**[C.2 Main Pesticide Exposure Questionnaire]{.smallcaps}**

**Instructions**

This is a sample questionnaire for use by an acute pesticide-related
illness and injury surveillance program. It includes questions that
satisfy the data requirements for all of the core variables needed by
the National Institute for Occupational Safety and Health (NIOSH),
Centers for Disease Control and Prevention (CDC). Additional questions
for administrative report management at the State level, as well as
optional suggested questions, are included. Optional questions are
indicated on the form by framing with a dashed border. The order of the
questions is designed to provide ease of data collection as well as data
entry using the SENSOR Pesticide Incident Data Entry and Reporting
(SPIDER) data management software. Shading on pages 1--17 indicates data
to be completed by the interviewer and not asked during the actual
interview. Pages 18-21 are to be completed following the initial
interview, as additional medical information is collected and case
closure is completed. States will need to customize this questionnaire
for their specific needs. Some States may choose to develop separate
questionnaires for agricultural, occupational, nonoccupational,
physician, or non-English speaker interviews. The design presented here
is not appropriate for interviewing non-English speaking farmworkers. An
example of a Spanish language questionnaire specific to agriculture
situations can be obtained from the California DHS SENSOR Pesticide
Poisoning California (SPPC) (510--622--4406 or
<http://www.dhs.ca.gov/ohb/AgInjury/>).

**Interviewer Name**

**Interviewer ID\_\_ \_\_ \_\_ Today's date \_\_ \_\_ / \_\_ \_\_ /\_\_
\_\_**

**^(mm/dd/yy)^**

**MAIN PESTICIDE EXPOSURE QUESTIONNAIRE**

Hello. May I speak to Mr./Ms. \_\_\_\_\_\_\_\_\_\_\_\_ This is
\_\_\_\_\_\_\_\_\_\_\_\_\_ with the \_\_\_\_\_\_\_\_Department of
Health. We recently received notification by
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ that you may have experienced a pesticide
exposure. We try to keep track of persons in our State that have been
exposed to pesticides, and what has happened to them. If you have a few
moments, I would like to ask you some questions. The information you
provide may help us prevent similar pesticide exposures in the future.
Your participation is voluntary, and you may skip any questions you do
not want to answer. Shall we begin? *(If the subject agrees, begin the
interview. If the subject says he/she does not have time right now, try
to schedule a time when you may call back. If the subject is unwilling
to answer any questions, thank him/her for his/her time, hang up, and
complete as much information as possible based on the original report.)*

**Case Information Screen**

First, I would just like to ask you a few questions about yourself.

*(It is not necessary to ask these questions if you already have this
information, although it is helpful to make sure the information is
correct by reading the spelling of names and checking the address and
phone number.)*

1\. What is your last name?

2\. What is your first name?

3\. What is your middle name?

3a.What is your Social Security Number? \_\_\_ \_\_\_ \_\_\_ -- \_\_\_
\_\_\_ -- \_\_\_ \_\_\_ \_\_\_ \_\_\_

4\. What is your home address?

City State\_\_ \_\_ Zip \_\_ \_\_ \_\_ \_\_ \_\_

5\. What is your home telephone number? (\_\_ \_\_ \_\_) \_\_ \_\_ \_\_
-- \_\_ \_\_ \_\_ \_\_

6\. What county do you live in?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

7\. Were you living in a different residence at time of exposure?  Yes
 No

***If the person answers yes, go to Number 8; if the person answers no,
skip Number 8.***

8\. What was your home address at the time you were exposed? *(Enter in
exposure incident screen if this was location where exposure occurred.)*

> Address line 1
>
> Address line 2
>
> City
>
> State \_\_ \_\_ ZIP \_\_ \_\_ \_\_ \_\_ \_\_ County Name

9\. Gender 1 Male 2 Female 8 Other 9 Unknown

10\. What is your race? 1 Am Indian 2 Asian/Pacific Is. 3 Black 5
White

6 Mixed 8 Other 9 Unknown

11\. Are you of Hispanic origin? 1 Yes 2 No 9 Unknown

12\. Are you comfortable speaking in English for this interview? 1 Yes
2 No

***If the person answers no, go to 12a.***

12.a What is your preferred
language?\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(*Interviewer, stop and arrange to call back with an interviewer in the
preferred language if necessary.*)

13\. What is your birth date? \_\_ \_\_ / \_\_ \_\_ / \_\_ \_\_
Estimated?  Y  N Basis \_\_\_\_\_\_\_\_\_\_\_\_

**^(mm/dd/yy)^**

Now I would like to ask you some questions about when you were exposed
to pesticides.

# Event Information Screen, Application/Release Event Narrative

14\. Can you briefly describe the events leading up to your pesticide
exposure?

**Event Information Screen, Event Summary---Application Information**

15\. Where did the application (*or event such as a spill, transport
accident, or fire*) that was associated with your exposure take place?
(*Interviewer, enter the code from the list below. Do not read
options.)*



  ---- ----------------------------------- ---- ---------------------------
  01   Farm (excluding, nursery,           32   Farm product warehousing
       livestock, forest)                       and storage

  02   Nursery                             33   Food manufacturing

  03   Forest                              39   Other manufacturing
                                                facility/industrial
                                                facility/warehouse facility

  04   Livestock and other animal          40   Office/business (nonretail,
       specialty production facility            nonindustrial)

  05   Greenhouse                          41   Retail establishment

  09   Other agricultural processing       42   Service establishment
       facility                                 

  10   Single family home                  43   Pet care services and
                                                veterinary facilities

  11   Mobile home                         50   Road/rail

  12   Multiunit housing (apartments,      51   Road, rail, or utility
       multiplexes)                             right-of-way

  13   Labor housing                       52   Park

  20   Residential institution (dorms,     54   Private vehicle
       shelters)                                

  21   School                              55   Public transportation
                                                vehicle

  22   Day care facility (including in     59   Other
       private residence)                       

  23   Prison                              60   Emergency response vehicle

  24   Hospital                            70   More than one site

  29   Other institution                   98   Not applicable

  30   Pesticide manufacturing/formulation 99   Unknown
       facility                                 
  ---- ----------------------------------- ---- ---------------------------

16a. What was the intended target for the pesticide?

