# C.3 PESTICIDE ILLNESS AND INJURY SURVEILLANCE 

# DATA COLLECTION FORM

**Instructions**

This is a sample data collection form for use by an acute
pesticide-related illness and injury surveillance program. This data
collection form is for States that choose not to use a standard
questionnaire but collect data via an open-ended interview. The form
includes fields that satisfy 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). Fields
needed for administrative report management at the State level, as well
as, optional suggested variables are also included. Optional items are
indicated on the form by framing with a dotted line border. The order of
the fields 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 indicates items that are to
be completed by the interviewer and not asked during the actual exposed
individual or attending health care professional (HCP) interview. The
form contains fields for information that may be collected from the
exposed individual, and additional medical and pesticide product
information collected from record reviews or additional interviews.
States will need to customize this data collection form for their
specific needs.

#   {#section .unnumbered}

# PESTICIDE ILLNESS AND INJURY SURVEILLANCE DATA COLLECTION FORM

# 

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

## Case Information

+-----------+----------------------------+----------------------------+
| **Social  |                            |                            |
| security  |                            |                            |
| number**  |                            |                            |
| \_\_\_    |                            |                            |
| \_\_\_    |                            |                            |
| \_\_\_ -- |                            |                            |
| \_\_\_    |                            |                            |
| \_\_\_--  |                            |                            |
| \_\_\_    |                            |                            |
| \_\_\_    |                            |                            |
| \_\_\_    |                            |                            |
| \_\_\_    |                            |                            |
+-----------+----------------------------+----------------------------+
| **Name**  |                            |                            |
|           |                            |                            |
| ^Las      |                            |                            |
| t\ First\ |                            |                            |
|  Initial^ |                            |                            |
+-----------+----------------------------+----------------------------+
| **DOB**   |                            |                            |
| \_\_\_\_/ |                            |                            |
| \_\_\_\_\ |                            |                            |
| _/\_\_\_\ |                            |                            |
| _\_\_\_\_ |                            |                            |
| E         |                            |                            |
| stimated? |                            |                            |
|  Y  N  |                            |                            |
| B         |                            |                            |
| asis\_\_\ |                            |                            |
| _\_\_\_\_ |                            |                            |
| \_\_\_\_\ |                            |                            |
| _\_\_\_\_ |                            |                            |
| \_\_\_\_\ |                            |                            |
| _\_\_\_\_ |                            |                            |
| \_\_\_\_\ |                            |                            |
| _\_\_\_\_ |                            |                            |
| \_\_\_\_\ |                            |                            |
| _\_\_\_\_ |                            |                            |
|           |                            |                            |
| ^MM\ **DD |                            |                            |
| \ YYYY**^ |                            |                            |
|           |                            |                            |
| **DOD**   |                            |                            |
| \_\_\_\_\ |                            |                            |
| _/\_\_\_\ |                            |                            |
| _\_/\_\_\ |                            |                            |
| _\_\_\_\_ |                            |                            |
+-----------+----------------------------+----------------------------+
| ^MM\ **DD |                            |                            |
| \ YYYY**^ |                            |                            |
+-----------+----------------------------+----------------------------+
| **Current |                            |                            |
| residence |                            |                            |
| info      |                            |                            |
| rmation** |                            |                            |
+-----------+----------------------------+----------------------------+
| Address   | \_\_\_\_\_\_\_\_           |                            |
| Line 1    | \_\_\_\_\_\_\_\_\_\_\_\_\_ |                            |
|           | \_\_\_\_\_\_\_\_\_\_\_\_\_ |                            |
|           | \_\_\_\_\_\_\_\_\_\_\_\_\_ |                            |
|           | \_\_\_\_\_\_\_\_\_\_\_\_\_ |                            |
+-----------+----------------------------+----------------------------+
| Address   | \_\_\_\_\_\_\_\_           |                            |
| Line 2    | \_\_\_\_\_\_\_\_\_\_\_\_\_ |                            |
|           | \_\_\_\_\_\_\_\_\_\_\_\_\_ |                            |
|           | \_\_\_\_\_\_\_\_\_\_\_\_\_ |                            |
|           | \_\_\_\_\_\_\_\_\_\_\_\_\_ |                            |
+-----------+----------------------------+----------------------------+
| City      | \_\_\_\_\_\_\_\_           |                            |
|           | \_\_\_\_\_\_\_\_\_\_\_\_\_ |                            |
|           | \_\_\_\_\_\_\_\_\_\_\_\_\_ |                            |
|           | \_\_\_\_\_\_\_\_\_\_\_\_\_ |                            |
|           | \_\_\_\_\_\_\_\_\_\_\_\_\_ |                            |
+-----------+----------------------------+----------------------------+
| State     | \_\_ \_\_ Zip \_\_ \_\_    |                            |
|           | \_\_ \_\_ \_\_ County      |                            |
|           | \_\_                       |                            |
|           | \_\_\_\_\_\_\_\_\_\_\_\_\_ |                            |
|           | \_\_\_\_\_\_\_\_\_\_\_\_\_ |                            |
+-----------+----------------------------+----------------------------+
| Phone     | (\_\_\_\_\_) \_\_\_\_\_\_  |                            |
|           | --                         |                            |
|           | \_\_\_\_\_\_\_\_\_\_\_\_\_ |                            |
+-----------+----------------------------+----------------------------+
| **        |                            |                            |
| Residence |                            |                            |
| at time   |                            |                            |
| of        |                            |                            |
| exposure  |                            |                            |
| if        |                            |                            |
| different |                            |                            |
| from      |                            |                            |
| above.**  |                            |                            |
| *(Enter   |                            |                            |
| in        |                            |                            |
| exposure  |                            |                            |
| incident  |                            |                            |
| screen if |                            |                            |
| this was  |                            |                            |
| location  |                            |                            |
| where     |                            |                            |
| exposure  |                            |                            |
| oc        |                            |                            |
| curred.)* |                            |                            |
+-----------+----------------------------+----------------------------+
| Address   | \_\_\_\_\_\_\_\_           |                            |
| Line 1    | \_\_\_\_\_\_\_\_\_\_\_\_\_ |                            |
|           | \_\_\_\_\_\_\_\_\_\_\_\_\_ |                            |
|           | \_\_\_\_\_\_\_\_\_\_\_\_\_ |                            |
|           | \_\_\_\_\_\_\_\_\_\_\_\_\_ |                            |
+-----------+----------------------------+----------------------------+
| Address   | \_\_\_\_\_\_\_\_           |                            |
| Line 2    | \_\_\_\_\_\_\_\_\_\_\_\_\_ |                            |
|           | \_\_\_\_\_\_\_\_\_\_\_\_\_ |                            |
|           | \_\_\_\_\_\_\_\_\_\_\_\_\_ |                            |
|           | \_\_\_\_\_\_\_\_\_\_\_\_\_ |                            |
+-----------+----------------------------+----------------------------+
| City      | \_\_\_\_\_\_\_\_           |                            |
|           | \_\_\_\_\_\_\_\_\_\_\_\_\_ |                            |
|           | \_\_\_\_\_\_\_\_\_\_\_\_\_ |                            |
|           | \_\_\_\_\_\_\_\_\_\_\_\_\_ |                            |
|           | \_\_\_\_\_\_\_\_\_\_\_\_\_ |                            |
+-----------+----------------------------+----------------------------+
| State     | \_\_ \_\_ Zip \_\_ \_\_    |                            |
|           | \_\_ \_\_ \_\_             |                            |
+-----------+----------------------------+----------------------------+
| County    | \_                         | FIPS \_\_ \_\_ \_\_        |
|           | \_\_\_\_\_\_\_\_\_\_\_\_\_ |                            |
|           | \_\_\_\_\_\_\_\_\_\_\_\_\_ |                            |
+-----------+----------------------------+----------------------------+

+-----------+--------------------------+-------------------------------+
| **Sex**   | ** M**ale  **F**emale  |                               |
|           |  **O**ther             |                               |
|           | **U**nknown              |                               |
+-----------+--------------------------+-------------------------------+
| **Race**  | ****1 Am Indian ****2  |                               |
|           | Asian/Pacific Is. ****  |                               |
|           | 3 Black **** 5 White    |                               |
|           | **** 6 Mixed            |                               |
|           |                          |                               |
|           | **** 8 Other **** 9    |                               |
|           | Unknown                  |                               |
+-----------+--------------------------+-------------------------------+
| **H       | ****Yes ****No         | **Speaks English?** ****Yes  |
| ispanic** | ****Unknown             | ****No                       |
+-----------+--------------------------+-------------------------------+

##  Event Information Screen---Event Summary---Application Information 

## *(Complete after interview.)*

+-------------------------+--------+---------+------------------------+
| Event ID \_\_ \_\_ \_\_ | Event  |         | County\_\_\_\_\_\_\_   |
| \_\_ \_\_ \_\_ \_\_     | date   |         | \_\_\_\_\_\_\_\_\_\_\_ |
| \_\_                    | \_     |         |                        |
|                         | \_\_/\ |         |                        |
|                         | _\_\_/ |         |                        |
|                         | \_\_\_ |         |                        |
+-------------------------+--------+---------+------------------------+
| **Event descriptor**    |        |         |                        |
|                         |        |         |                        |
| ^(Maximum\ 30\ charact  |        |         |                        |
| er\ name\ for\ event.)^ |        |         |                        |
+-------------------------+--------+---------+------------------------+
| **Licensed applicator** |        | **Labe  |                        |
|                        |        | l/use** |                        |
|                         |        |        |                        |
| *(Use code to indicate  |        |         |                        |
| level of applicator     |        | *(Use   |                        |
| supervision.)*          |        | code to |                        |
|                         |        | i       |                        |
| 1=Licensed applicator\  |        | ndicate |                        |
| 2=Licensed trainee,     |        | if      |                        |
| direct supervision\     |        | e       |                        |
| 3=Unlicensed,           |        | vidence |                        |
| intermittent            |        | in      |                        |
| supervision\            |        | dicates |                        |
| 4=Unlicensed\           |        | that    |                        |
| 8=Not applicable\       |        | the     |                        |
| 9=Unknown               |        | label   |                        |
|                         |        | dir     |                        |
|                         |        | ections |                        |
|                         |        | were    |                        |
|                         |        | [no     |                        |
|                         |        | t]{.und |                        |
|                         |        | erline} |                        |
|                         |        | foll    |                        |
|                         |        | owed.)* |                        |
|                         |        |         |                        |
|                         |        | 1=Yes,  |                        |
|                         |        | there   |                        |
|                         |        | was     |                        |
|                         |        | e       |                        |
|                         |        | vidence |                        |
|                         |        | that    |                        |
|                         |        | label   |                        |
|                         |        | dir     |                        |
|                         |        | ections |                        |
|                         |        | were    |                        |
|                         |        | not     |                        |
|                         |        | fo      |                        |
|                         |        | llowed. |                        |
|                         |        |         |                        |
|                         |        | 2=No,   |                        |
|                         |        | no      |                        |
|                         |        | e       |                        |
|                         |        | vidence |                        |
|                         |        | of      |                        |
|                         |        | label   |                        |
|                         |        | dir     |                        |
|                         |        | ections |                        |
|                         |        | not     |                        |
|                         |        | being   |                        |
|                         |        | fo      |                        |
|                         |        | llowed. |                        |
|                         |        |         |                        |
|                         |        | 8=Not   |                        |
|                         |        | app     |                        |
|                         |        | licable |                        |
|                         |        |         |                        |
|                         |        | 9=      |                        |
|                         |        | Unknown |                        |
+-------------------------+--------+---------+------------------------+

  ------------- -------------------------------- -------- ------------------------------
  Application                                             
  site                                                    
  **(Enter                                              
  code)**                                                 

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

  02            Nursery                          **33**   Food manufacturing

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

  04            Livestock and other animal       **40**   Office/business (non-retail,
                specialty production facility             non-industrial)

  05            Greenhouse                       **41**   Retail establishment

  09            Other nonproduction agricultural **42**   Service establishment
                facility                                  

  10            Single family home               **43**   Pet care services and
                                                          veterinary facilities

  11            Mobile home                      **50**   Road/rail

  12            Multi-unit 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 (inc. 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                        **99**   Unknown
                manufacturing/formulation                 
                facility                                  
  ------------- -------------------------------- -------- ------------------------------

  ------------- ------------------------------ -------- -------------------------------
  Application                                           
  equipment                                             
  **(Enter                                            
  code)**                                               

  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            Handheld granular/dust         **98**   Not applicable
                application                             

  08            Spray line, handheld           **99**   Unknown

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

**Application target (mark one)**

(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**

(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 (apricots, cherries, dates, mangoes, olives)
>
> (120) Subtropical/ other fruits (e.g., avocado, banana, coconut)
>
> (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, egg plant)
>
> (440) Root and tuber vegetables (e.g., beets, carrots, onions)
>
> (450) Seed and pod vegetables (e.g., beans, chick peas, lentils,
> peanuts, peas, soy beans, 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

> **Application purpose** 1 Agricultural pest eradication 8 NA
>
> 2 Public health pest control or eradication 9 Unknown

  ---------------- ------------------------- ----- -----------------------------------
  Specific pest                                    
  target of                                        
  community-wide                                   
  application                                      
  ** (Enter                                     
  code)**                                          

  **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            106   Emerald ash borer
                   encephalitis                    

  **005**          Western equine            107   Grain fungal diseases (e.g. black
                   encephalitis                    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      998   Not applicable (APPTARGT not=801)
                   European)                       

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

## Event Information Screen---Location 

Location where the exposure **event** occurred. 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**                                                                          \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                

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

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

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

  **Latitude**                                                                                                                                                                                                                   **Longitude**   

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

## Event Information Screen---Comments---Application/Release Event Narrative

*Do not describe exposure. Describe the use/event that involved the
release of pesticide. Include details of spill, application, accidental
release, etc., that will help clarify how exposures came about.*

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

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

**Event Information Screen---Pesticide Products**

If the EPA Registration Number is known, complete the EPA registration
number and product name below then skip to **Chemical Agent** Comments
on page 8. (Active ingredient code \[PC Code, percentage, form, chemical
class, and functional class are auto-entered in SPIDER; record only if
using lockup file for entry into nonautomated system.) If the EPA
registration number is unknown, but the identity of active ingredient(s)
is known, enter the most detailed product name available below and all
other available information regarding the ingredients on the table
labeled **Active Ingredient** on page 7. Information about products
where only form and functional class are known, or carriers and inerts
can be entered in the section labeled ***Other Source*** on page 8.

*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.

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

**Active Ingredient**

+-----------+------------------+-----+-----+-------+-------+--------+
| **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 that follow.*

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

+--------------------------------+-------------------------------------+
| **NIOSH form codes**           |                                     |
+--------------------------------+-------------------------------------+
| 01 Dust/powder (not            | 10 Flowable concentrate\            |
| pressurized)\                  | 11 Pressurized liquid/spray/fogger\ |
| 02 Granular/flake\             | 12 Ready-to-use liquid/solution\    |
| 03                             | 13 Other liquid formulation\        |
| Pellet/tablet/cake/briquette\  | 14 Pressurized gas/fumigant\        |
| 04 Wettable Powder/Dust\       | 15 Paint/liquid coating\            |
| 05 Impregnated material        | 16 Other\                           |
| (ant/plant stakes,animal       | 17 Soluble powder\                  |
| 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 Fungicide (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                    |                                      |
+-------------------------------+--------------------------------------+

Other Source If neither product nor chemical ingredient 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.

  ---------- ---------------------------- ------------ ------------ -------------- ------------------
  **Other    **Description of other       **Chemical   **Form\***   **Functional   **Poisoning
  ID**       source**                     class\***                 class\***      attribution^†^**

                                                                                   

                                                                                   

                                                                                   
  ---------- ---------------------------- ------------ ------------ -------------- ------------------

*\* 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.*

**Event Information---Comments**---**Chemical Agent Comments**

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

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

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

##  

## Exposure Information Screen---Incident Information

####### Incident Report Information

  ---------------- ----------------- -------- ---------- --------------- --------- ---------- ------------------
  **Exposure ID**                             **Report                                        
                                              date**                                          
                                              \_\_ \_\_                                       
                                              / \_\_                                          
                                              \_\_ /                                          
                                              \_\_ \_\_                                       
                                              \_\_ \_\_                                       

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

  **Report source                                        **Report source           **Report   
  1** \_\_ \_\_                                          2** \_\_ \_\_             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 02A-02Z or                                                                            
  020--029).*                                                                                 

  **Source codes**                                                                            

  **Code**         **Description**                                                            

  **01**           Physician report                                                           

  **02**           Poison control                                                             
                   center                                                                     

  **03**           Other health care                                                          
                   provider report                                                            
                   (including ER 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                                                                    
  ---------------- ----------------- -------- ---------- --------------- --------- ---------- ------------------

  -------------- ------------------------------------ -------- ----------------------------
  *Site of                                                     
  exposure*                                                    
  ***(*Enter                                                 
  code*)***                                                    

  **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 nonproduction agricultural     **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                                      
  -------------- ------------------------------------ -------- ----------------------------

#######  

####### Activity when exposed 

  ------------ -------------------------------------------------------------------
  **Activity   
  of case at   
  time of      
  exposure**   
  (*Enter    
  code*)       

  **01**       Applying pesticide

  **02**       Mixing/loading pesticide

  **03**       Transport or disposal of pesticide

  **04**       Repair or maintenance of pesticide application equipment

  **05**       Any combination of activities 01--04

  **06**       Involved in manufacture or formulation of pesticide

  **07**       Emergency response

  **08**       Routine work activity not involved with pesticide application
               (includes exposure to field residue)

  **09**       Routine indoor living activities not involved with pesticide
               application

  **10**       Routine outdoor living activities not involved with pesticide
               application

  **98**       Not applicable

  **99**       Unknown
  ------------ -------------------------------------------------------------------

**Others exposed**

+-----------------------------------------------------------------------+
| Were other persons possibly exposed? Yes No Unknown                |
|                                                                       |
| If Yes, How many? \_\_\_\_\_\_\_\_\_\_\_                              |
|                                                                       |
| Did any seek medical care? Yes No Unknown                          |
+-----------------------------------------------------------------------+
| *Use a separate sheet of paper to record names and contact            |
| information if appropriate.*                                          |
+-----------------------------------------------------------------------+

**Exposure address** *(That is, subject's location at time of exposure.
This may be the same as the case address or the event address.)*

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

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

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

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

  **FIPS**    \_\_ \_\_ \_\_ **County** \_\_ \_\_ \_\_

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

*Note: For cases reported multiple times, you can use the shortcut
buttons in SPIDER to either copy the existing address form the case
table, or if this is a new address, move this address to the case
table.*

+----------+------------------------+---+-------------------------------+
| *        |                        |   |                               |
| *Initial |                        |   |                               |
| t        |                        |   |                               |
| reatment |                        |   |                               |
| /HCP     |                        |   |                               |
| infor    |                        |   |                               |
| mation** |                        |   |                               |
+----------+------------------------+---+-------------------------------+
| **First  | Where was medical care |   |                               |
| care**   | first sought? (*Enter |   |                               |
|          | code*)                 |   |                               |
+----------+------------------------+---+-------------------------------+
|          | 1=Physician's office   |   | 5=No medical care sought      |
|          |                        |   |                               |
|          | 2=Emergency room       |   | 6=Other\                      |
|          |                        |   | 7=Employee health center      |
|          | 3=Hospital admissions  |   |                               |
|          |                        |   | 9=Unknown                     |
|          | 4=Advice of poison     |   |                               |
|          | control center         |   |                               |
+----------+------------------------+---+-------------------------------+
| **HCP    | Last                   |   |                               |
| name**   |                        |   |                               |
+----------+------------------------+---+-------------------------------+
|          | First                  |   |                               |
+----------+------------------------+---+-------------------------------+
| **Type** | Who provided care?     |   |                               |
|          | (*Enter code*)        |   |                               |
+----------+------------------------+---+-------------------------------+
|          | 1=Family physician     | 4 |                               |
|          |                        | = |                               |
|          | 2=Employer's           | C |                               |
|          | physician\             | o |                               |
|          | 3=Worker's Comp        | n |                               |
|          | physician              | s |                               |
|          |                        | u |                               |
|          |                        | l |                               |
|          |                        | t |                               |
|          |                        | i |                               |
|          |                        | n |                               |
|          |                        | g |                               |
|          |                        | s |                               |
|          |                        | p |                               |
|          |                        | e |                               |
|          |                        | c |                               |
|          |                        | i |                               |
|          |                        | a |                               |
|          |                        | l |                               |
|          |                        | i |                               |
|          |                        | s |                               |
|          |                        | t |                               |
|          |                        | \ |                               |
|          |                        | 5 |                               |
|          |                        | = |                               |
|          |                        | O |                               |
|          |                        | u |                               |
|          |                        | t |                               |
|          |                        | p |                               |
|          |                        | a |                               |
|          |                        | t |                               |
|          |                        | i |                               |
|          |                        | e |                               |
|          |                        | n |                               |
|          |                        | t |                               |
|          |                        | c |                               |
|          |                        | l |                               |
|          |                        | i |                               |
|          |                        | n |                               |
|          |                        | i |                               |
|          |                        | c |                               |
|          |                        |   |                               |
|          |                        | 9 |                               |
|          |                        | = |                               |
|          |                        | U |                               |
|          |                        | n |                               |
|          |                        | k |                               |
|          |                        | n |                               |
|          |                        | o |                               |
|          |                        | w |                               |
|          |                        | n |                               |
+----------+------------------------+---+-------------------------------+
|          | **Chart location**     |   | **Work location**             |
+----------+------------------------+---+-------------------------------+
| *        |                        |   |                               |
| *Address |                        |   |                               |
| 1**      |                        |   |                               |
+----------+------------------------+---+-------------------------------+
| *        |                        |   |                               |
| *Address |                        |   |                               |
| 2**      |                        |   |                               |
+----------+------------------------+---+-------------------------------+
| **City** |                        |   |                               |
+----------+------------------------+---+-------------------------------+
| *        | \_\_\_ \_\_\_          |   | \_\_\_ \_\_\_                 |
| *State** |                        |   |                               |
+----------+------------------------+---+-------------------------------+
| **ZIP**  | \_\_\_ \_\_\_ \_\_\_   |   | \_\_\_ \_\_\_ \_\_\_ \_\_\_   |
|          | \_\_\_ \_\_\_          |   | \_\_\_                        |
+----------+------------------------+---+-------------------------------+
| *        | ( \_\_ \_\_ \_\_ )     |   | ( \_\_ \_\_ \_\_ ) \_\_ \_\_  |
| *Phone** | \_\_ \_\_ \_\_-- \_\_  |   | \_\_ -- \_\_ \_\_ \_\_ \_\_   |
|          | \_\_ \_\_ \_\_         |   |                               |
+----------+------------------------+---+-------------------------------+

**Exposure Information Screen---Medical Information**

+-------------------+-------------------+-----------+-----------------+
| **\[ \] Diagnosis |                   |           |                 |
| made by HCP**     |                   |           |                 |
| (*Checked=Yes*)   |                   |           |                 |
+-------------------+-------------------+-----------+-----------------+
| **Diagnosis**     |                   |           |                 |
+-------------------+-------------------+-----------+-----------------+
| **ICD9**          | \_\_ \_\_ \_\_ .  |           |                 |
|                   | \_\_ \_\_         |           |                 |
+-------------------+-------------------+-----------+-----------------+
| **Summary**       |                   |           |                 |
+-------------------+-------------------+-----------+-----------------+
| **\[ \]           |                   |           |                 |
| Hospitalized**    |                   |           |                 |
| (*Checked=Yes*)   |                   |           |                 |
+-------------------+-------------------+-----------+-----------------+
| **Admit date**    | \_\_ \_\_ / \_\_  | **        | \_\_ \_\_ /     |
|                   | \_\_ / \_\_ \_\_  | Discharge | \_\_ \_\_ /     |
|                   |                   | date**    | \_\_ \_\_       |
+-------------------+-------------------+-----------+-----------------+
| **Length of       | \_\_ \_\_ \_\_    | Coding    |                 |
| stay**            | (days)            | 997 if \> |                 |
|                   |                   | 996 days  |                 |
|                   |                   |           |                 |
|                   |                   | 998=NA,   |                 |
|                   |                   | not       |                 |
|                   |                   | hos       |                 |
|                   |                   | pitalized |                 |
|                   |                   |           |                 |
|                   |                   | 99        |                 |
|                   |                   | 9=Unknown |                 |
+-------------------+-------------------+-----------+-----------------+

> **Facility where hospitalized**
>
> Facility name
>
> Facility address
>
> Treating physician

+------------+---+---+------+------------+-----------+---+---------------------+
| *          |   |   |      |            |           |   | **Coding for        |
| *Condition |   |   |      |            |           |   | conditions**        |
| present at |   |   |      |            |           |   |                     |
| time of    |   |   |      |            |           |   |                     |
| e          |   |   |      |            |           |   |                     |
| xposure?** |   |   |      |            |           |   |                     |
| *(Circle   |   |   |      |            |           |   |                     |
| one for    |   |   |      |            |           |   |                     |
| each       |   |   |      |            |           |   |                     |
| co         |   |   |      |            |           |   |                     |
| ndition.)* |   |   |      |            |           |   |                     |
+------------+---+---+------+------------+-----------+---+---------------------+
| **         |   |   |      | 1 2 3 4 5  |           | > |                     |
| Pregnant** |   |   |      | 9          |           |   |                     |
|            |   |   |      |            |           | 1 |                     |
|            |   |   |      |            |           | = |                     |
|            |   |   |      |            |           | D |                     |
|            |   |   |      |            |           | o |                     |
|            |   |   |      |            |           | c |                     |
|            |   |   |      |            |           | t |                     |
|            |   |   |      |            |           | o |                     |
|            |   |   |      |            |           | r |                     |
|            |   |   |      |            |           | > |                     |
|            |   |   |      |            |           |   |                     |
|            |   |   |      |            |           | r |                     |
|            |   |   |      |            |           | e |                     |
|            |   |   |      |            |           | p |                     |
|            |   |   |      |            |           | o |                     |
|            |   |   |      |            |           | r |                     |
|            |   |   |      |            |           | t |                     |
|            |   |   |      |            |           | e |                     |
|            |   |   |      |            |           | d |                     |
|            |   |   |      |            |           | > |                     |
|            |   |   |      |            |           | > |                     |
|            |   |   |      |            |           |   |                     |
|            |   |   |      |            |           | 2 |                     |
|            |   |   |      |            |           | = |                     |
|            |   |   |      |            |           | E |                     |
|            |   |   |      |            |           | x |                     |
|            |   |   |      |            |           | p |                     |
|            |   |   |      |            |           | o |                     |
|            |   |   |      |            |           | s |                     |
|            |   |   |      |            |           | e |                     |
|            |   |   |      |            |           | d |                     |
|            |   |   |      |            |           | > |                     |
|            |   |   |      |            |           |   |                     |
|            |   |   |      |            |           | p |                     |
|            |   |   |      |            |           | e |                     |
|            |   |   |      |            |           | r |                     |
|            |   |   |      |            |           | s |                     |
|            |   |   |      |            |           | o |                     |
|            |   |   |      |            |           | n |                     |
|            |   |   |      |            |           | > |                     |
|            |   |   |      |            |           |   |                     |
|            |   |   |      |            |           | r |                     |
|            |   |   |      |            |           | e |                     |
|            |   |   |      |            |           | p |                     |
|            |   |   |      |            |           | o |                     |
|            |   |   |      |            |           | r |                     |
|            |   |   |      |            |           | t |                     |
|            |   |   |      |            |           | e |                     |
|            |   |   |      |            |           | d |                     |
|            |   |   |      |            |           | > |                     |
|            |   |   |      |            |           | > |                     |
|            |   |   |      |            |           |   |                     |
|            |   |   |      |            |           | 3 |                     |
|            |   |   |      |            |           | = |                     |
|            |   |   |      |            |           | B |                     |
|            |   |   |      |            |           | o |                     |
|            |   |   |      |            |           | t |                     |
|            |   |   |      |            |           | h |                     |
|            |   |   |      |            |           | > |                     |
|            |   |   |      |            |           |   |                     |
|            |   |   |      |            |           | d |                     |
|            |   |   |      |            |           | o |                     |
|            |   |   |      |            |           | c |                     |
|            |   |   |      |            |           | t |                     |
|            |   |   |      |            |           | o |                     |
|            |   |   |      |            |           | r |                     |
|            |   |   |      |            |           | > |                     |
|            |   |   |      |            |           |   |                     |
|            |   |   |      |            |           | a |                     |
|            |   |   |      |            |           | n |                     |
|            |   |   |      |            |           | d |                     |
|            |   |   |      |            |           | > |                     |
|            |   |   |      |            |           |   |                     |
|            |   |   |      |            |           | p |                     |
|            |   |   |      |            |           | e |                     |
|            |   |   |      |            |           | r |                     |
|            |   |   |      |            |           | s |                     |
|            |   |   |      |            |           | o |                     |
|            |   |   |      |            |           | n |                     |
|            |   |   |      |            |           | > |                     |
|            |   |   |      |            |           |   |                     |
|            |   |   |      |            |           | r |                     |
|            |   |   |      |            |           | e |                     |
|            |   |   |      |            |           | p |                     |
|            |   |   |      |            |           | o |                     |
|            |   |   |      |            |           | r |                     |
|            |   |   |      |            |           | t |                     |
|            |   |   |      |            |           | e |                     |
|            |   |   |      |            |           | d |                     |
|            |   |   |      |            |           | > |                     |
|            |   |   |      |            |           | > |                     |
|            |   |   |      |            |           |   |                     |
|            |   |   |      |            |           | 4 |                     |
|            |   |   |      |            |           | = |                     |
|            |   |   |      |            |           | C |                     |
|            |   |   |      |            |           | o |                     |
|            |   |   |      |            |           | n |                     |
|            |   |   |      |            |           | d |                     |
|            |   |   |      |            |           | i |                     |
|            |   |   |      |            |           | t |                     |
|            |   |   |      |            |           | i |                     |
|            |   |   |      |            |           | o |                     |
|            |   |   |      |            |           | n |                     |
|            |   |   |      |            |           | > |                     |
|            |   |   |      |            |           |   |                     |
|            |   |   |      |            |           | w |                     |
|            |   |   |      |            |           | a |                     |
|            |   |   |      |            |           | s |                     |
|            |   |   |      |            |           | > |                     |
|            |   |   |      |            |           |   |                     |
|            |   |   |      |            |           | a |                     |
|            |   |   |      |            |           | b |                     |
|            |   |   |      |            |           | s |                     |
|            |   |   |      |            |           | e |                     |
|            |   |   |      |            |           | n |                     |
|            |   |   |      |            |           | t |                     |
|            |   |   |      |            |           | > |                     |
|            |   |   |      |            |           | > |                     |
|            |   |   |      |            |           |   |                     |
|            |   |   |      |            |           | 5 |                     |
|            |   |   |      |            |           | = |                     |
|            |   |   |      |            |           | N |                     |
|            |   |   |      |            |           | o |                     |
|            |   |   |      |            |           | t |                     |
|            |   |   |      |            |           | > |                     |
|            |   |   |      |            |           |   |                     |
|            |   |   |      |            |           | r |                     |
|            |   |   |      |            |           | e |                     |
|            |   |   |      |            |           | p |                     |
|            |   |   |      |            |           | o |                     |
|            |   |   |      |            |           | r |                     |
|            |   |   |      |            |           | t |                     |
|            |   |   |      |            |           | e |                     |
|            |   |   |      |            |           | d |                     |
|            |   |   |      |            |           | > |                     |
|            |   |   |      |            |           | > |                     |
|            |   |   |      |            |           |   |                     |
|            |   |   |      |            |           | 9 |                     |
|            |   |   |      |            |           | = |                     |
|            |   |   |      |            |           | U |                     |
|            |   |   |      |            |           | n |                     |
|            |   |   |      |            |           | k |                     |
|            |   |   |      |            |           | n |                     |
|            |   |   |      |            |           | o |                     |
|            |   |   |      |            |           | w |                     |
|            |   |   |      |            |           | n |                     |
+------------+---+---+------+------------+-----------+---+---------------------+
| **A        |   |   |      | 1 2 3 4 5  |           |   |                     |
| llergies** |   |   |      | 9          |           |   |                     |
+------------+---+---+------+------------+-----------+---+---------------------+
| **Asthma** |   |   |      | 1 2 3 4 5  |           |   |                     |
|            |   |   |      | 9          |           |   |                     |
+------------+---+---+------+------------+-----------+---+---------------------+
| **Acquired |   |   |      | 1 2 3 4 5  |           |   |                     |
| chemical   |   |   |      | 9          |           |   |                     |
| int        |   |   |      |            |           |   |                     |
| olerance** |   |   |      |            |           |   |                     |
+------------+---+---+------+------------+-----------+---+---------------------+
| **Other**  |   |   |      |            |           |   |                     |
| (*Enter    |   |   |      |            |           |   |                     |
| condition  |   |   |      |            |           |   |                     |
| and        |   |   |      |            |           |   |                     |
| code.)*    |   |   |      |            |           |   |                     |
+------------+---+---+------+------------+-----------+---+---------------------+
| *          |   | > |      |            |           |   |                     |
| *Outcome** |   |   |      |            |           |   |                     |
|           |   | 1 |      |            |           |   |                     |
|            |   | = |      |            |           |   |                     |
|            |   | > |      |            |           |   |                     |
|            |   |   |      |            |           |   |                     |
|            |   | F |      |            |           |   |                     |
|            |   | a |      |            |           |   |                     |
|            |   | t |      |            |           |   |                     |
|            |   | a |      |            |           |   |                     |
|            |   | l |      |            |           |   |                     |
|            |   | , |      |            |           |   |                     |
|            |   | > |      |            |           |   |                     |
|            |   |   |      |            |           |   |                     |
|            |   | p |      |            |           |   |                     |
|            |   | e |      |            |           |   |                     |
|            |   | s |      |            |           |   |                     |
|            |   | t |      |            |           |   |                     |
|            |   | i |      |            |           |   |                     |
|            |   | c |      |            |           |   |                     |
|            |   | i |      |            |           |   |                     |
|            |   | d |      |            |           |   |                     |
|            |   | e |      |            |           |   |                     |
|            |   | - |      |            |           |   |                     |
|            |   | r |      |            |           |   |                     |
|            |   | e |      |            |           |   |                     |
|            |   | l |      |            |           |   |                     |
|            |   | a |      |            |           |   |                     |
|            |   | t |      |            |           |   |                     |
|            |   | e |      |            |           |   |                     |
|            |   | d |      |            |           |   |                     |
|            |   | > |      |            |           |   |                     |
|            |   |   |      |            |           |   |                     |
|            |   | 8 |      |            |           |   |                     |
|            |   | = |      |            |           |   |                     |
|            |   | N |      |            |           |   |                     |
|            |   | o |      |            |           |   |                     |
|            |   | t |      |            |           |   |                     |
|            |   | > |      |            |           |   |                     |
|            |   |   |      |            |           |   |                     |
|            |   | a |      |            |           |   |                     |
|            |   | p |      |            |           |   |                     |
|            |   | p |      |            |           |   |                     |
|            |   | l |      |            |           |   |                     |
|            |   | i |      |            |           |   |                     |
|            |   | c |      |            |           |   |                     |
|            |   | a |      |            |           |   |                     |
|            |   | b |      |            |           |   |                     |
|            |   | l |      |            |           |   |                     |
|            |   | e |      |            |           |   |                     |
|            |   | > |      |            |           |   |                     |
|            |   |   |      |            |           |   |                     |
|            |   | ( |      |            |           |   |                     |
|            |   | n |      |            |           |   |                     |
|            |   | o |      |            |           |   |                     |
|            |   | t |      |            |           |   |                     |
|            |   | > |      |            |           |   |                     |
|            |   |   |      |            |           |   |                     |
|            |   | f |      |            |           |   |                     |
|            |   | a |      |            |           |   |                     |
|            |   | t |      |            |           |   |                     |
|            |   | a |      |            |           |   |                     |
|            |   | l |      |            |           |   |                     |
|            |   | ) |      |            |           |   |                     |
|            |   | > |      |            |           |   |                     |
|            |   | > |      |            |           |   |                     |
|            |   |   |      |            |           |   |                     |
|            |   | 2 |      |            |           |   |                     |
|            |   | = |      |            |           |   |                     |
|            |   | > |      |            |           |   |                     |
|            |   |   |      |            |           |   |                     |
|            |   | F |      |            |           |   |                     |
|            |   | a |      |            |           |   |                     |
|            |   | t |      |            |           |   |                     |
|            |   | a |      |            |           |   |                     |
|            |   | l |      |            |           |   |                     |
|            |   | , |      |            |           |   |                     |
|            |   | > |      |            |           |   |                     |
|            |   |   |      |            |           |   |                     |
|            |   | n |      |            |           |   |                     |
|            |   | o |      |            |           |   |                     |
|            |   | t |      |            |           |   |                     |
|            |   | > |      |            |           |   |                     |
|            |   |   |      |            |           |   |                     |
|            |   | p |      |            |           |   |                     |
|            |   | e |      |            |           |   |                     |
|            |   | s |      |            |           |   |                     |
|            |   | t |      |            |           |   |                     |
|            |   | i |      |            |           |   |                     |
|            |   | c |      |            |           |   |                     |
|            |   | i |      |            |           |   |                     |
|            |   | d |      |            |           |   |                     |
|            |   | e |      |            |           |   |                     |
|            |   | - |      |            |           |   |                     |
|            |   | r |      |            |           |   |                     |
|            |   | e |      |            |           |   |                     |
|            |   | l |      |            |           |   |                     |
|            |   | a |      |            |           |   |                     |
|            |   | t |      |            |           |   |                     |
|            |   | e |      |            |           |   |                     |
|            |   | d |      |            |           |   |                     |
|            |   | > |      |            |           |   |                     |
|            |   |   |      |            |           |   |                     |
|            |   | 9 |      |            |           |   |                     |
|            |   | = |      |            |           |   |                     |
|            |   | U |      |            |           |   |                     |
|            |   | n |      |            |           |   |                     |
|            |   | k |      |            |           |   |                     |
|            |   | n |      |            |           |   |                     |
|            |   | o |      |            |           |   |                     |
|            |   | w |      |            |           |   |                     |
|            |   | n |      |            |           |   |                     |
|            |   | > |      |            |           |   |                     |
|            |   | > |      |            |           |   |                     |
|            |   |   |      |            |           |   |                     |
|            |   | 3 |      |            |           |   |                     |
|            |   | = |      |            |           |   |                     |
|            |   | F |      |            |           |   |                     |
|            |   | a |      |            |           |   |                     |
|            |   | t |      |            |           |   |                     |
|            |   | a |      |            |           |   |                     |
|            |   | l |      |            |           |   |                     |
|            |   | , |      |            |           |   |                     |
|            |   | > |      |            |           |   |                     |
|            |   |   |      |            |           |   |                     |
|            |   | r |      |            |           |   |                     |
|            |   | e |      |            |           |   |                     |
|            |   | l |      |            |           |   |                     |
|            |   | a |      |            |           |   |                     |
|            |   | t |      |            |           |   |                     |
|            |   | i |      |            |           |   |                     |
|            |   | o |      |            |           |   |                     |
|            |   | n |      |            |           |   |                     |
|            |   | > |      |            |           |   |                     |
|            |   |   |      |            |           |   |                     |
|            |   | u |      |            |           |   |                     |
|            |   | n |      |            |           |   |                     |
|            |   | k |      |            |           |   |                     |
|            |   | n |      |            |           |   |                     |
|            |   | o |      |            |           |   |                     |
|            |   | w |      |            |           |   |                     |
|            |   | n |      |            |           |   |                     |
+------------+---+---+------+------------+-----------+---+---------------------+
|            |   |   |      |            |           |   |                     |
+------------+---+---+------+------------+-----------+---+---------------------+
| **Lost     | > |   |      |            |           |   |                     |
| time**   |   |   |      |            |           |   |                     |
|            | 1 |   |      |            |           |   |                     |
|            | = |   |      |            |           |   |                     |
|            | Y |   |      |            |           |   |                     |
|            | e |   |      |            |           |   |                     |
|            | s |   |      |            |           |   |                     |
|            | , |   |      |            |           |   |                     |
|            | > |   |      |            |           |   |                     |
|            |   |   |      |            |           |   |                     |
|            | o |   |      |            |           |   |                     |
|            | n |   |      |            |           |   |                     |
|            | e |   |      |            |           |   |                     |
|            | > |   |      |            |           |   |                     |
|            |   |   |      |            |           |   |                     |
|            | o |   |      |            |           |   |                     |
|            | r |   |      |            |           |   |                     |
|            | > |   |      |            |           |   |                     |
|            |   |   |      |            |           |   |                     |
|            | m |   |      |            |           |   |                     |
|            | o |   |      |            |           |   |                     |
|            | r |   |      |            |           |   |                     |
|            | e |   |      |            |           |   |                     |
|            | > |   |      |            |           |   |                     |
|            |   |   |      |            |           |   |                     |
|            | d |   |      |            |           |   |                     |
|            | a |   |      |            |           |   |                     |
|            | y |   |      |            |           |   |                     |
|            | s |   |      |            |           |   |                     |
|            | > |   |      |            |           |   |                     |
|            |   |   |      |            |           |   |                     |
|            | l |   |      |            |           |   |                     |
|            | o |   |      |            |           |   |                     |
|            | s |   |      |            |           |   |                     |
|            | t |   |      |            |           |   |                     |
|            | > |   |      |            |           |   |                     |
|            |   |   |      |            |           |   |                     |
|            | f |   |      |            |           |   |                     |
|            | r |   |      |            |           |   |                     |
|            | o |   |      |            |           |   |                     |
|            | m |   |      |            |           |   |                     |
|            | > |   |      |            |           |   |                     |
|            |   |   |      |            |           |   |                     |
|            | w |   |      |            |           |   |                     |
|            | o |   |      |            |           |   |                     |
|            | r |   |      |            |           |   |                     |
|            | k |   |      |            |           |   |                     |
+------------+---+---+------+------------+-----------+---+---------------------+
|            | > |   |      |            |           |   |                     |
|            |   |   |      |            |           |   |                     |
|            | 2 |   |      |            |           |   |                     |
|            | = |   |      |            |           |   |                     |
|            | N |   |      |            |           |   |                     |
|            | o |   |      |            |           |   |                     |
|            | , |   |      |            |           |   |                     |
|            | > |   |      |            |           |   |                     |
|            |   |   |      |            |           |   |                     |
|            | n |   |      |            |           |   |                     |
|            | o |   |      |            |           |   |                     |
|            | > |   |      |            |           |   |                     |
|            |   |   |      |            |           |   |                     |
|            | t |   |      |            |           |   |                     |
|            | i |   |      |            |           |   |                     |
|            | m |   |      |            |           |   |                     |
|            | e |   |      |            |           |   |                     |
|            | > |   |      |            |           |   |                     |
|            |   |   |      |            |           |   |                     |
|            | l |   |      |            |           |   |                     |
|            | o |   |      |            |           |   |                     |
|            | s |   |      |            |           |   |                     |
|            | t |   |      |            |           |   |                     |
+------------+---+---+------+------------+-----------+---+---------------------+
|            | > |   |      |            |           |   |                     |
|            |   |   |      |            |           |   |                     |
|            | 3 |   |      |            |           |   |                     |
|            | = |   |      |            |           |   |                     |
|            | U |   |      |            |           |   |                     |
|            | n |   |      |            |           |   |                     |
|            | e |   |      |            |           |   |                     |
|            | m |   |      |            |           |   |                     |
|            | p |   |      |            |           |   |                     |
|            | l |   |      |            |           |   |                     |
|            | o |   |      |            |           |   |                     |
|            | y |   |      |            |           |   |                     |
|            | e |   |      |            |           |   |                     |
|            | d |   |      |            |           |   |                     |
|            | , |   |      |            |           |   |                     |
|            | > |   |      |            |           |   |                     |
|            |   |   |      |            |           |   |                     |
|            | l |   |      |            |           |   |                     |
|            | o |   |      |            |           |   |                     |
|            | s |   |      |            |           |   |                     |
|            | t |   |      |            |           |   |                     |
|            | > |   |      |            |           |   |                     |
|            |   |   |      |            |           |   |                     |
|            | 1 |   |      |            |           |   |                     |
|            | > |   |      |            |           |   |                     |
|            |   |   |      |            |           |   |                     |
|            | o |   |      |            |           |   |                     |
|            | r |   |      |            |           |   |                     |
|            | > |   |      |            |           |   |                     |
|            |   |   |      |            |           |   |                     |
|            | m |   |      |            |           |   |                     |
|            | o |   |      |            |           |   |                     |
|            | r |   |      |            |           |   |                     |
|            | e |   |      |            |           |   |                     |
|            | > |   |      |            |           |   |                     |
|            |   |   |      |            |           |   |                     |
|            | d |   |      |            |           |   |                     |
|            | a |   |      |            |           |   |                     |
|            | y |   |      |            |           |   |                     |
|            | s |   |      |            |           |   |                     |
|            | > |   |      |            |           |   |                     |
|            |   |   |      |            |           |   |                     |
|            | f |   |      |            |           |   |                     |
|            | r |   |      |            |           |   |                     |
|            | o |   |      |            |           |   |                     |
|            | m |   |      |            |           |   |                     |
|            | > |   |      |            |           |   |                     |
|            |   |   |      |            |           |   |                     |
|            | s |   |      |            |           |   |                     |
|            | c |   |      |            |           |   |                     |
|            | h |   |      |            |           |   |                     |
|            | o |   |      |            |           |   |                     |
|            | o |   |      |            |           |   |                     |
|            | l |   |      |            |           |   |                     |
|            | > |   |      |            |           |   |                     |
|            |   |   |      |            |           |   |                     |
|            | o |   |      |            |           |   |                     |
|            | r |   |      |            |           |   |                     |
|            | > |   |      |            |           |   |                     |
|            |   |   |      |            |           |   |                     |
|            | r |   |      |            |           |   |                     |
|            | e |   |      |            |           |   |                     |
|            | g |   |      |            |           |   |                     |
|            | u |   |      |            |           |   |                     |
|            | l |   |      |            |           |   |                     |
|            | a |   |      |            |           |   |                     |
|            | r |   |      |            |           |   |                     |
|            | > |   |      |            |           |   |                     |
|            |   |   |      |            |           |   |                     |
|            | a |   |      |            |           |   |                     |
|            | c |   |      |            |           |   |                     |
|            | t |   |      |            |           |   |                     |
|            | i |   |      |            |           |   |                     |
|            | v |   |      |            |           |   |                     |
|            | i |   |      |            |           |   |                     |
|            | t |   |      |            |           |   |                     |
|            | i |   |      |            |           |   |                     |
|            | e |   |      |            |           |   |                     |
|            | s |   |      |            |           |   |                     |
+------------+---+---+------+------------+-----------+---+---------------------+
|            | > |   |      |            |           |   |                     |
|            |   |   |      |            |           |   |                     |
|            | 9 |   |      |            |           |   |                     |
|            | = |   |      |            |           |   |                     |
|            | U |   |      |            |           |   |                     |
|            | n |   |      |            |           |   |                     |
|            | k |   |      |            |           |   |                     |
|            | n |   |      |            |           |   |                     |
|            | o |   |      |            |           |   |                     |
|            | w |   |      |            |           |   |                     |
|            | n |   |      |            |           |   |                     |
+------------+---+---+------+------------+-----------+---+---------------------+
| **Total    | \ |   |      |            |           |   |                     |
| time       | _ |   |      |            |           |   |                     |
| lost**     | \ |   |      |            |           |   |                     |
|            | _ |   |      |            |           |   |                     |
|            | \ |   |      |            |           |   |                     |
|            | _ |   |      |            |           |   |                     |
|            | \ |   |      |            |           |   |                     |
|            | _ |   |      |            |           |   |                     |
|            | \ |   |      |            |           |   |                     |
|            | _ |   |      |            |           |   |                     |
|            | \ |   |      |            |           |   |                     |
|            | _ |   |      |            |           |   |                     |
|            | \ |   |      |            |           |   |                     |
|            | _ |   |      |            |           |   |                     |
|            | \ |   |      |            |           |   |                     |
|            | _ |   |      |            |           |   |                     |
|            | \ |   |      |            |           |   |                     |
|            | _ |   |      |            |           |   |                     |
|            | * |   |      |            |           |   |                     |
|            | * |   |      |            |           |   |                     |
|            | . |   |      |            |           |   |                     |
|            | * |   |      |            |           |   |                     |
|            | * |   |      |            |           |   |                     |
|            | \ |   |      |            |           |   |                     |
|            | _ |   |      |            |           |   |                     |
|            | \ |   |      |            |           |   |                     |
|            | _ |   |      |            |           |   |                     |
|            | \ |   |      |            |           |   |                     |
|            | _ |   |      |            |           |   |                     |
|            | \ |   |      |            |           |   |                     |
|            | _ |   |      |            |           |   |                     |
|            | \ |   |      |            |           |   |                     |
|            | _ |   |      |            |           |   |                     |
|            | \ |   |      |            |           |   |                     |
|            | _ |   |      |            |           |   |                     |
|            | d |   |      |            |           |   |                     |
|            | a |   |      |            |           |   |                     |
|            | y |   |      |            |           |   |                     |
|            | s |   |      |            |           |   |                     |
+------------+---+---+------+------------+-----------+---+---------------------+
| **Followup |   |   |     |            | **When?** |   | \_\_ \_\_ / \_\_    |
| needed?**  |   |   | *C   |            |           |   | \_\_ / \_\_ \_\_    |
|            |   |   | heck |            |           |   |                     |
|            |   |   | if   |            |           |   |                     |
|            |   |   | y    |            |           |   |                     |
|            |   |   | es.* |            |           |   |                     |
+------------+---+---+------+------------+-----------+---+---------------------+

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

+--------+----------+-------------------+-----------------------------+
| *      |          | Yes No Unknown |                             |
| *Other |          |                   |                             |
| biol   |          |                   |                             |
| ogical |          |                   |                             |
| te     |          |                   |                             |
| sts?** |          |                   |                             |
+--------+----------+-------------------+-----------------------------+
|        | **Test   |                   | **Test 2**                  |
|        | 1**      |                   |                             |
+--------+----------+-------------------+-----------------------------+
| **Test |          |                   |                             |
| type** |          |                   |                             |
+--------+----------+-------------------+-----------------------------+
| **Draw | \_\_     |                   | \_\_ \_\_ / \_\_ \_\_ /     |
| date** | \_\_ /   |                   | \_\_ \_\_                   |
|        | \_\_     |                   |                             |
|        | \_\_ /   |                   |                             |
|        | \_\_     |                   |                             |
|        | \_\_     |                   |                             |
+--------+----------+-------------------+-----------------------------+
| **N    |          |                   |                             |
| umeric |          |                   |                             |
| re     |          |                   |                             |
| sult** |          |                   |                             |
+--------+----------+-------------------+-----------------------------+
| **An   |         |                   |  Abnormal  Normal         |
| alysis | Abnormal |                   |                             |
| re     |  Normal |                   |  Not applicable  Unknown  |
| sult** |          |                   |                             |
|        |  Not    |                   |                             |
|        | ap       |                   |                             |
|        | plicable |                   |                             |
|        |         |                   |                             |
|        | Unknown  |                   |                             |
+--------+----------+-------------------+-----------------------------+

Notes

**Exposure Information Screen---Cholinesterase Results**

####### Coding guidance for completing table of results

**Option 1 Detailed version.**

***Option 2 Required minimum.** Enter single test response for **Test
type** and **Result type**, the only required fields.*

<table>
<colgroup>
<col style="width: 7%" />
<col style="width: 2%" />
<col style="width: 10%" />
<col style="width: 8%" />
<col style="width: 9%" />
<col style="width: 16%" />
<col style="width: 11%" />
<col style="width: 9%" />
<col style="width: 11%" />
<col style="width: 12%" />
</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>
</tbody>
</table>

## 

## Exposure Information Screen---Narrative

####### Brief exposure description (120 characters)

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

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

***Exposure narrative** Include details of person's activity or
situation that resulted in the exposure. Include notes on medical,
exposure, and follow-up activity information. Continue on a separate
sheet if necessary.*

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

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

**Exposure Information Screen---**Nature of Exposure

  ---------------- ----------- ------------ ------------- ----------- -----------
  **Type of                                 **Route of                
  exposure**                                exposure**                

  \[ \] Drift      \[ \]       \[ \]        \[ \] Dermal  \[ \]       \[ \]
                   Indoor Air  Contact                    Ingestion   Ocular

  \[ \] Spray      \[ \]       \[ \]        \[ \]         \[ \]       \[ \]
                   Surface     Unknown      Inhalation    Injection   Unknown

  \[ \] Other                                                         

  **Intentional?                                                      
  \_\_\_** Coding                                                     
  **:** 1=Yes,                                                        
  suspected                                                           
  intentional                                                         
  2=No,                                                               
  unintentional                                                       
  9=Unknown                                                           
  ---------------- ----------- ------------ ------------- ----------- -----------

  ------------------------------- -------------------------------------------------------------
  Date first exposed\* \_\_       Time \_\_ \_\_ \_\_ \_\_ (24 Hour Clock)
  \_\_/\_\_ \_\_/\_\_ \_\_        

  Date symptom onset\* \_\_       Time \_\_ \_\_ \_\_ \_\_ (24 Hour Clock)
  \_\_/\_\_ \_\_/\_\_ \_\_        

  Other date \_\_ \_\_/\_\_       Other Date
  \_\_/\_\_ \_\_                  Description\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
  ------------------------------- -------------------------------------------------------------

***\*** At least one of the following dates must be entered: first
exposure, symptom onset or laboratory test (page 12).*

**Exposure Information Screen---Narrative**

####### *Date Comments. Indicate any notes on date of exposure onset, report, or lab test pertinent to understanding case chronology.*

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

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

**Exposure Information Screen---**Occupational Information

+-----------------------------------+------------+---------------------+
| **Work related?** 1=Yes          |            |                     |
| 2=Possibly 3=No 4=Unknown 5=Not   |            |                     |
| Applicable                        |            |                     |
|                                   |            |                     |
| *If answer is 3 or 5, skip to PPE |            |                     |
| Use below.*                       |            |                     |
+-----------------------------------+------------+---------------------+
| **COC** \_\_ \_\_ \_\_ **CIC**    |            |                     |
| \_\_ \_\_ \_\_                    |            |                     |
+-----------------------------------+------------+---------------------+
| **Job title** 60 characters       | **COC      |                     |
|                                   | title**    |                     |
+-----------------------------------+------------+---------------------+
|                                   |            |                     |
+-----------------------------------+------------+---------------------+
|                                   |            |                     |
+-----------------------------------+------------+---------------------+
| **Occupation narrative** 125      | **CIC      |                     |
| Characters                        | title**    |                     |
+-----------------------------------+------------+---------------------+
|                                   |            |                     |
+-----------------------------------+------------+---------------------+
|                                   |            |                     |
+-----------------------------------+------------+---------------------+
| **Industry at Time of Exposure**  |            |                     |
| 100 Characters                    |            |                     |
+-----------------------------------+------------+---------------------+

**Employer Information---**Employer Screen

  -------------------- -------- -------- --------- --------- ---------- -------------------------
  **Employer                    Name                                    
  ID**\_\_\_\_\_\_\_                                                    

  **Address Line 1**                                                    

  **Address Line 2**                                                    

  **City**                                                              

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

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

  **Contact**                                                           

                                         **NAICS             \_\_ \_\_  
                                         Code**              \_\_ \_\_  
                                                             \_\_ \_\_  
                                                             \_\_ \_\_  
  -------------------- -------- -------- --------- --------- ---------- -------------------------

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

+-----------------------------------+----------------------------------+
| ####### PP                        |                                  |
| E Use (*Complete this section aft |                                  |
| er interview using codes below.*) |                                  |
+-----------------------------------+----------------------------------+
| 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 requirements)     | 8=Not applicable                 |
+-----------------------------------+----------------------------------+
| 4=Not used (some PPE required)    | 9=Unknown                        |
+-----------------------------------+----------------------------------+

**Specific PPE Used**  

Codes: 1=Yes, used 2=No, not used 8=Not applicable 9=Unknown

*Check one box for each form of PPE.*

  ------------- --------------------- --------------- --------------------
  Supplied Air  1  2  8  9        Natural Gloves  1  2  8  9 

  Respirator    1  2  8  9        Synthetic       1  2  8  9 
                                      Gloves          

  Dust Mask     1  2  8  9        Goggles         1  2  8  9 

  Boots         1  2  8  9        Engineering     1  2  8  9 

  Clothing      1  2  8  9                        
  ------------- --------------------- --------------- --------------------

## Worker Protection Standard

  -----------------------------------------------------------------------
  ***If agricultural worker or pesticide handler (farm, nursery or
  forestry), for each question indicate if response is (Y)Yes (N) N o (U)
  Unknown/Not asked by circling the letter for the response.***

  a\. Did this incident involve entering a treated area (including field
  or greenhouse)? **Y N U**

  b\. If yes, did your employer/crew leader tell you how soon you could
  go into the area after it was treated? **Y N U**
  -----------------------------------------------------------------------

##  

## Exposure Information Screen---Signs and Symptoms

***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 18. 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  | **     | **Abs | *   |
|             |                        | tient | Doctor | ent** | *Fi |
|             |                        | repor | repo   |       | nal |
|             |                        | ted** | rted** |       | 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     |       |        |       |     |
+-------------+------------------------+-------+--------+-------+-----+
|             | *Oliguria/anuria*      |       |        |       |     |
+-------------+------------------------+-------+--------+-------+-----+
|             | Blood in urine         |       |        |       |     |
+-------------+------------------------+-------+--------+-------+-----+
|             | *Proteinuria*          |       |        |       |     |
+-------------+------------------------+-------+--------+-------+-----+
|             | Other\_\_\_\_          |       |        |       |     |
|             | \_\_\_\_\_\_\_\_\_\_\_ |       |        |       |     |
|             | \_\_\_\_\_\_\_\_\_\_\_ |       |        |       |     |
+-------------+------------------------+-------+--------+-------+-----+
| **Neu       | Altered taste          |       |        |       |     |
| rological** |                        |       |        |       |     |
+-------------+------------------------+-------+--------+-------+-----+
|             | Anxiety/hype           |       |        |       |     |
|             | ractivity/irritability |       |        |       |     |
+-------------+------------------------+-------+--------+-------+-----+
|             | Ataxia /trouble        |       |        |       |     |
|             | walking                |       |        |       |     |
+-------------+------------------------+-------+--------+-------+-----+
|             | Blurred vision         |       |        |       |     |
+-------------+------------------------+-------+--------+-------+-----+
|             | Coma                   |       |        |       |     |
+-------------+------------------------+-------+--------+-------+-----+
|             | Confusion              |       |        |       |     |
+-------------+------------------------+-------+--------+-------+-----+
|             | Diaphoresis (profuse   |       |        |       |     |
|             | sweating)              |       |        |       |     |
+-------------+------------------------+-------+--------+-------+-----+
|             | Dizziness              |       |        |       |     |
+-------------+------------------------+-------+--------+-------+-----+
|             | Fainting               |       |        |       |     |
+-------------+------------------------+-------+--------+-------+-----+
|             | Headache               |       |        |       |     |
+-------------+------------------------+-------+--------+-------+-----+
|             | Memory loss            |       |        |       |     |
+-------------+------------------------+-------+--------+-------+-----+
|             | Muscle pain            |       |        |       |     |
+-------------+------------------------+-------+--------+-------+-----+
|             | *Muscle rigidity*      |       |        |       |     |
+-------------+------------------------+-------+--------+-------+-----+
|             | Muscle                 |       |        |       |     |
|             | tw                     |       |        |       |     |
|             | itching/fasciculations |       |        |       |     |
+-------------+------------------------+-------+--------+-------+-----+
| **N         | Muscle weakness        |       |        |       |     |
| eurological |                        |       |        |       |     |
| (           |                        |       |        |       |     |
| continued** |                        |       |        |       |     |
+-------------+------------------------+-------+--------+-------+-----+
|             | Paralysis              |       |        |       |     |
+-------------+------------------------+-------+--------+-------+-----+
|             | Paresthesias/tingling  |       |        |       |     |
|             | or numbness            |       |        |       |     |
+-------------+------------------------+-------+--------+-------+-----+
|             | Peripheral neuropathy  |       |        |       |     |
+-------------+------------------------+-------+--------+-------+-----+
|             | Salivation             |       |        |       |     |
+-------------+------------------------+-------+--------+-------+-----+
|             | Seizure                |       |        |       |     |
+-------------+------------------------+-------+--------+-------+-----+
|             | Slurred speech         |       |        |       |     |
+-------------+------------------------+-------+--------+-------+-----+
|             | Other\_\_\_\_          |       |        |       |     |
|             | \_\_\_\_\_\_\_\_\_\_\_ |       |        |       |     |
|             | \_\_\_\_\_\_\_\_\_\_\_ |       |        |       |     |
+-------------+------------------------+-------+--------+-------+-----+
| #           | Anorexia (loss of      |       |        |       |     |
| ##### Gastr | appetite)              |       |        |       |     |
| ointestinal |                        |       |        |       |     |
+-------------+------------------------+-------+--------+-------+-----+
|             | 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/l*acrimation*  |       |        |       |     |
+-------------+------------------------+-------+--------+-------+-----+
|             | Other\_\_\_\_          |       |        |       |     |
|             | \_\_\_\_\_\_\_\_\_\_\_ |       |        |       |     |
|             | \_\_\_\_\_\_\_\_\_\_\_ |       |        |       |     |
+-------------+------------------------+-------+--------+-------+-----+
| **Dermal**  | Blisters/*bullae*      |       |        |       |     |
+-------------+------------------------+-------+--------+-------+-----+
|             | Burns                  |       |        |       |     |
+-------------+------------------------+-------+--------+-------+-----+
|             | Edema/swelling         |       |        |       |     |
+-------------+------------------------+-------+--------+-------+-----+
|             | Hives                  |       |        |       |     |
+-------------+------------------------+-------+--------+-------+-----+
|             | Pain                   |       |        |       |     |
+-------------+------------------------+-------+--------+-------+-----+

  ----------------- ----------------------------------------------------------- ------------ ------------ ------------ ---------
  **System**        **Sign/symptom**                                            **Patient    **Doctor     **Absent**   **Final
                                                                                reported**   reported**                code**

  **Dermal          Pattern\* of rash or lesions                                                                       
  (continued)**                                                                                                        

                    Pruritis (itching)                                                                                 

                    Rash                                                                                               

                    Redness                                                                                            

                    Other\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                          

  **Respiratory**   *Asthma (diagnosis of)*                                                                            

                    Cough                                                                                              

                    *Cyanosis*                                                                                         

                    *Depression*                                                                                       

                    Difficulty breathing/shortness of breath                                                           

                    LR irritation                                                                                      

                    Pleural pain (pain on deep breathing)                                                              

                    *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

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

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

## Exposure Information Screen---Narrative

Health Comments

## Exposure Information Screen---Medical Staff

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

  *Enter one                                           
  Medical ID for                                       
  each medical                                         
  person involved                                      
  in the case. Use                                     
  F2 in SPIDER to                                      
  select from pick                                     
  list. See HCP                                        
  Information on                                       
  Page 11 and                                          
  enter on Medical                                     
  Staff screen if                                      
  not on pick list                                     
  to complete full                                     
  medical staff                                        
  information.*                                        
  ---------------- ----------------- ----------------- -------------------

## Case Tracking and Closure 

## Event Information Screen---Event Summary

+------------+------------------+---+------------+------------------------+
| Violations | 1 2 3 4 8 9      |   | Were       |                        |
| FIFRA      |                  |   | citations  |                        |
|            |                  |   | for        |                        |
|            |                  |   | violations |                        |
|            |                  |   | of         |                        |
|            |                  |   | r          |                        |
|            |                  |   | egulations |                        |
|            |                  |   | by these   |                        |
|            |                  |   | agencies   |                        |
|            |                  |   | issued?\   |                        |
|            |                  |   | 1          |                        |
|            |                  |   | =Violation |                        |
|            |                  |   | cited      |                        |
|            |                  |   | 8=Decision |                        |
|            |                  |   | not to     |                        |
|            |                  |   | refer\     |                        |
|            |                  |   | 2=No       |                        |
|            |                  |   | violation  |                        |
|            |                  |   | cited      |                        |
|            |                  |   | 9=Unknown  |                        |
|            |                  |   |            |                        |
|            |                  |   | 3=Citation |                        |
|            |                  |   | pending    |                        |
|            |                  |   |            |                        |
|            |                  |   | 4=Case     |                        |
|            |                  |   | refused    |                        |
|            |                  |   | referral   |                        |
|            |                  |   | to agency  |                        |
+------------+------------------+---+------------+------------------------+
| Violations | 1 2 3 4 8 9      |   |            |                        |
| OSHA       |                  |   |            |                        |
+------------+------------------+---+------------+------------------------+
| Violations | 1 2 3 4 8 9      |   |            |                        |
| Other      |                  |   |            |                        |
+------------+------------------+---+------------+------------------------+
| **R        | **Check if       | * |            | **Notes**              |
| eferrals** | Referral Made**  | * |            |                        |
|            |                  | D |            |                        |
|            |                  | a |            |                        |
|            |                  | t |            |                        |
|            |                  | e |            |                        |
|            |                  | o |            |                        |
|            |                  | f |            |                        |
|            |                  | R |            |                        |
|            |                  | e |            |                        |
|            |                  | f |            |                        |
|            |                  | e |            |                        |
|            |                  | r |            |                        |
|            |                  | r |            |                        |
|            |                  | a |            |                        |
|            |                  | l |            |                        |
|            |                  | ( |            |                        |
|            |                  | M |            |                        |
|            |                  | M |            |                        |
|            |                  | / |            |                        |
|            |                  | D |            |                        |
|            |                  | D |            |                        |
|            |                  | / |            |                        |
|            |                  | Y |            |                        |
|            |                  | Y |            |                        |
|            |                  | ) |            |                        |
|            |                  | * |            |                        |
|            |                  | * |            |                        |
+------------+------------------+---+------------+------------------------+
| IH Staff   |                  |   |            |                        |
+------------+------------------+---+------------+------------------------+
| Ag and Mkt |                  |   |            |                        |
| Program    |                  |   |            |                        |
+------------+------------------+---+------------+------------------------+
| State      |                  |   |            |                        |
| E          |                  |   |            |                        |
| nvironment |                  |   |            |                        |
+------------+------------------+---+------------+------------------------+
| EPA        |                  |   |            |                        |
+------------+------------------+---+------------+------------------------+
| Ag Program |                  |   |            |                        |
+------------+------------------+---+------------+------------------------+
| Other      |                  |   |            |                        |
| State Pgm. |                  |   |            |                        |
+------------+------------------+---+------------+------------------------+
| Local      |                  |   |            |                        |
| Health     |                  |   |            |                        |
| Unit       |                  |   |            |                        |
+------------+------------------+---+------------+------------------------+

## 

## Event Information Screen---Comments

**Other Violation Descriptions**

**Violation Comments**

## Exposure Information Screen---Exposure and Classification

+-----------------------------------------------------------------------+
| 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 6 - 8 to determine if illness is attributable to products, active ingredients, or substances listed there.