# Industry’s Voluntary 6(a)(2) Incident Reporting Forms
&
Guidance Documents

August 4, 19982 

## Table of Contents

Page
Introduction 3

General Considerations 4

Reporting categories and Time Frames (TABLE) 5

Incident Reporting Process (SCHEMATIC) 6

Trade & Professional Association contact list 6

Key to Form Data Fields 7

Administrative/ Pesticide/Incident Data 7

Human Incident Information Data 8

Fish, Wildlife or Other Non-Target Organisms Data 9

Domestic Animal Data 10

Detections of Pesticides in Surface Water Data 11

Detections of Pesticides in Groundwater Data 12

Property Damage with Risk of Human Injury Data 13

Unauthorized Residue in Food & Feed 14

Individual Incident Forms 15

Administrative/ Pesticide/Incident Form 15

Human Incident Information Form 16

Fish, Wildlife or Other Non-Target Organisms Form 17

Domestic Animal Form 18

Detections of Pesticides in Surface Water Form 19

Detections of Pesticides in Groundwater Form 20

Property Damage with Risk of Human Injury Form 21

Unauthorized Residue in Food & Feed Form 22

Aggregate Reporting Key 23

Summary of Exposure Types & Severity Categories Included in Aggregate Reporting (Table) 24

Aggregate Form Example I 25

Aggregate Form Example II 263 

# Information Regarding the Use of the Voluntary 6(a)(2) Incident Reporting Forms

Introduction

A number of industry trade organizations, registrant s, professional groups and other interested parties have worked together in cooperation with the EPA to develop a set of reporting forms that can be used by Registrants to report 6(a)(2) related incidents to the EPA. These forms and their corresponding guidance documents provide useful tips and suggestions for meeting reporting re quirements under 6(a)(2). Use of these specific forms for required reporting is volunta ry. These forms have been developed to meet incident reporting requirements. EPA supports their use in 6(a)(2) compliance efforts as well as other methods of reporting to achieve the same purpose.

There are two sets of forms to reflect the two methods of reporting incidents to the Agency. Incidents that are of a more significant nature must be reported indi vidually. Incidents that are either minor or more commonly encountered must be reported in aggregate. Severity categories and their respective reporting requirement are noted in the guidance instructions.

Typically, the single incident forms can be used to collect data regarding any incident. After the severity category of any given incident is determined the appr opriate method of reporting that incident to the EPA

can then be determined.

The single incident forms are divided into two speci fic areas. The first area describes “administrative data” or general demographic and product information th at is gathered for any incident. There are seven supplemental addenda relating to the seven in cident types i.e., human, domestic animal, fish/wildlife/plant/other non-target organisms, groun dwater, surface water, food and feed, and property damage with risk of human injury. After collec ting the information and the severity classification is determined, the Registrant can then ascertain whether the incident must be reported individually or in aggregate. If the incident must be reported individua lly the single incident forms can be used to submit the information directly. If the incident must be reported in aggregate certain information must be transferred to the aggregate report form and submitted in that manner.

General guidance information is provided in this doc ument to aid in the completion of these forms. For further, or more specific guidance, consult 40 CFR Part 159.184 for full text and definitions. Some additional information is provided in Pes ticide Registration Notice (PR Notice) 98-3.

These forms contain fields for reporting of informati on which may or may not be required to be reported to EPA under FIFRA 6(a)(2) and the regulations at 40 CFR 159.152 et.seq.. Use of this form is voluntary and is not intended to infer that any designated fiel ds should be submitted to EPA or to mandate reporting of any specific information to EPA. Registrants/or applicants should consult th eir own legal counsel or FIFRA 6(a)(2) Reporting Officers before responding.4 

### General Considerations:

• Due to the nature of incidents and how they ar e typically reported through the 6(a)(2) process, Registrants do not guarantee the authenticity or accu racy of information contained in the reports required to be submitted to the Agency.

• The forms contain some fields of data that are optiona l. These fields are used to aid the Registrant in general data collection purposes. In some cases thes e fields represent data that are not required but can be submitted to document important informati on the Registrant believes is vital to a better understanding of the incident.

• The information collected on the form for Domestic Animal data is not required for single incident reporting as none of the severity classifications relate d to domestic animals are reported individually. All of these incidents are submitted on the aggregate forms. Data collected on the domestic animal form may be required by the EPA in cases of incident follow-up.