(*Interviewer, mark only one from the list. Do not read options.)*

(060) Aquatic (pond, stream, lake, irrigation canal)

(800) Bait for rodent, bird or predator

(200) Beverage crops

(041) Building structure (including crack and crevice treatment.)

(042) Building surface

(043) Building space treatment

(530) Cereal grain crops (e.g., barley, corn, wheat, rice)

(650) Crops that cross categories 90--600 (general farming)

(801) **Community wide application target** *(go to 16b below)*

(501) Fiber crops (e.g., cotton)

(300) Flavoring and spice crops

(510) Forage, fodder hay, and silage grasses, silage legumes, and
related crops

(020) Forest trees and forest lands

(100) Fruit crops

> (110) Tree fruits
>
> (111) Citrus fruits (e.g., grapefruit, kumquat, lemon, oranges)
>
> (113) Pome fruits (e.g., apples, pears, quince, Japan plum)
>
> (101) Small fruits (e.g., berries, currants, grapes)
>
> (114) Stone Fruits (e.g., apricots, cherries, dates, mangoes, olives)
>
> (120) Subtropical/other fruits (e.g., avocado, banana, coconuts)
>
> (112) Tree nuts (e.g., almonds, hazelnuts, pecans)

(500) Grains, grasses, and fiber crops

(700) Human

(701) Human---skin/hair

> (702) Human---clothing
>
> (703) Human---skin/hair and clothing

(010) Landscape/ornamental

(550) Miscellaneous field crops

(600) Oil crops

(850) Other (e.g., mixed crop and noncrop, mammal feeding and nesting
areas, boats and docks)

(601) Seed treatment (application to seeds)

(070) Soil

(540) Sugar crops (e.g., sugar cane, sorghum)

(050) Undesired plant (the plant is the target pest)

(400) Vegetable crops

> (410) Curcubit vegetables (e.g., cucumbers)
>
> (420) Fruiting vegetables (e.g., cantaloupe, melon, squash)
>
> (430) Leafy vegetables (e.g., cabbage, celery, endive, lettuce)
>
> (460) Other vegetables (e.g., broccoli, cauliflower, eggplant)
>
> (440) Root and tuber vegetables (e.g., beets, carrots, onions)
>
> (450) Seed and pod vegetables (e.g., beans, chick-peas, lentils,
> peanuts, peas, soybeans, sweet corn)

(032) Veterinary/domestic animal

(031) Veterinary/livestock

(080) Wood product (e.g., utility poles, decking, fencing, boardwalk,
railroad ties, bulwarks, pilings)

(998) Not applicable, application not involved

(999) Unknown

***If 16a is coded as community-wide application target "801," complete
items 16b and 16c.***

16b.What was the purpose of the community wide application?

1 Agricultural pest eradication 2 Public health pest control or
eradication

8 Not Applicable 9 Unknown

16c. What was the specific target of the community-wide application? 

  ----- ------------------------------ ----- ------------------------------
  001   Mosquito (no disease           103   Japanese beetle
        specified)                           

  002   West Nile virus                104   Imported fire ant (red or
                                             black)

  003   St. Louis encephalitis         105   Asian longhorn beetle

  004   Eastern equine encephalitis    106   Emerald ash borer

  005   Western equine encephalitis    107   Grain fungal diseases (e.g.,
                                             black stem rust)

  006   La Crosse encephalitis         108   Grasshopper/Mormon cricket

  007   Dengue fever                   888   Default if State chooses not
                                             to code this variable

  100   Boll weevil                    996   Multiple pests

  101   Gypsy moth (Asian or European) 998   Not applicable (APPTARGT not =
                                             801)

  102   Fruit fly (Mediterranean,      999   Unknown
        Mexican, Oriental, Olive,            
        etc.)                                
  ----- ------------------------------ ----- ------------------------------

17\. What type of equipment was used in this application? (*Interviewer,
mark only one from the list below. Do not read options.)* 

  -------- ------------------------------ -------- ------------------------------
  **01**   Aerial application equipment   **10**   Trigger pump/compressed air

  **02**   Chemigation                    **11**   Ground sprayer

  **03**   Pressurized can                **12**   Manual placement

  **04**   Aerosol generator/fogger       **13**   Dip tank or tray

  **05**   Soil injector                  **14**   More than one type of
                                                   equipment

  **06**   High-pressure fumigator        **15**   Other

  **07**   Hand-held granular/dust        **98**   Not applicable
           application                             

  **08**   Spray line, hand-held          **99**   Unknown

  **09**   Sprayer, backpack                       
  -------- ------------------------------ -------- ------------------------------

# Event Information Screen, Location

*18. What is the address where the **event** occurred that is associated
with this exposure? This address is the site of the pesticide
application, spill, or release (that is, field, orchard, business,
institution, residence, or roadway). (For locations without specific
addresses, include closest crossroad and distances. This may differ from
a person\'s location at the time of exposure. For example, the exposed
person might be located at a school and the actual event is a fire at a
nearby pesticide storage facility. The event location is the pesticide
storage facility.)*

  -------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------- ------------------------ --------------------------------
  **Address line 1**                                 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                            

  **Address line 2**                                 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                            

  **City**                                           \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                            

  **State**                                          \_\_ \_\_                                                                                                                    **ZIP** \_\_ \_\_ \_\_   **Latitude**
                                                                                                                                                                                  \_\_ \_\_                \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

  **County name**                                                                                                                                                                                          **Longitude**
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                                                                                                                                         \_\_\_\_\_\_\_\_\_\_\_\_\_
  **FIPS** \_\_\_ \_\_\_ \_\_\_                                                                                                                                                                            
  -------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------- ------------------------ --------------------------------

# 

# Next, I am going to ask you some questions about the pesticide products you were exposed to and how you were exposed.

# Event Information Screen, Pesticide Products

*Interviewer, complete the information below (complete as much of the
information as possible for each chemical) by asking the following
questions*:

*19. What is the name of the chemical that you were exposed to? If you
were exposed to more than one chemical, please tell me the name of each
one. (Interviewer, record all information available including
manufacturer and any modifiers on label, e.g., spray, dust, 4E.)*

