Ecological Health Organization, Inc.                                                        Pesticide Incident Report

PO Box 8232

Berlin, CT 0637                               Today's Date: ________________

Date of Incident (if known)___________________________

Name of Person Filling out this form, if different from injured ________________________________________________

Relationship to Injured Person_______________________________________________________________________

I. Name of Injured Person or type of animal/plant (Optional)_______________________________________________

Address________________________ Town____________________________________State_______Zip_____________

(Circle your answers)

A. Sex:   Male   Female  B. Age: Under 1 year1-56-1011-1718-2930-39 40-4950-5960-69   70 +Years

C. Race: White  Hispanic Black Asian/Pacific Native American     Other________________________

II. PLACE OF RECENT EXPOSURE INCIDENT: (Circle your answer)

A. INDOORS:    

HomeWorkplace  SchoolPublic government buildings          Nursery

Store (Name)________________________________ Other _________________________________________ 

B. OUTDOORS:

Yard/GardenForest areaGolf CourseRoadsideTree spraying

Power line SprayingLake/Cove/PondPublic GroundsPark & Recreation Areas

Neighbors driftAgricultureMosquito Abatement

Other Outdoor Places (Please list)____________________________________________

Food and or Water (residues on food, in water, please list consumable item________________________________

III. APPLICATION: (Circle your answer)

A. What pesticides were you exposed to? ______________________________________________________________

B. Reason for Pesticide Use:  Routine Spraying    Response to pest problem    West Nile Virus Threat    Other ___________

C. Who applied the pesticide?D. Method of Applications:

CommercialAerial

Self Public Aerosol spray

Government      Fogger

FarmerFumigating/Tenting

Homeowner       Ground/Backpack Application

Neighbor    Wood Preservative

Landlord     Subterranean

Utility Company/Transportation Authority Other_____________________________

Golf course operatorOther ___________________

E. Were you provided with alternative pest control methods?   Yes  No

F. Were you told or lead to believe that the pesticides were safe?    Yes No

G. Were you notified in advance of the pesticide application?  Yes   No  

If yes, how much notice did you receive? Less than 12 hours       24 hrs          48 hours72 hours       A week or more

IV.EXPOSURE HISTORY (Circle your answer)

  A. Exposure occurred because of:  Application InsideOutdoor Drift   Direct spraying       Residual on treated area

Residual on foodResidual on WaterOther:____________________________________

V. REACTIONS:

A. What were your reactions?(PleaseList)______________________________________________________________

______________________________________________________________________________________________

B. Are you chemically sensitized? Yes No

If yes, was it a result of this pesticide-poisoning incident?   Yes   No 

If no, when did you first react to pesticides? ____________________________Date__________________________

C. Was the poisoning diagnosed by a medical professional? Yes   No   Diagnosis_________________________________

Please indicate the diagnostic medical tests that were conducted: Blood CountBiochemical screenUrinalysis

Liver profile     Red Blood Cell       Serum Cholinesterase with Dibucane Level       Nerve Conductions        Timing Test  

Please add any further comments or additional information on back.     Send to ECHO Pesticide Registry -PO BOX 8232 Berlin, CT 06037 Any questions call Grassroots at 860/632-0407 or ECHO at 860-828-4200. Thanks You!