• The Registrant is only required to submit informati on that has been provided. No investigation or follow-up is required, but may be useful if furt her information helps qualify or clarify reported

incidents.

• A portion of the category of H–E (anticipated or “may suffer” clinical effects) has been dropped from the reporting requirement by the EPA until further not ice (see PR notice 98-4). The category of H-E is now limited to adverse effects that are unspecified or unknown.

• Exposure type and severity categories of human s and domestic animals take into account both duration and intensity of clinical effects. As noted in PR Notice 98-3 for human incidents:

“The persistence of symptoms or the developm ent of delayed symptoms should be considered when classifying severity. For example, human cases may report developing common symptoms like headaches, general weakness, me mory and concentration problems, depression, irritability, muscular aches and pains, or shortness of breath. If these symptoms last for just a few days and are minimally troublesome (do not require treatment) then they would be classified as minor (H-D). However, if symptoms persist for one month or longer they would be classified as moderate (H-C). Symptoms persisting for two or more months that significantly alter daily activities would be classified as major (H-B).”

Generally, major effects would include “life threatening” or effects resulting in “residual disability”. They could also include “adverse reproductive” effects.

Moderate effects are typically “more pronounced, more prolonged, or of a more systemic nature than minor effects”. Examples include , “isolated brief seizures”, “gastro-intestinal systems leading to dehydration” and “corneal abrasions.”

Minor effects would include effects such as “skin ra sh, itching, conjuctivitis (red, tearing eyes), drowsiness, transient cough, headache, joint pain, agitation, restlessness, or mild gastrointestinal symptoms such as self-limited diarrhea, stomach cramps, or nausea. These effects are reported to have lasted less than one month.”

Note: See PR Notice 98-3 for a more detailed d escription of severity categorization for humans

and domestic animals.5 

### • The following table provides a quick referen ce guide to reporting timeframes and content:



### SEVERITY CATEGORIES
and/or Other Reporting Categories REPORTING TIMEFRAMES

Human Deaths (H-A) ASAP-No Later than 15 days

Submission Format: Individual Report

Provide detailed information for each
incident

Scientific Studies described in (159.165) Information about discontinued studies (159.167) Human epidemiology and exposure studies (159.167) Detection of a unauthorized pesticide in or on food or feed (159.178) Detection of metabolites, degradates, contaminates, impurities (159.179) Failure of performance studies related to public health products (159.188 (a)(2), (b)(2)) Substantiated incidents of pest resistance (159.188 (c)) Other information described in (159.195) Property Damage with risk to human health (PD-A) and other information (159.195) Submit within 30 calendar days

Submission Format: - Individual Report (Food/Feed, Property Damage with risk of injury to humans)

- For all other submissions refer to
159.156

Human – Major (H-B) Human – Moderate (H-C)

Major – Wildlife (W-A) Plant (P-A)

Detection of pesticide in water at levels greater than MCL/HAL (G-A) (159.178 (b) & 159.184 (c)(5))

Efficacy failure incidents regarding public health products(159.188 (a)(1) & (b)(1)) Accumulate 1 Month

Submit by the end of the month following the accumulation period.

Submission Format: Individual Report

Provide detailed information for each incident as required in section 159.184(c)

Human – Minor (H-D) Unspecified or Unknown effects (H-E)

All Domestic Animal (D-A,B,C,D,E) All Other Categories for Wildlife (W-B) Plant (P-B)

Detection of pesticide in water below MCL/HAL but otherwise reportable (G-B,C) ((159.178 (b) & 159.184 (c)(5)) Accumulate 3 Months

Submit by the end of the 2 nd month following the accumulation period

Submission Format: Aggregate

Aggregate and submit count of incidents and effects for each product or AI as required in section 159.184 (e)

Incomplete toxicological and ecological studies (159.165 (d)) Consult sec. 159.165 (d) when testing is completed but study not finalized6 

### • The overall flow of the reporting process is depicted in the following diagram:

• Original and updated versions of these forms and guidance tools are available from the following organizations. These organizations have been clo sely involved in the form development process and
serve as a valuable resource to their constituents a nd others interested in 6(a)(2) related efforts.