  ---------------------------------- --------------------- ------------ ------------------
  **EPA registration                 **Name**              **Form\***   **Poisoning
  number/distributor number**                                           attribution**^†^

  a\. \_\_ \_\_ \_\_ \_\_ \_\_                                          
  \_\_--\_\_ \_\_ \_\_ \_\_ \_\_ /                                      
  \_\_ \_\_ \_\_ \_\_ \_\_ \_\_                                         

  b.\_\_ \_\_ \_\_ \_\_ \_\_ \_\_                                       
  --\_\_ \_\_ \_\_ \_\_ \_\_ / \_\_                                     
  \_\_ \_\_ \_\_ \_\_ \_\_                                              

  c\. \_\_ \_\_ \_\_ \_\_ \_\_                                          
  \_\_--\_\_ \_\_ \_\_ \_\_ \_\_ /                                      
  \_\_ \_\_ \_\_ \_\_ \_\_ \_\_                                         

  d\. \_\_ \_\_ \_\_ \_\_ \_\_                                          
  \_\_--\_\_ \_\_ \_\_ \_\_ \_\_ /                                      
  \_\_ \_\_ \_\_ \_\_ \_\_ \_\_                                         

  e\. \_\_ \_\_ \_\_ \_\_ \_\_                                          
  \_\_--\_\_ \_\_ \_\_ \_\_ \_\_ /                                      
  \_\_ \_\_ \_\_ \_\_ \_\_ \_\_                                         
  ---------------------------------- --------------------- ------------ ------------------

**\****See form codes on next page.*

^†^*Check box if product is thought to have contributed to illness.
Complete this column at time of case closure.*

*Interviewer, if the EPA Registration Number is unknown, but the
identity of active ingredient(s) is known, enter the most detailed
product name available above and the active ingredients below.
Information about products where only form and functional class are
known, and information about carriers and inerts can be section labeled
**Other Pesticide Information** (Item 21, page 7). If the EPA
Registration Number is entered in the known, complete the EPA
Registration Number and Product name, then skip to Item 22 **Chemical
Agent Comments, page 7**.*

**Event Information Screen, Pesticide Product---Active Ingredients and
Other Sources**

20\. **Active Ingredient.** *If product name is unknown but active
ingredient is known, enter active ingredient here.* (*Code is auto
entered in SPIDER; only record if using lookup file for entry into a
nonautomated system.*)

+-----------+------------------+-----+-----+-------+-------+--------+
| **Active  | **Name**         | *   | *   | **Che | **    | **Poi  |
| i         |                  | *Pe | *Fo | mical | Funct | soning |
| ngredient |                  | r - | rm\ | clas  | ional | attr   |
| code**    |                  | cen | *** | s\*** | clas  | ibutio |
|           |                  | tag |     |       | s**\* | n**^†^ |
|           |                  | e** |     |       |       |        |
+-----------+------------------+-----+-----+-------+-------+--------+
| > a\.     |                  |     |     |       |       |       |
+-----------+------------------+-----+-----+-------+-------+--------+
| > b\.     |                  |     |     |       |       |       |
+-----------+------------------+-----+-----+-------+-------+--------+
| > c\.     |                  |     |     |       |       |       |
+-----------+------------------+-----+-----+-------+-------+--------+
| > d\.     |                  |     |     |       |       |       |
+-----------+------------------+-----+-----+-------+-------+--------+

> *\*Indicate the product form, chemical, and functional class from the
> tables below.*
>
> *† Check box if product is thought to have contributed to illness.
> Complete this column at time of case closure.*

+-----------------------------------+-----------------------------------+
| **NIOSH form codes**              | 10 Flowable concentrate\          |
|                                   | 11 Pressurized                    |
| 01 Dust/powder (not pressurized)\ | liquid/spray/fogger\              |
| 02 Granular/flake\                | 12 Ready-to-use liquid/solution\  |
| 03 Pellet/tablet/cake/briquette\  | 13 Other liquid formulation\      |
| 04 Wettable powder/dust\          | 14 Pressurized gas/fumigant\      |
| 05 Impregnated material           | 15 Paint/liquid coating\          |
| (ant/plant stakes,                | 16 Other\                         |
|                                   | 17 Soluble powder\                |
| > animal collars, water filters)  | 18 Liquid concentrate\            |
|                                   | 99 Unknown                        |
| 06 Other dry formulation\         |                                   |
| 07 Microencapsulated\             |                                   |
| 08 Emulsifiable concentrate\      |                                   |
| 09 Soluble concentrate            |                                   |
+-----------------------------------+-----------------------------------+

+-------------------------------+--------------------------------------+
| **Chemical class codes**      | **Functional class codes**           |
+-------------------------------+--------------------------------------+
| 01 Organochlorine compound    | 01 Insecticide (excluding solely IGR |
|                               | and fumigants)                       |
+-------------------------------+--------------------------------------+
| 02 Organophosphorous compound | 02 Insect growth regulator (IGR)     |
+-------------------------------+--------------------------------------+
| 03 N-methyl carbamates        | 03 Herbicide/algicide                |
+-------------------------------+--------------------------------------+
| 04 Pyrethrin                  | 04 Fungicide                         |
+-------------------------------+--------------------------------------+
| 05 Pyrethroid                 | 05 Fumigant                          |
+-------------------------------+--------------------------------------+
| 06 Dipyridyl compound         | 06 Rodenticide                       |
+-------------------------------+--------------------------------------+
| 07 Chlorophenoxy compound     | 07 Disinfectant/broad spectrum for   |
|                               | water sanitation                     |
+-------------------------------+--------------------------------------+
| 08 Triazines                  | 08 Insect repellent                  |
+-------------------------------+--------------------------------------+
| 09 Carbamates (non AChE       | 09 Antifouling agent (marine paints) |
| inhibitors)                   |                                      |
+-------------------------------+--------------------------------------+
| 10 Organo-metallic compound   | 10 Insecticide and herbicide (01 &   |
|                               | 03)                                  |
+-------------------------------+--------------------------------------+
| 11 Inorganic compounds        | 11 Insecticide and fungicide (01 &   |
|                               | 04)                                  |
+-------------------------------+--------------------------------------+
| 12 Coumarins                  | 12 Insecticide and herbicide and     |
|                               | fungicide (01, 03, & 04)             |
+-------------------------------+--------------------------------------+
| 13 Indandiones                | 13 Insecticide and other (01 & 96)   |
+-------------------------------+--------------------------------------+
| 14 Convulsants                | 14 Herbicide and fFungicide (03 &    |
|                               | 04)                                  |
+-------------------------------+--------------------------------------+
| 15 Microbial                  | 96 Other (includes biological        |
|                               | controls, plant growth regulators,   |
| 16 Dithiocarbamates           | antibiotics, etc.)                   |
+-------------------------------+--------------------------------------+
| 95 Unidentified               | 97 Multiple (product is classified   |
| cholinesterase inhibitor      | as multiple classes which do not fit |
|                               | in any of the codes specified in     |
| 97 Multiple (PC Code          | codes 10--14)                        |
| indicates a code for a        |                                      |
+-------------------------------+--------------------------------------+
| > combination of active       | 99 Unknown                           |
| > ingredients that cross      |                                      |
| > chemical classes)           |                                      |
|                               |                                      |
| 99 Unknown                    |                                      |
+-------------------------------+--------------------------------------+

**21. Other Pesticide Information.** If neither product nor active
ingredient is known.

*Enter a description of the other pesticide, e.g., "Some kind of spray
from a highway truck"; "unspecified Black Flag wasp spray"; "unlabeled
spray can." This area can also be used to record information about
carriers and inerts at the State level.*

+-------+--------------------------+-------+-----+---------+--------+
| **    | **Description of other   | *     | **F | **Fun   | **Poi  |
| Other | source**                 | *Chem | orm | ctional | soning |
| ID**  |                          | icalc | *** | cl      | attr   |
|       |                          | lass* | \** | ass**\* | ibutio |
|       |                          | **\** |     |         | n^†^** |
+-------+--------------------------+-------+-----+---------+--------+
| > a\. |                          |       |     |         |       |
+-------+--------------------------+-------+-----+---------+--------+
| > b\. |                          |       |     |         |       |
+-------+--------------------------+-------+-----+---------+--------+
| > c\. |                          |       |     |         |       |
+-------+--------------------------+-------+-----+---------+--------+

*\* Indicate the product form, chemical, and functional class from the
tables above.*

*^†^Check box if product is thought to have contributed to illness.
Complete this column at time of case closure*.

**22. Event Information, Comments---Chemical Agent Comments**

*(Note additional information about pesticide products and adjuvants.)*

*Interviewer, complete this section after completing interview. All ID
numbers are assigned by SPIDER upon data entry. Data entry clerk should
enter ID numbers onto form.*

+-----------------------+-------------------+--------------------------+
| **Event ID** \_\_     | **Event           |                          |
| \_\_ \_\_ \_\_ \_\_   | descriptor**      |                          |
| \_\_ \_\_             | \_\_              |                          |
|                       | \_\_\_\_\_\_\_\_\ |                          |
|                       | _\_\_\_\_\_\_\_\_ |                          |
|                       | \_\_\_\_\_\_\_\_\ |                          |
|                       | _\_\_\_\_\_\_\_\_ |                          |
|                       |                   |                          |
|                       | ^(Maximum\        |                          |
|                       |  30\ character\ n |                          |
|                       | ame\ for\ event)^ |                          |
+-----------------------+-------------------+--------------------------+
| 23\. Was the          |                   | 24\. Is there evidence   |
| pesticide applied by  |                   | indicating that the      |
| a licensed            |                   | label directions were    |
| applicator?           |                   | [not]{.underline}        |
| (*Indicate the level  |                   | followed?                |
| of applicator         |                   |                          |
| supervision. This may |                   | (1)Yes, there is        |
| require interviewing  |                   | evidence that label      |
| affected person,      |                   | directions were not      |
| employer, or contract |                   | followed.\               |
| applicator to         |                   | (2)No, no evidence of   |
| determine response.*) |                   | label directions not     |
|                       |                   | being followed.\         |
| (1)Licensed          |                   | (8)Not applicable.\     |
| applicator\           |                   | (9)Unknown.             |
| (2)Licensed trainee, |                   |                          |
| direct supervision\   |                   |                          |
| (3)Unlicensed,       |                   |                          |
| intermittent          |                   |                          |
| supervision\          |                   |                          |
| (4)Unlicensed\       |                   |                          |
| (8)Not applicable\   |                   |                          |
| (9)Unknown           |                   |                          |
+-----------------------+-------------------+--------------------------+

# Exposure Information Screen, Incident Information

# *Incident report information. Interviewer, complete Items 25--28 prior to interview. All ID numbers assigned by SPIDER on data entry. Data entry clerk, enter onto form here.*

  ------------ ----------------- ---------------- -------- ------------------ ------- -------- -----------------
  Exposure ID                    \_\_\_\_\_\_\_   25\.                                         
                                                  Report                                       
                                                  date                                         
                                                  \_\_                                         
                                                  \_\_ /                                       
                                                  \_\_                                         
                                                  \_\_ /                                       
                                                  \_\_                                         
                                                  \_\_                                         
                                                  \_\_                                         
                                                  \_\_                                         

  Case ID                        \_\_ \_\_ \_\_                               Event            \_\_ \_\_ \_\_
                                 \_\_ \_\_ \_\_                               ID               \_\_ \_\_ \_\_
                                 \_\_                                                          \_\_

  26\. Report                                              27\. Report source         28\.     
  source 1                                              2                       Report   
                                                                                      source 3 
                                                                                            

  *Use codes                                                                                   
  for sources                                                                                  
  below. Note                                                                                  
  that an                                                                                      
  additional                                                                                   
  character                                                                                    
  can be added                                                                                 
  for State                                                                                    
  specific                                                                                     
  codes under                                                                                  
  each                                                                                         
  category                                                                                     
  (e.g.,                                                                                       
  listing                                                                                      
  specific                                                                                     
  poison                                                                                       
  control                                                                                      
  centers in                                                                                   
  the State by                                                                                 
  using codes                                                                                  
  020-029 or                                                                                   
  02A --                                                                                       
  02Z).*                                                                                       

  **Source     **Description**                                                                 
  Code**                                                                                       

  01           Physician report                                                                

  02           Poison control                                                                  
               center                                                                          

  03           Other health care                                                               
               provider report                                                                 
               (including                                                                      
               emergency room or                                                               
               hospital report)                                                                

  04           Laboratory report                                                               

  05           Death certificate                                                               
               or medical                                                                      
               examiner\'s                                                                     
               report                                                                          

  06           Report or                                                                       
               referral from                                                                   
               governmental                                                                    
               agency                                                                          

  07           Obituary/news                                                                   
               report                                                                          

  08           Ascertainment                                                                   
               through Worker\'s                                                               
               Compensation                                                                    

  09           Self-report                                                                     

  10           Co-worker report                                                                

  11           Friend or                                                                       
               relative report                                                                 

  12           Identified during                                                               
               site visit                                                                      

  13           Worker                                                                          
               representative                                                                  
               (e.g., union,                                                                   
               lawyer/legal                                                                    
               services/other                                                                  
               advocate)                                                                       

  14           Medical record                                                                  
               review (clinic or                                                               
               hospital record                                                                 
               review performed                                                                
               by surveillance                                                                 
               staff)                                                                          

  97           State Department                                                                
               of Health                                                                       

  98           Other (not                                                                      
               captured in any                                                                 
               code category                                                                   
               listed)                                                                         

  99           Unknown                                                                         
  ------------ ----------------- ---------------- -------- ------------------ ------- -------- -----------------

####### 29. Where were you when the exposure took place? (Interviewer, enter from the list below. Do not read options, but base entry upon verbal response.) 

  ---- ------------------------------------ ---- ----------------------------
  01   Farm (excluding, nursery, livestock, 32   Farm product warehousing and
       forest)                                   storage

  02   Nursery                              33   Food manufacturing

  03   Forest                               39   Other manufacturing
                                                 facility/industrial
                                                 facility/warehouse facility

  04   Livestock and other animal specialty 40   Office/business (nonretail,
       production facility                       nonindustrial)

  05   Greenhouse                           41   Retail establishment

  09   Other agricultural processing        42   Service establishment
       facility                                  

  10   Single family home                   43   Pet care services and
                                                 veterinary facilities

  11   Mobile home                          50   Road/rail

  12   Multiunit housing (apartments,       51   Road, rail, or utility
       multiplexes)                              right-of-way

  13   Labor housing                        52   Park

  20   Residential institution (dorms,      54   Private vehicle
       shelters)                                 

  21   School                               55   Public transportation
                                                 vehicle

  22   Day care facility (including in      59   Other
       private residence)                        

  23   Prison                               60   Emergency response vehicle

  24   Hospital                             70   More than one site

  29   Other institution                    98   Not applicable

  30   Pesticide manufacturing/formulation  99   Unknown
       facility                                  
  ---- ------------------------------------ ---- ----------------------------

> 30\. What is the address for the location where you were exposed?
> (*This may be the same as the case address or the event address.*)

  -------------- ------------------------------------------------------------------------------------------------------------------ --------------- -- ---------------------
  **Address 1**  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                      

  **Address 2**  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                      

  **City**       \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                      

  **State**      \_\_ \_\_ **ZIP** \_\_ \_\_ \_\_ \_\_ \_\_                                                                                            

  **Latitude**                                                                                                                      **Longitude**      

  **County       \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                                              **FIPS** \_\_ \_\_
  name**                                                                                                                                               \_\_
  -------------- ------------------------------------------------------------------------------------------------------------------ --------------- -- ---------------------

31\. What were you doing when you were exposed? (*Interviewer, determine
appropriate code for the response; do not read from the list of coded
options. Check one only.*)

32\. Were other people possibly exposed? (1) Yes (2) No (9) Unknown

**If yes, continue with 32a and 32b.**

32a. How many \_\_\_\_\_\_

32b. Did any seek medical care? (1) Yes (2) No (9) Unknown

*Use a separate sheet of paper to record names and contact information,
if appropriate.*

33\. Please describe the exposure to me, especially anything we haven\'t
yet discussed. I may ask you some more detailed questions about what you
describe as we proceed with the interview.

34\. When you were exposed to the pesticide, did you seek any type of
medical care?

(2) No (1) Yes

(9) Unknown

***Complete items 35--43.***

***Go to item 44a on page 11.***

35\. Where did you receive your initial medical care after the exposure?

(1) Physician office/ clinic visit (5) No medical care sought

(2) Emergency room (6) Other

(3) Hospital admission (9) Unknown

(4) Advice from the poison control center

36\. When did you first receive medical care? \_\_ \_\_ / \_\_ \_\_ /
\_\_ \_\_

> **^(mm/dd/yy)^**
>
> 37\. What is the name of the health care professional (HCP) you saw?
>
> Last name
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> First name
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

  ---------- ------------------------------ -----------------------------
  38\. What                                 
  is their                                  
  address?                                  

             **[Chart                       **[Work
             location]{.underline}**        location]{.underline}**

  Address 1                                 

  Address 2                                 

  City                                      

  State      \_\_\_ \_\_\_                  \_\_\_ \_\_\_

  Zip        \_\_\_ \_\_\_ \_\_\_ \_\_\_    \_\_\_ \_\_\_ \_\_\_ \_\_\_
             \_\_\_                         \_\_\_

  Phone      ( \_\_ \_\_ \_\_ ) \_\_ \_\_   ( \_\_ \_\_ \_\_ ) \_\_ \_\_
             \_\_ - \_\_ \_\_ \_\_ \_\_     \_\_ - \_\_ \_\_ \_\_ \_\_
  ---------- ------------------------------ -----------------------------

> 39\. Did you have a test for pesticides in your blood or urine?

(2)No (1) Yes

> (9)Unknown *Interviewer, obtain medical record to complete tables on
> pages 18-19.*

***Go to item 41**.*

40\. Did you have a cholinesterase test, which requires that blood be
drawn?

> (2) No (1) Yes (9) Unknown
>
> *If yes, complete tables on pages 18-19 from the medical record.*
>
> 41\. Were you admitted to the hospital due to the pesticide exposure?
> (2) No (1) Yes (9) Unknown
>
> ***If No, go to item 44a.***
>
> 42\. Facility where hospitalized
>
> Address\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Treating physician
>
> 43\. How many days did you stay in the hospital? \_\_\_ \_\_\_ \_\_\_
>
> *(Enter number of days,* 997 if \> 996 days, 998=NA, not hospitalized
> 999=Unknown *or 999 if unknown.)*

44a. Did you spend one or more days away from work due to the pesticide
exposure? (1) Yes (2) No

(9) Unknown

> 44b. How many days were you away from work? \_\_\_\_\_\_\_\_\_\_ ***Go
> to item 44c***
>
> 44c. If not employed, did you spend one or more days away from school
> or regular activities?
>
> (1) Yes (2) No (9) Unknown
>
> 44d. How many days were you away from school or regular activities?
> \_\_\_\_\_\_\_\_\_\_\_\_\_

45\. Do you have any of the following medical conditions that were not
due to this exposure?

+------------------+-------------------------+-----------------+------+
| **Condition**    | **Describe**            | (*Interviewer,  | **F  |
|                  |                         | com-plete after | inal |
| **(Check all     |                         | interview.*)    | code |
| that apply.)**   |                         |                 | \*** |
|                  |                         | **Medical       |      |
|                  |                         | history (from   |      |
|                  |                         | HCP interview   |      |
|                  |                         | or medical      |      |
|                  |                         | records)**      |      |
+------------------+-------------------------+-----------------+------+
| \_\_\_a.         |                         |                 |      |
| Pregnancy        |                         |                 |      |
+------------------+-------------------------+-----------------+------+
| \_\_\_b. Asthma  |                         |                 |      |
+------------------+-------------------------+-----------------+------+
| \_\_\_c.         |                         |                 |      |
| Allergies        |                         |                 |      |
+------------------+-------------------------+-----------------+------+
| \_\_\_ d.        |                         |                 |      |
| Multiple         |                         |                 |      |
| chemical         |                         |                 |      |
| sensitivity      |                         |                 |      |
| (acquired        |                         |                 |      |
| chemical         |                         |                 |      |
| intolerance)     |                         |                 |      |
+------------------+-------------------------+-----------------+------+
| \_\_\_ e. Any    |                         |                 |      |
| other medical    |                         |                 |      |
| condition you    |                         |                 |      |
| are seeing a     |                         |                 |      |
| doctor for       |                         |                 |      |
+------------------+-------------------------+-----------------+------+

> *\*Use the following codes for Final code after completion of
> interview and medical record review*
>
> 1=Doctor reported 2=Exposed person reported 3=Both doctor and person
> reported
>
> 4=Condition was absent 5=Not reported 9=Unknown

*Interviewer, was response to question 31 on page 9 in the range of
01‑08?*

*YES---proceed to question 46.*

*NO---skip to question 63 on page 14.*

**Exposure Information Screen, Occupational Information, PPE Use**

46\. Did the pesticide exposure occur while you were working?

(1) Yes (3) No

(2) Possibly (4) Unknown

(5) Not Applicable

***Go to Item 54 on page 13.***

Now I am going to ask you some questions about your employer **at the
time you were exposed to pesticides**. *(If necessary, reassure the
subject that you are not associated with OSHA.)*

47\. What is your employer's name?

48\. What is your employer's address (or your work address if
self-employed)?

Street
Address\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

City \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ State
\_\_ \_\_ Zip code \_\_ \_\_ \_\_ \_\_ \_\_

49\. What was your occupation/job title when you were injured/exposed?

50\. What type of work was being done at your place of employment at
time of injury/exposure?

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> *Is this individual an agricultural worker or pesticide handler?*
>
> *YES---Complete item 51a.*
>
> *NO---Proceed to item 54.*

*To be completed by the interviewer after interview.*

> 52\. *Bureau of Census code for occupation of exposed worker \_\_ \_\_
> \_\_*
>
> ***^Occ\ code^***
>
> 53\. *Bureau of Census code for industry or North American Industry
> Classification System (NAICS)*
>
> \_\_ \_\_ \_\_ *or* \_\_ \_\_ \_\_ \_\_ *(Note that Census codes are
> preferred.)*
>
> *^Indcic^ ^Indsic^*

54\. Were you wearing any personal protective equipment?

(2) No (1) Yes

(9) Unknown

***Go to item 63***

***Complete items 55--61.***

*62. Interviewer, complete after interview. Indicate the level of PPE
used and required for this individual according to the product label.*

+-----------------------------------+----------------------------------+
| > (1) Used (all or some of PPE   | > (5) Not used (unknown         |
| > required)                       | > requirements)                  |
+-----------------------------------+----------------------------------+
| > (2) Used (not required)        | > (6) Not used (not required)   |
+-----------------------------------+----------------------------------+
| > (3) Used (unknown              | > (8) Not applicable            |
| > requirements)                   |                                  |
+-----------------------------------+----------------------------------+
| > (4) Not used (some PPE         | > (9) Unknown                   |
| > required)                       |                                  |
+-----------------------------------+----------------------------------+

63\. What was the date and approximate time that your exposure to the
pesticide(s) first started? Date\* \_\_\_/\_\_\_/\_\_\_ Time \_\_\_:
\_\_\_\_ Use 24-hour clock

**^(mm/dd/yy)^**

***\*** At least one of the following dates must be entered: first
exposure, symptom onset or laboratory test (see pages 18-19).*

64\. What was the date and approximate time that you first started to
experience symptoms?

Date \_\_\_/\_\_\_/\_\_\_ Time \_\_\_: \_\_\_\_ Use 24-hour clock

**^(mm/dd/yy)^**

65\. What was the date and approximate time that your exposure to the
pesticide(s) ended?

Date \_\_\_/\_\_\_/\_\_\_ Time \_\_\_: \_\_\_\_ Use 24-hour clock

**^(mm/dd/yy)^**

**[Signs/Symptoms]{.underline}**

66\. Next I\'d like you to describe your symptoms? (*Interviewer, fill
in "Doctor reported" column based on medical records or HCP interview.
Final code column should be completed prior to data entry. Codes are
listed following the table on page 17.)*

Check all signs or symptoms described or stated as absent (items in
italics should be taken from HCP interview or medical record only).

+-------------+------------------------+-------+-------+-------+-----+
| **System**  | **Sign/symptom**       | **Pa  | **D   | **Abs | *   |
|             |                        | tient | octor | ent** | *Fi |
|             |                        | repor | repor |       | nal |
|             |                        | ted** | ted** |       | cod |
|             |                        |       |       |       | e** |
+=============+========================+=======+=======+=======+=====+
| **General** | *Acidosis*             |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | *Alkalosis*            |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Fatigue/malaise        |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Fever                  |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | *Increased anion gap*  |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Other                  |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
| **Cardi     | *Bradycardia*          |       |       |       |     |
| ovascular** |                        |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | *Cardiac arrest*       |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Chest pain             |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | *Conduction            |       |       |       |     |
|             | disturbance*           |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | *Hypertension*         |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | *Hypotension*          |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | *Palpitations*         |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | *Tachycardia*          |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Other                  |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
| **Renal**   | Frequent urination     |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Hematuria              |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | *Oliguria/anuria*      |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | *Proteinuria*          |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Other                  |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
| **Neu       | Altered taste          |       |       |       |     |
| rological** |                        |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Anxiety/hype           |       |       |       |     |
|             | ractivity/irritability |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Ataxia /trouble        |       |       |       |     |
|             | walking                |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Blurred vision         |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
| **N         | Coma                   |       |       |       |     |
| eurological |                        |       |       |       |     |
| (c          |                        |       |       |       |     |
| ontinued)** |                        |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Confusion              |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Diaphoresis (profuse   |       |       |       |     |
|             | sweating)              |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Dizziness              |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Fainting               |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Fasciculations         |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Headache               |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Memory loss            |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Muscle pain            |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | *Muscle rigidity*      |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Muscle weakness        |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Paralysis              |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Paresthesias/tingling  |       |       |       |     |
|             | or numbness            |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Peripheral neuropathy  |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Salivation             |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Seizure                |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Slurred speech         |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Other                  |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
| #####       | Anorexia (loss of      |       |       |       |     |
| # **Gastroi | appetite)              |       |       |       |     |
| ntestinal** |                        |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Constipation           |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Diarrhea               |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | GI Bleeding (blood in  |       |       |       |     |
|             | stool or vomit)        |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Nausea                 |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Pain                   |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Vomiting               |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Other                  |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
| **Eye**     | *Burns*                |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | *Conjunctivitis        |       |       |       |     |
|             | (diagnosis)*           |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | *Corneal abrasion*     |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | *Miosis*               |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | *Mydriasis*            |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Pain/i                 |       |       |       |     |
|             | rritation/inflammation |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Tearing/*lacrimation*  |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Other                  |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
| **Dermal**  | Blisters/*bullae*      |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Burns                  |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Edema/swelling         |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Hives                  |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Pain                   |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Pruritis (itching)     |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Pattern\* of rash or   |       |       |       |     |
|             | lesions                |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Rash                   |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Redness                |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Other                  |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
| **Re        | *Asthma (diagnosis     |       |       |       |     |
| spiratory** | of)*                   |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Cough                  |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | *Cyanosis*             |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Depression             |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Dyspnea                |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | LR Irritation          |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Pleural pain           |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | *Pulmonary edema*      |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Tachypnea              |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | UR irritation          |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Wheezing               |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+
|             | Other                  |       |       |       |     |
+-------------+------------------------+-------+-------+-------+-----+

> \*Coding for pattern of dermal lesions
>
> 1=Corresponds well with physical pattern of exposure
>
> 2=Discrete patches of lesions do not correspond with the pattern of
> exposure
>
> 3=Generalized distribution of lesions on the body
>
> 4=Absent
>
> 9=Unknown

*Complete final code column prior to data entry.*

  ----------- ------------------------------------------------------------
  ***Final    *1=Doctor reported 2=Exposed person reported 3=Both Dr. and
  Code for    person reported\
  All         9=Unknown*
  Fields***   

  ----------- ------------------------------------------------------------

#  

# Exposure Information Screen, Narrative

Health
Comments\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Ending Statement**

**This concludes the interview. The information you have given us is
very important. We appreciate your willingness to take time to answer
all of our questions. Do you have any questions at this time?**
*(Interviewer, provide the caller with your name and phone number and
information about any additional contacts or actions that will result
from the interview.)*

The following section should be completed after reviewing medical
records or interviewing the attending HCP. Also, go to pages 15--17 to
update signs and symptoms based on the medical records/HCP interview, if
this section is not pertinent. Make sure diagnosis, outcome, and any
notes are entered on page 19.

# Exposure Information Screen, Medical Staff

  ----------------- ----------------- ----------------- -----------------
  Medical ID        \_\_ \_\_ \_\_    \_\_ \_\_ \_\_    \_\_ \_\_ \_\_
                    \_\_ \_\_ \_\_    \_\_ \_\_ \_\_    \_\_ \_\_ \_\_
                    \_\_              \_\_              \_\_

  *Enter one                                            
  Medical ID for                                        
  each medical                                          
  person involved                                       
  in the case. In                                       
  SPIDER, use F2 to                                     
  select from pick                                      
  list. See Item 37                                     
  on Page 10 and                                        
  enter on Medical                                      
  Staff screen if                                       
  not on pick list                                      
  to complete full                                      
  medical staff                                         
  information.*                                         
  ----------------- ----------------- ----------------- -----------------

*Interviewer, complete this section and shaded columns on the table for
Item 45 on page 12,* *based on interview with HCP or review of medical
records.*

**Non-Cholinesterase Chemical-Specific Biological Test for Pesticides or
Metabolites**

+-------------+------------------------+------------------------------+
| Were any    |                        | Yes No Unknown            |
| non-cho     |                        |                              |
| linesterase |                        | *If yes, complete table if   |
| biological  |                        | part of State protocol*      |
| tests done  |                        |                              |
| for         |                        |                              |
| pesticides  |                        |                              |
| in blood,   |                        |                              |
| urine or    |                        |                              |
| hair?       |                        |                              |
+-------------+------------------------+------------------------------+
|             | **Test 1**             | **Test 2**                   |
+-------------+------------------------+------------------------------+
| **Test      |                        |                              |
| type**      |                        |                              |
+-------------+------------------------+------------------------------+
| **Sample    | \_\_ \_\_ / \_\_ \_\_  | \_\_ \_\_ / \_\_ \_\_ / \_\_ |
| date**      | / \_\_ \_\_            | \_\_                         |
+-------------+------------------------+------------------------------+
| **Numeric   |                        |                              |
| result**    |                        |                              |
+-------------+------------------------+------------------------------+
| **Analysis  |  Abnormal  Normal    |  Abnormal  Normal          |
| result**    |                        |                              |
|             |  Not applicable      |  Not applicable  Unknown   |
|             | Unknown                |                              |
+-------------+------------------------+------------------------------+

Was a cholinesterase test(s) performed? (*Only ask if exposure involved
an organophosphate or N-methyl carbamate pesticide.*) (1) Yes (2) No
(9) Unknown

(**If yes, complete table of results below**.)

**Coding Guidance for Completing Table of Results Below**

**Option 1: Detailed version---complete all.**

**Option 2: Required minimum---enter a single response for *Test Type*
and *Result Type*, the only required fields.**

<table>
<colgroup>
<col style="width: 7%" />
<col style="width: 2%" />
<col style="width: 9%" />
<col style="width: 9%" />
<col style="width: 9%" />
<col style="width: 16%" />
<col style="width: 10%" />
<col style="width: 11%" />
<col style="width: 11%" />
<col style="width: 11%" />
</colgroup>
<tbody>
<tr class="odd">
<td><strong>PFI</strong></td>
<td colspan="9">Lab code from lab pick list or enter lab name</td>
</tr>
<tr class="even">
<td colspan="3"><strong>Test type codes</strong></td>
<td colspan="7"><p>1=RBC 2=Plasma 3=Both RBC and Plasma 4=Not done</p>
<p>5=Either RBC or Plasma 8=Not applicable 9=Unknown</p></td>
</tr>
<tr class="odd">
<td colspan="3"><strong>Result type codes</strong></td>
<td colspan="7"><p>1=Abnormal compared to lab 2=Abnormal compared to
baseline</p>
<p>3=Normal compared to lab 4=Normal compared to baseline</p>
<p>7=Bad specimen 8=Not applicable 9=Unknown</p></td>
</tr>
<tr class="even">
<td colspan="2"><strong>PFI</strong></td>
<td colspan="2"><strong>Lab name</strong></td>
<td><p><strong>Test</strong></p>
<p><strong>type</strong></p></td>
<td><strong>Test date</strong></td>
<td><strong>Numeric result</strong></td>
<td><p><strong>Result</strong></p>
<p><strong>type</strong></p></td>
<td><strong>Lab low</strong></td>
<td><strong>Lab high</strong></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td>___ /___/___</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td>___ /___/___</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td>___ /___/___</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td>___ /___/___</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td>___ /___/___</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

+--------------------+--------------------------+----------------------+
| \[ \] **Diagnosis  |                          | **Outcome**          |
| made by HCP**      |                          |                      |
+--------------------+--------------------------+----------------------+
| **Diagnosis**      |                          | (1) Fatal,          |
|                    |                          | pesticide-related   |
|                    |                          |                      |
|                    |                          | (2) Fatal, not      |
|                    |                          | pesticide-related    |
+--------------------+--------------------------+----------------------+
| **ICD-9**          | \_\_ \_\_ \_\_ . \_\_    | (3) Fatal, relation |
|                    | \_\_                     | unknown              |
+--------------------+--------------------------+----------------------+
| **Summary**        |                          | (8) Not applicable  |
|                    |                          | (not fatal)          |
+--------------------+--------------------------+----------------------+

Notes\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

***Interviewer, review the form for completeness and complete the
following sections:***

Pages 4 - 7 Check to determine if other interviews are needed to
complete questions 18--22.

Pages 5 - 7 Any necessary chemical product coding.

Page 7 Event descriptor, items 23 and 24.

Page 12 Item 45 enter shaded columns: pre-existing conditions from
medical professional interview or medical record review and complete
final code for medical conditions.

Page 13 Items 52 and 53.

Page 14 Item 62.

Pages 15-17 Make sure all signs and symptoms are entered from medical
professional interview or medical record review and complete final code
column.

Indicate your assessment of how the individual came into contact with
the pesticide. *(Check all that apply, bolding indicates variable label
in SPIDER.)*

 **Drift**

 Direct **spray**

 **Indoor air** contamination

 Contact with treated **surface** (plant material, carpets, treated
animal)

 Direct **contact** (spill, leaking container or equipment,
floodwaters, emergency response)

 **Other**

 **Unknown**

Indicate the route(s) of exposure *(Check all that apply.)*

 Dermal  Inhalation

 Ingestion

 Injection

 Ocular

 Unknown

Indicate if the exposure was intentional.

1=Yes, suspected intentional 2=No, unintentional 9=Unknown

***The remaining sections are to be completed by the interviewer
following standard case classification procedures***

+-----------------------------------------------------------------------+
| **Severity**                                                         |
|                                                                       |
| 1 = Fatal 2 = High 3 = Moderate 4 = Low 8 =Evaluated, Not applicable  |
+-----------------------------------------------------------------------+
| **A. Documentation of Exposure**                                    |
|                                                                       |
| *(Put a number in the first box and letter in the second box if       |
| appropriate.)*                                                        |
|                                                                       |
| 1 - Confirmed by a-envir/bio testing b-professional observation       |
| c-biological evidence\                                                |
| d-eye/derm signs e. 2+ findings by medical staff                      |
|                                                                       |
| 2 - Reported by a-case b-witness c-application records\               |
| d-nonprofessional observation e-other                                 |
|                                                                       |
| 3 - Strong evidence of no exposure                                    |
|                                                                       |
| 4 - Insufficient data                                                 |
+-----------------------------------------------------------------------+
| **B. Documentation of Health Effect** \                              |
| 1 - 2+ Findings by medical staff\                                     |
| 2 - 2+abnormal symptoms\                                              |
| 3 - No post exposure findings\                                        |
| 4 - Insufficient Data                                                 |
+-----------------------------------------------------------------------+
| **C. Evaluation of Causal Relationship**                            |
|                                                                       |
| *(Put a number in first box and letter in second box if first box is  |
| 1.)\                                                                  |
| * 1 - Fits known toxicology\                                          |
| a-characteristic (Appendix 2 of case classification) and temporal     |
| relationship is plausible\                                            |
| b-consistent with literature and known toxicology                     |
|                                                                       |
| 2 - Inconsistent with known toxicology                                |
|                                                                       |
| 3 - Definitely ruled out (evidence of non-pesticide causal agent)     |
|                                                                       |
| 4 - Insufficient toxicologic information available                    |
+-----------------------------------------------------------------------+
| **NIOSH Classification**  **Alternate Classification**              |
|                                                                       |
| Classification categories 1=Definite 5=Unlikely 2=Probable            |
| 6=Insufficient Information\                                           |
| 3=Possible 7=Exposed/Asymptomatic\                                    |
| 4=Suspicious 8=Unrelated                                              |
+-----------------------------------------------------------------------+

# Exposure Information Screen---Poisoning Attribution

Return to pages 5 through 7 to determine if illness is attributable to
products, active ingredients, or substances listed there.