Information about http://www.oehha.ca.gov/pesticides/pdf/PIR_99.pdf
State of California - Environmental Protection Agency …
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Created: Tue Sep 12 10:51:36 2006
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State of California - Environmental Protection Agency Office of Environmental Health Hazard Assessment
CONFIDENTIAL REPORT OF KNOWN OR SUSPECTED PESTICIDE-RELATED ILLNESS
Please provide as much information as possible. Fields marked with an asterisk* are critical for follow-up investigations.
Patient's Last Name* Social Security Number Birth Date* Ethnicity* (check one)
Month Day Year Hispanic or Latino
Not Hispanic or Latino
First Name* Middle Name (or Initial) Age Units Unknown
Race* (check one or more)
American Indian or
Address: Number, Street* Apt/Unit Number Alaska Native
Asian
Asian Indian
City/Town* State* ZIP Code* County* Black or African American
Filipino
Guamanian
Native Hawaiian
Home Telephone* Cellular Telephone* Gender* Other Pacific Islander
( ) ( ) Male Female Unknown Samoan
White
Work Telephone Occupation Other Race:__________
____________________
( ) Unknown
Reporting Provider - Last Name* First Name* Telephone Number*
( )
Reporting Health Care Facility* FAX Number
( )
Address: Number, Street Suite Number Submitted by*
City State ZIP Code Date Submitted*
Month Day Year
Illness Onset Date Initial Examination Date* List Any Pre-existing Conditions, If Known (e.g., allergies, asthma, pregnancy, etc)
Month Day Year Month Day Year
Signs and Symptoms* (check all that apply)
Dermatologic Neurologic/Sensory Ocular Other Systemic
Blistering Anxiety/Irritability Blurred vision Chest pain
Burns Ataxia (incoordination) Corneal abrasion Excessive urination
Edema Confusion Irritation/Pain Fatigue
Erythema (redness) Depressed consciousness/Coma Lacrimation (tearing) Fever/Hyperexia
Irritation/Pain Diaphoresis (profuse sweating) Miosis (pinpoint pupils) Malaise
Pruritis (itching) Dizziness Photophobia Tachycardia
Rash Fasciculation (muscle twitching) Other_____________________ Other__________________
Other_________________ Headache Respiratory
Muscle pain/cramping Cough Asymptomatic
Gastrointestinal Muscle weakness
Abdominal pain/cramping Dyspnea (shortness of breath)
Numbness/Tingling Rhinitis (runny nose)
Diarrhea Pesticide-related death
Salivation Upper respiratory irritation/Pain
Nausea Date of Death
Seizure Wheezing
Vomiting Month Day Year
Tremors Other_____________________
Other_________________
Other_____________________
Were Diagnostic or Laboratory Tests Conducted? Treatment Rendered*
No Yes, Completed Yes, Pending
If Completed or Pending, Please Describe:
Test:
Medical Diagnosis
Results (include reporting units):
Normal range or baseline used:
Remarks (Include physician observations, or other detail relevant to the case, not provided above. Additional pages may be attached.)
OEH 700 (9/2006) Page 1 of 2
State of California - Environmental Protection Agency Office of Environmental Health Hazard Assessment
Pesticide Exposure Date Name of Pesticide(s) or Active Ingredient(s)*
Month Day Year
Unknown
Location Where Pesticide Exposure Occurred (please provide street address, cross streets, or other appropriate detail)*
County of Exposure* Describe How Patient Was Exposed to Pesticide (e.g., drift, direct spray, environmental residue, spill, ingestion)
Did Exposure Occur at Work?* If Yes, Name of Patient's Employer Name of Patient's Supervisor
Yes No Unknown
Patient's Activity When Pesticide Exposure Occurred (Check one)
Mixing/loading/applying pesticide Transporting/storing/disposing of pesticide
Field work Routine indoor activity not involved with pesticide application
Flagging Routine outdoor activity not involved with pesticide application
Maintaining/repairing pesticide application equipment Emergency response
Manufacturing/formulating pesticide Other_____________________________________________________
Packing/processing agricultural commodities Unknown
Were Others Exposed? Additional Detail on Pesticide Exposure Incident
Yes No Unknown
Reporting Agency Name*
Street Address Suite Number
City State ZIP Code County
Telephone Number FAX Number Date Reported* Person Filing Report with State
Month Day Year
( ) ( )
Definition of a Pesticide Illness
A pesticide illness case is a patient who is or may be suffering from pesticide poisoning or any disease or condition caused by a
pesticide. The term pesticide includes any product intended to repel, kill, prevent, destroy, control, or mitigate any pest. Pesticides
include insecticides, herbicides, plant growth regulators, rodenticides or other vertebrate control agents, repellents, dessicants,
fungicides, miticides, disinfectants, sterilants, and sanitizers. Spray adjuvants are pesticides under California law.
Reporting Requirement
Physicians are required to report known or suspected pesticide-related illness to the local health officer within 24 hours (Health and
Safety Code §105200). Failure to report is a citable offense and subject to civil penalty ($250).
The local health officer is required to immediately notify the county agricultural commissioner and to file the pesticide-illness
report with the following state agencies within 7 calendar days:
Office of Environmental Health Hazard Assessment Department of Pesticide Regulation Department of Industrial Relations
Pesticide and Environmental Toxicology Branch Worker Health and Safety Branch Division of Labor Statistics and Research
P.O. Box 4010 P.O. Box 4015 P.O. Box 420603
Sacramento, CA 95812-4010 Sacramento, CA 95812-4015 San Francisco, CA 94142-0603
(916) 327-7324 (Voice) (916) 445-4222 (Voice) (415) 703-3020 (Voice)
(916) 327-7320 (Fax) (916) 322-8577 (Fax) (415) 703-3029 (Fax)
Medical Cost Reimbursements from Pesticide Drift Episodes
Food and Agricultural Code §12997.5 requires that persons responsible for pesticide drift, which causes acute pesticide illness or
injury in a non-occupational setting that requires emergency medical transport or treatment, be liable to the individual harmed or to the
medical provider for the immediate costs of uncompensated medical care. The acute pesticide illness or injury must result from a
pesticide use violation where the pesticide was used for agricultural commodities. For more information, visit the Department of
Pesticide Regulation website at http://www.cdpr.ca.gov/docs/county/sb391.pdf.
Confidential Patient Medical Information Requirements
This document contains confidential medical information, subject to federal and state law. Submission as prescribed will not violate
the Health Insurance Portability and Accountability Act of 1996, or HIPAA (Pub. L. 104-191; 45 CFR Part 160 and Part 164, Subparts
A and E). Information is confidential pursuant to Cal. Const. Art. 1, §1; Gov. Code §6254(c); and Civil Code §1798 et seq.
Reporting of known or suspected pesticide illness is mandatory. Use of this exact form is not required, but it is provided for data standardization.
For additional forms, please visit: http://www.oehha.ca.gov/pesticides.
Thank-you for reporting a known or suspected pesticide-related illness!
OEH 700 (9/2006) Page 2 of 2