American Crop Protections Association Ch emical Specialties Manufacturers Association 1156 Fifteenth St., NW, Suite 400 1913 Eye St. NW Washington, DC 20005 Washington, DC 20006 Phone: (202) 296-1585 Phone: (202) 872-8110 Fax: (202) 463-0474 Fax: (202) 872-8114 Staff contact: Ray McAllister Staff contact: Steve Kellner
Web site: http://www.acpa.org Web site: http://www.csma.org

Chemical Manufacturers Association International Sanitary Supply Association
1300 Wilson Blvd. 7373 North Lincoln Ave. Arlington, VA 22209 Lincolnwood, IL 60646-1799 Phone: (703) 741-5637 Phone: (847) 982-0800 Fax: (703) 741-6091 Fax: (847) 982-1012
Staff contact: Has Shah Staff contact: Bill Balek
Web site: http://www.cmahq.com Web site: http://www.issa.com

Chemical Producers and Distributors Associati on PROSAR Product Safety Call Center
1430 Duke Street 1295 Bandana Blvd. Suite 335 Alexandria, VA 22314 St. Paul, Minnesota 55108 Phone: (703) 548-7700 Phone: (651) 917-6100 Fax: (703) 548-3149 Fax: (651) 641-0341
Staff contact: Warren Stickle Staff contact: Joele Richardson
Web site: http://www.cpda.com Web site: http://www.prosarcorp.com 

## Administrative Incident Data

Aggregate Incident Report

Minor and/or More Common Reportable Incidents 

## Reported Event



# 6(a)(2) Incident Reporting Process

Severity

Classification Single Incident Report (Significant Reportable Incident)

Property Damage with

Risk of Human Injury

Data Fish, Wildlife Plants, NonTarget Organisms

Data Domestic

Animal

Data

Surface

Water

Data Ground

Water

Data Human

Data

Food and Feed Data7 

## KEY TO DATA FIELDS ON INDIVIDUAL INCIDENT FORMS Administrative, Pesticide and In cident Circumstance Data Section
(See attached form)

Row 1 Administrative Data

Field Comments/Description

Reporter name, Address,
Phone # This field refers to the individual that is reporting the incident to the Registrant or Registrants Agent. Anonymous reports where an individual declines to provide a name and other identifying information are not reportable to the EPA.

Submission date This field refers to the date the report is submitted to the agency.

Contact person (If different than reporter), Address,
Phone # This field can be used to identify an individual, other than the reporter, to be contacted for further information related to the incident. Examples could include; parent, physician, lawyer, etc.

Internal ID This optional field may be used by the registrant for internal purposes.

Incident status: New, Update Use this field to identify if this is a new report or an update regarding a previous report.

Location and date of incident Self-explanatory

Date registrant became
aware of incident This date refers to when the registrant, or the registrants agent, was advised of the incident.

Was incident part of larger study An example would include ongoing monitoring of de tections of pesticides in ground or surface

water.



### Row 2 Pesticide Data

Field Comments/Description

EPA Registration # (for up to 3 product identifications) In order for the incident to be a reportable event the product must be identified in at least one of two ways. In order of preference by the agency, they are: 1) EPA Product Registration Number or, 2) Active Ingredient. The product name mu st also be included, if known, but must be accompanied by either EPA Product Regist ration Number or Active Ingredient.

AI (s) Identify the active ingredient here. (see above)

Product name If known, identify the Product Name here. (see above)

Exposed to concentrate prior
to dilution If product is sold in a concentrated form in tended for dilution and the incident involves the concentrate prior to being diluted, indicate so here.

Formulation Identify the formulation if known. Examples c ould include wettable powder, liquid, granules, etc.



### Row 3 Incident Circumstances

Field Comments/Description

Evidence label directions
were not followed If this can be determined from the history and circ umstances of the incident indicate so here.

Applicator certified PCO If the individual applying the pesticide is a certifie d Pest Control Operator, indicate so here.

Incident site Indicate where incident occurred in this area. Examples of incident sites could include home, yard, school, industrial, nursery/greenhouse, surf ace water, commercial turf, building/office, forest/ woods, agricultural (specify crop), right-of-way (rail, utility, highway)). Use descriptors that best describe the information reported.
Situation Describe how the product was being used at the time of the reported incident or what the exposed individual was doing when the expos ure occurred. Examples could include mixing/loading, reentry, applicati on, transportation, repair/ main tenance of application equipment, manufacturing/ formulating). How Exposed Indicate how the individual came in contact with the substance/product. Examples could include direct contact with treated surface, ingestion, spill, drift, runoff, etc.

