certified Naval Reactor Nuclear Engineer Certified Navy Nuclear Engineer State Sponsored Doctor of Medicine Emergency Medical Technician (EMT) Lawyer Professional Engineer, Aeronautical Professional Engineer, Chemical Professional Engineer, Civil Professional Engineer, Electrical Professional Engineer, Environmental Professional Engineer, Fire Protection Professional Engineer, Mechanical Professional Engineer, Mining Professional Engineer, Nuclear Professional Engineer, Safety Registered Environmental Assessor RN - Registered Nurse Commercially Sponsored Certified Helicopter Pilot Certified Senior Reactor Operator Licensed Commercial Pilot Licensed Private Pilot Professionally Sponsored Certified Associate Safety Professional Certified Geologist Certified Hazardous Material Handler Certified Industrial Hygienist Certified Lead Auditor (American Society of Quality Control) Certified Protection Professional (American Society of Industrial Security) Certified Quality Engineer (American Society of Quality Control) Certified Safety Professional Comprehensive Certification (American Board of Health Physics) National Registry of Radiological Protection Prof. Assoc. of Diving (SCUBA) Instructors Tap Root Incident Investigation/Root Cause Analysis If you have other current certifications that are not listed above, please indicate the type of certification and certifying authority:

Educational Background: Please check all educational degrees held.

University Sponsored Bachelor of Arts, History Bachelor of Business Administration Bachelor of Science, Aeronautical Engineering Bachelor of Science, Anthropology Bachelor of Science, Biology Bachelor of Science, Business Administration Bachelor of Science, Chemical Engineering Bachelor of Science, Chemistry Bachelor of Science, Civil Engineering Bachelor of Science, Criminal Justice Bachelor of Science, Electrical & Marine Engineering Bachelor of Science, Electrical Engineering Bachelor of Science, Engineering Science Bachelor of Science, Environmental Engineering Bachelor of Science, Environmental Health and Safety Bachelor of Science, Fire Protection Bachelor of Science, Fire Protection Engineering Bachelor of Science, Forestry Bachelor of Science, Forestry Bachelor of Science, Geology Bachelor of Science, Geophysical Engineering Bachelor of Science, Geophysics Bachelor of Science, Geotechnical Engineering Bachelor of Science, Health Physics Bachelor of Science, Human Resource Management Bachelor of Science, Industrial Engineering Master of Science, Meteorology Bachelor of Science, Letters and Forestry Bachelor of Science, Marine Engineering Bachelor of Science, Mathematics Bachelor of Science, Mechanical Engineering Bachelor of Science, Metallurgical Engineering Bachelor of Science, Meteorology Bachelor of Science, Microbiology Bachelor of Science, Mining Engineering Master of Science, Science Bachelor of Science, Nuclear Engineering Bachelor of Science, Occupational Safety and Health Bachelor of Science, Oceanography Bachelor of Science, Physics Bachelor of Science, Psychology Bachelor of Science, Safety Engineering Doctor of Jurist Prudence Doctor of Medicine, Internal Medicine Doctor of Medicine, Occupational & Environmental Doctor of Philosophy, Civil Engineering Doctor of Philosophy, Communications Doctor of Philosophy, Environmental Engineering Doctor of Philosophy, Geochemistry Doctor of Philosophy, Industrial Health Doctor of Philosophy, Management (Occupational Health) Doctor of Philosophy, Nuclear Physics Doctor of Philosophy, Physical/Organic Chemistry Doctor of Philosophy, Psychology Doctor of Philosophy, Psychology Juris Doctorate, Law Master of Arts, Organizational Leadership Master of Business Administration Master of Engineering, Chemical Engineering Master of Engineering, Nuclear Engineering Master of Public Administration Master of Public Health, Industrial Hygiene Master of Science, Aeronautical Engineering Master of Science, Analytical Chemistry Master of Science, Biology Master of Science, Chemical Engineering Master of Science, Civil Engineering Master of Science, Computer Science Master of Science, Criminal Justice Master of Science, Electrical Engineering Master of Science, Engineering Master of Science, Engineering Management Master of Science, Engineering Science Master of Science, Environmental Engineering Master of Science, Environmental Health (Industrial Hygiene) Master of Science, Environmental Management Master of Science, Geology Master of Science, Health Physics Master of Science, Industrial Engineering Master of Science, International Prgs/Foreign Affairs Master of Science, Mechanical Engineering Master of Science, Metallurgical Engineering Bachelor of Science, Industrial Engineering Bachelor of Science, Industrial Technology Master of Science, Nuclear Engineering Master of Science, Pathology Master of Science, Physical Science Master of Science, Preventive Medicine Master of Science, Psychology Master of Science, Rhetoric Master of Science, Safety Engineering Master of Science, Safety Program Management Bachelor of Science, Nuclear Master of Science, Technical Management If you hold other degrees not listed above, please indicate here: