## C.4 Field investigation Contact Form and Health Safety 

## Checklist for Field Personnel 

The following checklist is designed to remind field staff about
equipment and safety precautions they need to take when embarking on a
field investigation or any form of on-site follow-up. It also ensures
that supervisory staff have appropriate contact information for field
staff. In addition, PPSPs may decide to use this form when staff are
accompanying partner enforcement agency staff. The checklist is to be
completed by PPSP personnel BEFORE going out into the field. For team
visits, only the team leader is required to complete the form. Team
leaders are responsible for ensuring that all team members meet the
required checklist items stated below. As with all of the sample forms,
this form should be modified to meet the specific needs of the PPSP.

### Field Investigation Contact Form 

### and Health Safety Checklist for Field Personnel

(Adapted from California Occupational Health Branch, DHS)

This checklist is to be completed by PPSP personnel BEFORE going out
into the field. For team visits, *only* the team leader is required to
complete the form. Team leaders are responsible for ensuring that all
team members meet the required checklist items stated below.

**Directions**

16. Fill out **Part I**.

```{=html}
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```
2.  Have it reviewed and signed by your supervisor **before** the site
    visit.

```{=html}
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```
3.  After the visit, fill out **Part II** and turn in completed form to
    supervisor.

```{=html}
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```
4.  **Supervisors:** Forward a copy of this form
    to\_\_\_\_\_\_\_\_\_\_\_.

**Part I: Pre-Site Visit Checklist**

**A. Names of PPSP field team members**

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

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

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

**Date(s) of proposed site
visit**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**B. Emergency Contact Information**

Employer Name
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Type of business
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Address
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

City
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Contact person.
Name\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Phone
(\_\_ \_\_ \_\_) \_\_ \_\_ \_\_ -\_\_ \_\_ \_\_ \_\_

> **How can you be reached?**

Phone number where you are staying (e.g., hotel friend=s house, etc.)
(\_\_ \_\_ \_\_) \_\_ \_\_ \_\_ -\_\_ \_\_ \_\_ \_\_

> Hotel Name *(if applicable)*
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Cellular Phone Number (if applicable) (\_\_ \_\_ \_\_) \_\_ \_\_ \_\_
-\_\_ \_\_ \_\_ \_\_

If more than one location, write down team members= locations (*use back
of page if necessary*).

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

> Hotel Name *(if applicable):*
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Cellular Phone No*. (if applicab*le) (\_\_ \_\_ \_\_) \_\_ \_\_ \_\_
-\_\_ \_\_ \_\_ \_\_

**Training (hazards, guidelines, regulations)**

> **(1)** Will you be potentially exposed to the following hazards?
> *(Check all that apply.)*

 TB: PPD of staff performed in past year?  yes  no

 other chemical(s)

 noise

 bloodborne pathogens

> HBV vaccination completed?  yes  no

 safety (falling objects, electricity, etc.):

 violence

 other:

(2) If you checked any of the boxes above, have you had training on how
    to protect

> yourself from these hazards?  yes  no
>
>  ***If you answered NO, please talk to your supervisor about how you
> will obtain***
>
> ***appropriate training prior to the site visit.***
>
> **(3)** Have you reviewed applicable regulations and guidelines on
> likely exposures?
>
>  yes  no

 ***If you answered NO, please review any applicable regulations and
guidelines that***

> ***are available. If none exist, you should discuss alternative
> information sources***
>
> ***with your supervisor.***

**Personal Protective Equipment (PPE)**

> **(1)** Are respirators required or recommended on this site visit?
>
>  yes  no  not sure

 ***If NOT SURE, please discuss this with your supervisor.***

> **If you are using a respirator for this site visit, answer a through
> c.**
>
> **(a)** Have team members had

-   respirator medical clearance within the last year?  yes  no

-   respirator training within the last year?  yes  no

-   respirator fit-testing within the last year?  yes  no

>  ***if NO, please discuss this with your supervisor.***

**(b)** Do you have extra cartridges/filters?  yes  no

> If you are going to wear a PAPR, have you charged the battery packs?
>
>  yes  no
>
> **(2)** Are other PPE required?  yes  no, If YES, check all that
> apply:
>
>  head protection (hard hat)  foot protection (safety shoes or
> chemical resistant boots)

 hearing protection  eye protection (goggles, faceshield)  hand
protection

 other

**Communications Equipment**

> \(1\) If you are traveling to remote areas, do you need a cellular
> phone?  yes  no
>
> \(2\) Do you have a list of emergency contact numbers (e.g., section
>
> chief, etc.) to bring with you?  yes  no

Employee signature:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date:
\_\_\_\_\_\_\_\_\_\_\_\_

Supervisor signature:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date:
\_\_\_\_\_\_\_\_\_\_\_\_

**Part II: Post-Site Visit Review**

Were there any items missing or not foreseen prior to visit that should
be considered during future

visits to similar sites?  yes  no

* If YES, please explain below.*

## C.5 Instructions for National Transportation Safety Board (NTSB) Search to Obtain Reports of Airplane accidents Involving Aerial Pesticide Applicators 

NTSB maintains data on aviation accidents. The Aviation Synopses can be
searched for information about aviation accidents involving aerial
agricultural applications. These applications are covered by 14 CFR Part
137. The synopses may be reviewed by searching monthly lists of
accidents or performing a query. Make sure your browser is set to accept
cookies.

Go to the NTSB website http://www.ntsb.gov/NTSB/query.asp.

The first item on the list is a Database Query. First, look at the
general instructions for searching, then select the Database Query form.
Complete the various fields. This includes entering the date range you
are interested in, selecting your State, severity, and a specific
category of aircraft (if you are searching for a particular accident or
type of accident). You can leave the Operation category as All. In the
area labeled Enter your word string below, type 137. Choose Sort by Date
Ascending unless you want to sort on an option other than date. Click on
Submit Query. This search strategy should catch all of the agricultural
accidents (since applications are regulated by 14 CFR Part 137).

## C.6 Sample Templates for

## Tables Presenting Surveillance Data

**1. Work-Relatedness by Case Classification Status**

  --------------- -------------- -------------- -------------- ---------------- ------------
                  **Definite**   **Probable**   **Possible**   **Suspicious**   **Total**

  WORKREL                                                                       

  Yes                                                                           

  Possibly                                                                      

  No                                                                            

  Unknown                                                                       

  Total                                                                         
  --------------- -------------- -------------- -------------- ---------------- ------------

**2. Cases by Pesticide Type and Case Classification**.

Each case should be included only once in this table (excluding the rows
and columns of totals). (Note that this tabular presentation can be done
separately for occupational and nonoccupational cases or can include
occupational status by splitting the case classification columns into
occupational and nonoccupational.)

+--------------------+--------+--------+---------+---------+--------+
|                    | **Defi | **Prob | **Pos   | **Suspi | **T    |
|                    | nite** | able** | sible** | cious** | otal** |
+--------------------+--------+--------+---------+---------+--------+
| Pesticide type     |        |        |         |         |        |
+--------------------+--------+--------+---------+---------+--------+
| Insecticides-total |        |        |         |         |        |
+--------------------+--------+--------+---------+---------+--------+
| > Cholinesterase   |        |        |         |         |        |
| > inhibitors       |        |        |         |         |        |
+--------------------+--------+--------+---------+---------+--------+
| > Py               |        |        |         |         |        |
| rethrin/pyrethroid |        |        |         |         |        |
+--------------------+--------+--------+---------+---------+--------+
| > Other            |        |        |         |         |        |
| > insecticides     |        |        |         |         |        |
+--------------------+--------+--------+---------+---------+--------+
| Insect growth      |        |        |         |         |        |
| regulators         |        |        |         |         |        |
+--------------------+--------+--------+---------+---------+--------+
| Herbicide/algicide |        |        |         |         |        |
+--------------------+--------+--------+---------+---------+--------+
| Fungicide          |        |        |         |         |        |
+--------------------+--------+--------+---------+---------+--------+
| Fumigant           |        |        |         |         |        |
+--------------------+--------+--------+---------+---------+--------+
| Rodenticide        |        |        |         |         |        |
+--------------------+--------+--------+---------+---------+--------+
| Disinfectant       |        |        |         |         |        |
+--------------------+--------+--------+---------+---------+--------+
| Insect repellent   |        |        |         |         |        |
+--------------------+--------+--------+---------+---------+--------+
| Other              |        |        |         |         |        |
+--------------------+--------+--------+---------+---------+--------+
| Multiple           |        |        |         |         |        |
+--------------------+--------+--------+---------+---------+--------+
| Unknown            |        |        |         |         |        |
+--------------------+--------+--------+---------+---------+--------+

3\. Occupational Pesticide Injury and Illness Cases by Occupation and
Case Classification

+--------------------------------+------+-------+------+--------+----+
|                                | **De | **    | **Po | **     | *  |
|                                | fini | Proba | ssib | Suspic | *T |
|                                | te** | ble** | le** | ious** | ot |
|                                |      |       |      |        | al |
|                                |      |       |      |        | ** |
+--------------------------------+------+-------+------+--------+----+
| Occupation                     |      |       |      |        |    |
+--------------------------------+------+-------+------+--------+----+
| AgricultureCprovide total for  |      |       |      |        |    |
| COC codes 473B499              |      |       |      |        |    |
+--------------------------------+------+-------+------+--------+----+
| > List specific agriculture    |      |       |      |        |    |
| > occupations                  |      |       |      |        |    |
+--------------------------------+------+-------+------+--------+----+
| NonagricultureCprovide total   |      |       |      |        |    |
+--------------------------------+------+-------+------+--------+----+
| > List specific nonagriculture |      |       |      |        |    |
| > occupations                  |      |       |      |        |    |
+--------------------------------+------+-------+------+--------+----+
| TOTAL                          |      |       |      |        |    |
+--------------------------------+------+-------+------+--------+----+

**4. Source of case report by gender and case classification**

  ------------------------- -------------- ------- ------- -------------- ------- ------- -------------- ------- ------- ---------------- ------- ------- ----------- ------- -------
                            **Definite**                   **Probable**                   **Possible**                   **Suspicious**                   **Total**           

  **Sex**                   **M**          **F**   **U**   **M**          **F**   **U**   **M**          **F**   **U**   **M**            **F**   **U**   **M**       **F**   **U**

  **Source of Report**                                                                                                                                                        

  Physician                                                                                                                                                                   

  Poison control center                                                                                                                                                       

  Other health care                                                                                                                                                           
  professional                                                                                                                                                                

  Death certificate                                                                                                                                                           

  Government agency                                                                                                                                                           

  Media report                                                                                                                                                                

  Workers Compensation                                                                                                                                                        

  Self-report (inc.                                                                                                                                                           
  relative or co-worker)                                                                                                                                                      

  Employer                                                                                                                                                                    

  Other                                                                                                                                                                       

  Unknown                                                                                                                                                                     

  Total                                                                                                                                                                       
  ------------------------- -------------- ------- ------- -------------- ------- ------- -------------- ------- ------- ---------------- ------- ------- ----------- ------- -------

**5. Age of cases by gender and case classification (produce this table
for occupational and nonoccupational exposure status)**

  ----------- -------------- ------- ------- -------------- ------- ------- -------------- ------- ------- ---------------- ------- ------- ----------- ------- -------
              **Definite**                   **Probable**                   **Possible**                   **Suspicious**                   **Total**           

  **Sex**     **M**          **F**   **U**   **M**          **F**   **U**   **M**          **F**   **U**   **M**            **F**   **U**   **M**       **F**   **U**

  **Age**                                                                                                                                                       

  \<10                                                                                                                                                          

  11B14                                                                                                                                                         

  15B17                                                                                                                                                         

  18B29                                                                                                                                                         

  30B39                                                                                                                                                         

  40B59                                                                                                                                                         

  60B79                                                                                                                                                         

  80+                                                                                                                                                           

  Unknown                                                                                                                                                       

  Total                                                                                                                                                         
  ----------- -------------- ------- ------- -------------- ------- ------- -------------- ------- ------- ---------------- ------- ------- ----------- ------- -------

## C.7 Sample Letters for PPSP Case Follow-up

The following sample letters are provided as templates that PPSPs can
modify to meet their specific needs and legal requirements.

• Thank-you letter to an HCP who reports a case

• A request for cooperation to an HCP who failed to report a case

• A request to an HCP for medical records

• A letter to an employer regarding an upcoming site inspection

**Thank-You Letter to HCP Who Reported Case**

**\[Agency Letterhead\]**

**DATE**

**INSIDE ADDRESS**

Re: **\[case number\]**

Dear **\[insert HCP name\]:**

Thank you for the information you recently provided regarding the
illness and possible pesticide exposure of \[**insert patient name**\].
Your report helps us to identify pesticide products and practices that
may affect public health, as well as provide exposure prevention
information to affected individuals.

If you would like further information about this case, the \[**insert
agency name**\] \[**insert surveillance program name**\], or other State
agency resources, please call me at \[**insert phone number**\].
\[**Option---include a copy of the *EPA Recognition and Management of
Pesticide Poisonings***\]

Sincerely,

**Request for Cooperation Letter to HCP Who Failed to Report Case**

**\[Agency Letterhead\]**

**DATE**

**INSIDE ADDRESS**

Re: \[**patient**\] Case number:

Dear \[**insert HCP name**\]:

The \[**insert agency name**\] is currently investigating a reported
pesticide-related illness of your above-named patient. (We have been in
touch with a member of your staff regarding the observable signs,
diagnosis, and treatment of the individual.) The \[**surveillance
program name**\] routinely identifies and investigates illnesses and
injuries associated with pesticide exposure.

Suspected pesticide poisoning is a reportable condition in the
\[**insert State name**\]. Health care providers are required by
\[**insert rule reference**\] to report acute or subacute conditions
that are caused by, or suspected of being caused by, pesticide exposure.
All medical details and the person's identity are kept confidential.
Resources and referrals are available to the reporting provider and the
patient, including exposure prevention information.

Your report helps us identify pesticide products or practices that may
affect public health. Your cooperation in reporting any future
pesticide-related illnesses is appreciated. If you would like further
information about the program, please contact us at \[**insert phone
number**\]. \[**Option---include a copy of the *EPA Recognition and
Management of Pesticide Poisonings***.\]

Sincerely,

**Medical Records Request Letter**

\[**Agency Letterhead**\]

**DATE**

**INSIDE ADDRESS**

Re: \[**case number**\]

Dear \[**insert HCP name**\]:

This letter is sent by \[**agency name (agency abbreviation)**\] to
request medical records relevant to illness investigations conducted by
the \[**agency abbrev.**\]. The \[**agency**\] collects medical records
in accordance with State law. Copies of relevant sections of State code
are attached for your convenience.

The \[**agency**\] has received a notice of pesticide-related illness
involving the patient listed below and requests copies of any medical
information (including chart notes and laboratory test results) that you
might have.

\[**First name Last name, SSN, DOB; injured on: date; seen on: date**\]

Please also check your records for any information you have on other
patients seen on the same date, or within several days before or after,
who may have a pesticide-related illness or injury associated with the
same exposure incident. Please provide copies of any such records to the
\[**agency**\].

Please mail or fax these records to the return address indicated above.
If you have any questions, please call me at \[**insert phone
number**\]. Thank you for your cooperation in providing the requested
information.

Note that the \[**agency name**\] is an agency of \[**parent authority,
e.g., the State of \_\_\_\_\_** \] and is conducting pesticide poisoning
surveillance in its capacity as a public health authority as defined by
the Health Insurance Portability and Accountability Act (HIPAA),
Standards for Privacy of Individually Identifiable Health Information;
Final Rule (Privacy Rule) \[45 CFR 164.501\]. Persuant to 45 CFR
164.512(b) of the Privacy Rule, covered entities such as your
organization may disclose, without individual authorization, protected
health information to public health authorities ". . .authorized by law
to collect or receive such information for the purpose of preventing or
controlling disease, injury, or disability, including, but not limited
to, the reporting of disease, injury, vital events such as birth or
death, and the conduct of public health surveillance, public health
investigations, and public health interventions . . ." The information
being requested represents the minimum necessary to carry out the public
health purposes of pesticide poisoning surveillance pursuant to 45 CFR
164.514(d) of the Privacy Rule.

Sincerely,

**Letter to Employer Regarding an Upcoming Site Inspection**

\[**Agency Letterhead**\]

**DATE**

**INSIDE ADDRESS**

Re: Site inspection scheduled for \[**date**\]

Dear \[**name**\]:

Thank you for your cooperation with the \[**agency name**\]
investigation of illness reports among employees at \[**company
name**\]. We are writing to confirm our meeting and to provide you with
logistical and other information about our investigation. The meeting
will take place at \[**insert location**\].

Based on phone conversations with \[**person's name (date)**\], it is
our understanding that the following persons will be present at the
meeting: \[**names and titles**\]. In addition to ourselves, \[**list
any additional names and titles**\] working with \[**agency and program
name**\] on pesticide illness tracking will also attend our meeting.

Background: \[**agency**\] is mandated to investigate the causes of
morbidity and mortality from work-induced diseases and develop
recommendations for improved control of work-induced diseases \[**code
reference**\] \[**Modify sentence as needed to reflect agencies'
authority**\]. In contrast to \[**State**\] -OSHA, \[**program name**\]
is not an enforcement agency, and we do not issue citations.
\[**agency**\] initiated this investigation in response to physician
reports of illness among \[**worker types**\] potentially exposed to
pesticides as a result of \[**work activity or task**\]. Between
\[**dates**\], \[**agency**\] received \[**insert number**\] incident
reports involving a total of \[**insert number**\] workers. \[**Give
reason there is concern about the reports.**\]

Purpose: The purpose of our on-site field investigation on \[**date**\]
is to gather information and make observations about \[**activity**\]
practices at \[**company name**\].

Process: The process for the \[**date**\] site visit will be an opening
conference for introductions, a review of the purpose, scope, and
methodology of our investigation, and an opportunity for company and
worker representatives to ask us questions. We will then conduct an
on-site observation of \[**process, site, or activity**\]. We will walk
through the \[**facility type**\], at which time we will ask \[**company
name**\] representatives to provide a detailed explanation of the
pesticide application process including local ventilation conditions at
the time of the application. We will ask worker representatives for
their knowledge of the process as well. We will take photographs. The
site visit will end with a closing conference at which time we will
summarize our progress in the investigation and answer any additional
questions you may have. We anticipate that the site visit will take
about four hours (assuming that we will have received much of the
information/documentation about the application from \[**company
name**\] prior to the site visit).

Scope: The scope of \[**agency**\] investigation is limited to
\[**describe scope**\]. The limited nature of \[**agency name's**\]
investigation does not imply there are, or are not, other safety and
health issues at the workplace.

Methodology: \[**agency name**\] will evaluate and classify \[**worker
or specific worker job type**\] illness reports according to criteria
established by the National Institute for Occupational Safety and Health
(NIOSH). Enclosed is a copy of these criteria. They are also available
at [http://www.cdc.gov/niosh
/pestsurv/pdfs/pest-casdef2000.pdf](http://www.cdc.gov/niosh /pestsurv/pdfs/pest-casdef2000.pdf).
Worker exposure to pesticides will be assessed utilizing data from (1)
interviews with employees, employee representatives, and employer
representatives; (2) work-site observations and interviews with company
and employee representatives regarding the work process, tasks, and
exposure control measures; (3) review of medical records, policy and
procedures, and other written materials; and (4) a review of the
relevant scientific literature. \[**Agency**\] will attempt to conduct a
voluntary interview with all workers with a reported illness at the
worker's home by phone. Employer interviews will be conducted at the
work-site and by phone as needed.

Exposure control measures will be evaluated according to the presence,
use, and efficacy of standard industrial hygiene hierarchy of controls
(i.e., engineering, administration, and personal protection).
Recommendations to prevent illness will be based on a public health
approach; i.e., primary, secondary, and tertiary measures. To the extent
possible, it is normal practice for \[**agency**\] to direct each of our
recommendations to the persons or groups that have the authority to
implement change.

Our investigation will be conducted independently of regulatory
agencies. However, if while at a workplace, we observe a condition that
could reasonably be expected to cause death or serious physical harm
immediately (that is, an imminent hazard), we are obliged to notify the
employer and affected workers of the hazard and to notify \[**State
name**\]-OSHA and/or other appropriate agencies. In practice,
circumstances that would require a referral to an enforcement agency
have almost never been encountered by \[**agency**\] investigators. The
investigation may not identify all hazards or violations of good
practice within the scope of the practices reviewed Allowing \[agency\]
to conduct the investigation and/or following recommendations made in
the investigation report will not exempt \[**company name**\] or the
worksite from an enforcement inspection or regulatory compliance.

At a minimum, all of \[**agency's**\] findings and recommendations to
prevent illness will be reported in writing in a timely manner to the
incident cases, reporting physicians, employee representatives, and
\[**company name**\]. Publications may also be disseminated to other
interested parties, such as health and safety professionals,
industry-based organizations, government agencies, and labor unions. Our
report will not contain any personal-identifying information about
individual workers. Although not confidential information, our
publications for general distribution do not usually specify the name of
the employer.

Specific information we are seeking from \[**company name**\]: In order
to make the best use of your time during our site visit, we are
providing you with a list of the questions and information we will
request from \[**company**\]. We will also have additional questions
based on what we learn from you. All of the information requested below
relates to the time period covered by the scope of this investigation
(\[**date range**\]), except where otherwise indicated.

\[**list questions**\]

We have tried to compile a comprehensive list of questions and sources
of information that are relevant to this investigation. However, it is
likely that we have omitted something. Please do not hesitate to provide
any other data that you are aware of that may be useful in understanding
the work process of \[**process, site, or activity being
investigated**\]. Also, please note if certain data are not available,
as it is important for us to understand where there may be gaps in data.

We appreciate your time and participation in the \[**agency**\]
investigation. It is our goal that the information collected will
contribute to our ability to determine the severity and extent of the
potential problem and identify possible causes and solutions. Please
contact \[**name**\] by e-mail (\[**e-mail address**\]) or phone (
\[**phone number**\] ) if you have any questions. We look forward to
meeting you on \[**date**\].

Sincerely,

cc:

Enclosures

## C.8 Instructions for Obtaining Acute Pesticide-Related Illnesses and Injuries From Poison Control Centers (PCCs)

**A. Obtaining the annual number of incident cases**

1\. Contact your local PCC. Contact information can be obtained from
American Association of Poison Control Centers
http://www.aapcc.org/director2.htm. Some States have more than one PCC.

2\. Include in-State residents and unknown residence.

3\. Determine if the PCC uses the Toxicall7 data system.

> a\. If YES, go to step A.4.
>
> b\. If NO, go to step A.5.

4\. If the PCC uses Toxicall7, ask the PCC to run Report 57.

> a\. To obtain occupational cases only: Cases should either have reason
> for the call (ExpReason) = 3 (occupational) OR exposure site (ExpSite)
> = 3 (workplace).
>
> b\. To obtain all acute pesticide-related illnesses and injuries:
> Neither ExpReason nor ExpSite need to be specified.
>
> c\. To calculate incidence rates, go to B. Estimating the Total
> Population at Risk (denominator).

5\. If the PCC does not use Toxicall7 or if it cannot generate Report
57, determine if the PCC will provide a data set of all received calls.

> a\. If YES, go to Step A.6.
>
> b\. If NO, go to Step A.7.

6\. If the PCC can provide a data set of all received calls, query the
dataset to identify cases that meet the following criteria

> a\. Exposure to an agent included in one of the pesticide generic
> categories (**SubGenricCode**) =
>
> **Disinfectants**
>
> 0201008 disinfectant industrial cleaner
>
> 0201055 bromine water/shock treatment
>
> 0201056 chlorine water/shock treatment
>
> 0042281 hypochlorite disinfectant: hypochlorite, non-bleach product
>
> 0040280 phenol disinfectant: phenol (e.g., lysol)
>
> 0039282 pine oil disinfectant
>
> 0077286 other/unknown disinfectant:
>
> **Fungicides (nonmedicinal)**
>
> 0243566 carbamate fungicide
>
> 0201033 copper compound fungicide
>
> 0077564 mercurial fungicide
>
> 0077565 non-mercurial (inactive) fungicide
>
> 0253000 phthalimide fungicide
>
> 0254371 wood preservative
>
> 0077566 other/unknown (inactive) nonmedicinal fungicide
>
> 0201034 other nonmedicinal fungicide
>
> 0201035 unknown nonmedicinal fungicide
>
> **Fumigants**
>
> 0201036 aluminum phosphide fumigant
>
> 0201037 metam sodium (fumigant, fungicide, or herbicide)
>
> 0201038 methyl bromide (fumigant, fungicide, or herbicide)
>
> 0201039 sulfuryl fluoride fumigant
>
> 0201040 other fumigant
>
> 0201041 unknown fumigant
>
> **Herbicides (includes algicides, defoliants, dessicants, plant growth
> regulators)**
>
> 0201054 algicide
>
> 0254370 anti-algae paint: anti-algae
>
> 0243561 carbamate herbicide
>
> 0017000 2,4-d or 2,4,5-t (inactive)
>
> 0201042 chlorophenoxy herbicide
>
> 0049562 diquat
>
> 0201043 glyphosate
>
> 0049000 paraquat
>
> 0049561 paraquat/diquat combination
>
> 0077121 plant hormone
>
> 0213000 triazine herbicide
>
> 0215000 urea herbicide
>
> 0077561 other herbicide
>
> 0077567 unknown herbicide
>
> **Insecticides (includes insect growth regulators, molluscicides,
> nematicides)**
>
> 0004562 arsenic pesticide
>
> 0062562 borate/boric acid pesticide
>
> 0070000 carbamate only (alone)
>
> 0070560 carbamate with other insecticide
>
> 0050000 chlorinated hydrocarbon only (alone)
>
> 0050560 chlorinated hydrocarbon with other insecticide
>
> 0201044 insect growth regulator
>
> 0172000 metaldehyde(molluscicide)
>
> 0208562 nicotine(excluding tobacco products)
>
> 0038000 organophosphate
>
> 0038560 organophosphate/carbamate combined
>
> 0038561 organophosphate/chlorinated hydrocarbon (inactive)
>
> 0038562 organophosphate/other insecticide
>
> 0038563 organophosphate/carbamate/chlorinated hydrocarbon (inactive)
>
> 0176000 piperonyl butoxide only (inactive)
>
> 0144000 piperonyl butoxide/pyrethrin (inactive) (without carbamate or
> o.p.)
>
> 0144001 pyrethrins only (inactive)
>
> 0201045 pyrethrin
>
> 0201046 pyrethroid
>
> 0145000 rotenone
>
> 0077568 veterinary insecticide (inactive) (for petsCflea collars,
> etc.)
>
> 0077562 other insecticide
>
> 0077569 unknown insecticide
>
> **Repellents**
>
> 0201047 bird, dog, deer, or other mammal repellent
>
> 0201048 insect repellent with deet
>
> 0201049 insect repellent without deet
>
> 0218000 insect repellent: unknown (inactive)
>
> 0033000 naphthalene moth repellent
>
> 0050430 paradichlorobenzene moth repellent
>
> 0077431 other mothball or moth repellent
>
> 0077430 unknown mothball or moth repellent
>
> **Rodenticides**
>
> 0174000 antu
>
> 0048563 anticoagulant: warfarin-type anticoagulant rodenticide
>
> 0048564 anticoagulant: long-acting, superwarfarin anticoagulant
> rodenticide
>
> 0244577 barium carbonate barium carbonate containing rodenticides
>
> 0201050 bromethalin
>
> 0201051 cholecalciferol rodenticide
>
> 0012563 cyanide rodenticide (excluding industrial or misc. Chemical)
>
> 0162000 monofluoroacetate 1080/monofluoroacetate/smfa
>
> 0043000 strychnine rodenticide
>
> 0197000 vacor/pnu
>
> 0201052 zinc phosphide
>
> 0217000 thallium
>
> 0077563 other rodenticide
>
> 0077577 unknown rodenticide
>
> b\. Medical outcome (**MedicalOutcome**) is coded into one of the
> following values:
>
> 201=minor effect
>
> 202=moderate effect
>
> 203=major effect
>
> 204=death
>
> 206=not followed, minimal clinical effects possible
>
> 207=unable to follow, judged as a potentially toxic exposure
>
> c\. Request specific values for ExpReason and ExpSite, if needed.
>
> \(1\) To obtain occupational cases only: Cases should either have
> reason for the call (ExpReason) = 3 (occupational) OR exposure site
> (ExpSite) = 3 (workplace).

ii\) (2) To obtain all acute pesticide-related illnesses and injuries:
Neither ExpReason nor ExpSite need to be specified.

7\. Using the case number, delete any duplicate cases.

8\. Tally the total number of cases that meet the criteria.

9\. If interested in calculating an incidence rate, go to *B. Estimating
the Total Population at Risk (denominator).*

10\. If the PCC will not provide a data set:

> a\. Ask the PCC to tally the number of cases that meet the criteria in
> A.6.a through A.6.d.
>
> b\. If interested in calculating a rate, go to *B. Estimating the
> Total Population at Risk (denominator).*

B. Estimating the Total Population at Risk (denominator for rate
calculations)

> 1\. Determine whether the rate is for acute occupational
> pesticide-related illness and injury, or for all acute
> pesticide-related illness and injury.
>
> a\. If for acute occupational pesticide-related illness and injury, go
> to B.2.
>
> b\. If for all acute pesticide-related illnesses and injuries, go to
> B.3.
>
> 2\. To obtain the denominator for an occupational case rate:
>
> a\. Go to Current Population Statistics:
> http://www.bls.gov/opub/gp/laugp.htm
>
> b\. Select *Section II: Estimate for States*
>
> c\. Select *Table 12. Employment status of the civilian
> noninstitutional population by sex, age, race, and Hispanic origin*
>
> d\. Find your state from the first column.
>
> e\. Read the *Total* row for your State and the 4th columnC*Employment
> Number*. This is the *Number of Employer Persons 16 years of age or
> older* (in thousands). Multiply by 1000.
>
> f\. Go to *C. Calculating the annual incidence rate.*
>
> 3\. To obtain the denominator for the total population case rate:
>
> a\. Use the US Census standard population. The most recent figures can
> be found at http://quickfacts.census.gov/qfd/index.html.
>
> b\. After selecting your State, total population estimates will be
> provided.
>
> c\. Go to *C. Calculating the annual incidence rate*.

**C. Calculating the annual incidence rate**

> 1\. Divide the numerator (A) by the denominator (B).
>
> 2\. Multiply this result by 100,000 to get the Annual rate per 100,000
> persons.