Incident circumstances Provide a brief description of what happened.8 

## KEY TO DATA FIELDS ON INDIVIDUAL INCIDENT FORMS
Human Incident Information Addendum
(See attached form)

Field Comments/Description

Demographic (Age, Sex, Occupation) Provide the age and sex of the indi vidual exposed. If the incident was occupationally related state the occupation of the individual involved.

Exposure route Exposure route refers to how the person came in contact with the substance or product. Examples could include skin, respiratory, ingestion etc.

Suicide/homicide related

event Indicate here if the incident was the result of a suicide or homicide.

Protective clothing Indicate what type of protective clothing was being used by the individual at the time of the
incident.

Pregnancy Status If the individual is a female and her pregn ancy status is known, indicate here.

Occupational exposure status and workdays lost For those incidents occurring in t he workplace, and where the number of workdays lost is known,
indicate so here.

Time from exposure to development of symptoms Indicate how long after the incident occurred that the first signs and symptoms were noted.

Type of medical care sought If the individual sought medical care indicate t he type of medical care sought. Examples include none, clinic, hospital emergency department, private physician, PCC (Poison Control Center), hospital inpatient.

Signs/symptoms Provide a description of the reported signs and symptoms.

Lab tests If laboratory tests related to the exposure were performed indicate the results.

Exposure Data: (amount, duration, Patient Weight) If amount of product involved and the duration of contact with the product can be determined
indicate so here.

Severity category See information provided in the guidance attachment.

Qualifying information (Optional field) The rule allows Registrants to provide any clarifying or qualifying information
related to the incident or their evaluation of the in cident. Registrant may use this space to record this information and, attach additional pages if necessary.

Internal ID (Optional field) This field is for internal use by Registrant.9 

## KEY TO DATA FIELDS ON INDIVIDUAL INCIDENT FORMS Fish, Wildlife, Plant or Other Non-Target Organism Incidents
Addendum
(See attached form)

Field Comments/Description

List species affected and number of individuals per species Record as noted.

List symptoms or adverse
effects Record as noted.

Magnitude of the effect Record as noted.

Pesticide application rate, intended use site, application
method Record as noted.

If Plant, plant type Record as noted.

If lab test(s) performed, list
name of tests and results (submit laboratory report(s) if available) Record as noted.

Description of the habitat and
the circumstances under
which the incident occurred. Record as noted.

Distance from treatment site This is defined as the distance gener ally reported in feet or yards that a species, generally a bird or fish has been found (usually dead) adjacent to the treated field or site. For instance, a fish kill could have been reported to have occurred 100 yard from the treatment site.

Fish, wildlife, plant, other nontarget organism severity category Record as noted.

Other severity categories reported: Record as noted.

Additional space for answers or explanatory information in
this box. (Optional field) The rule allows Registrants to provide any clarifying or qualifying information
related to the incident or their evaluation of the in cident. Registrant may use this space to record this information and, attach additional pages if necessary.

Internal ID# (Optional field) This field is for internal use by Registrant.10 

## KEY TO DATA FIELDS ON INDIVIDUAL INCIDENT FORMS
Domestic Animals
(See attached form)

Field Comments/Description

Type of animal Record as noted.

Breed/species (name, no./adv effect) Identify the breed and species as well as number of animals displaying each category of adverse
effect.

Exposure route Exposure route refers to how the animal came in contact with the substance or product. Examples could include skin, respiratory, ingestion etc.

Time between exposure and onset of symptoms Indicate how long after the incident occurred that the first signs and symptoms were noted.

Signs/symptoms/adverse
effects Provide a description of the reported signs and symptoms.

If lab test(s) performed, list
name of tests and results (submit laboratory report(s) if available) Record as noted.

Additional space for answers or explanatory information (Optional field) The rule allows Registrants to provide any clarifying or qualifying information
related to the incident or their evaluation of the in cident. Registrant may use this space to record this information and, attach additional pages if necessary.11 

## KEY TO DATA FIELDS ON INDIVIDUAL INCIDENT FORMS
Detections of Pesticides in Surface Water Information
(See attached form)

Field Comments/Description

Pesticide/degradates analyzed for, methods of analysis, corresponding
detection limits and amount
detected Record as noted.

If raw water samples, water bodies sampled and approximate locations in each water body Record as noted.

If raw water samples, proximity of sampling locations to drinking water supply intakes and identities of systems supplied Record as noted.

If finished water samples, water supply systems sampled Record as noted.

If finished water samples, percent surface water source by specific surface water sources to water supply system(s) Record as noted.

Amount of pesticide detected Record as noted.

Sampling times/frequency Record as noted.

Sample type: (Grab, composite, Other) Record as noted.

Water severity category Record as noted.

Additional space for answers or explanatory information in
this box (Optional field) The rule allows Registrants to provide any clarifying or qualifying information
related to the incident or their evaluation of the in cident. Registrant may use this space to record this information and, attach additional pages if necessary.12 

## KEY TO DATA FIELDS ON INDIVIDUAL INCIDENT FORMS
Detections of Pesticides in Groundwater Incident
(See attached form)

Field Comments/Description

Pesticide/degradates analyzed for, methods of analysis, corresponding detection limits
and amount detected Record as noted.

Sample dates (s) Record as noted.

Depth to Water Record as noted.

Well use/well identifier Record as noted.

Screened interval Record as noted.

Soil series/texture: (Sand/Clay/Silt/Other) Record as noted.

Latitude/longitude Record as noted.

Aquifer description:
Confined/Unconfined Record as noted.

Hydrologic group Record as noted.

Hydraulic conductivity Record as noted.

pH of water Record as noted.

Organic matter/organic carbon (percent) Record as noted.

Maximum rainfall/date Record as noted.

Annual cumulative rainfall (inches) Record as noted.

Cumulative irrigation (inches) Record as noted.

Years pesticide used Record as noted.

Application frequency/yr. Record as noted.

Application method Record as noted.

Date of last application Record as noted.

Water severity category Record as noted.

Additional space for answers or explanatory information in
this box (Optional field) The rule allows Registrants to provide any clarifying or qualifying information
related to the incident or their evaluation of t he incident. Registrant may use this space to record this information and, attach additional pages if necessary.13 

## KEY TO DATA FIELDS ON INDIVIDUAL INCIDENT FORMS

Property Damage with Risk of Human Injury Information
(See attached form)

Field Comments/Description

Describe Property damage Record as noted.

Property severity category All reportable property damage should be labeled “PD-A”

Additional space for answers or explanatory information in
this box (Optional field) The rule allows Registrants to provide any clarifying or qualifying information
related to the incident or their evaluation of the in cident. Registrant may use this space to record this information and, attach additional pages if necessary.14 

## KEY TO DATA FIELDS ON INDIVIDUAL INCIDENT FORMS
Unauthorized Residue in Food & Feed
(See attached form)

Field Comments/Description

Pesticide/degradates analyzed for and corresponding detection limits Record as noted.

Amount of Pesticide detected Record as noted

Sample type Record as noted

Method of analysis Record as noted

Tolerance level Record as noted

Additional space for answers or explanatory information (Optional field) The rule allows Registrants to provide any clarifying or qualifying information
related to the incident or their evaluation of the in cident. Registrant may use this space to record this information and, attach additional pages if necessary.15 

### Voluntary Industry Reporting Form for 6(a )(2) Adverse Effects In cident Information
Provide all known, required information. If required data field informa tion is unknown, designate as such in appropriate area. Page# of

Row 1

Administrative

Data Reporter Name Submission
date. Contact person (if different than reporter) Internal ID

Address Address

Phone # Phone #

Incident Status: New__ Update__ If update, include date of original submission. Location and date of incident. (City, County, State) Date registrant
became aware of
incident. Was incident part of larger study? Y___N___U___

Row 2

Pesticide(s)
Involved EPA Registration # (Product 1) EPA Registration # (Product 2) EPA Registration # (Product 3

A.I. (s) A.I. (s) A.I. (s)

Product 1 name Product 2 Name Product 3 Name

Exposed to concentrate prior to dilution? Y___N___U___NA___ Exposed to concentrate prior to dilution? Y___N___U___NA___ Exposed to concentrate prior to dilution? Y___N___U___NA___

Formulation Formulation Formulation

Evidence label
directions were not
followed? Yes___No___U___ Intentional misuse___ Row 3

Incident
Circumstances

Applicator certified

PCO? Yes__No__U__ Incident site: (examples include home, yard, school, industrial, nursery/greenhouse, surface water, commercial turf, building/office, forest/ woods, agricultural (specify crop) right-of-way (rail, utility, highway)). Situation (act of using product): (examples include mixing/loading, reentry, application, transportation, repair/ maintenance of application equipment, manufacturing/ formulating).

How exposed: (examples include
direct contact with treated surface, ingestion, spill, drift, runoff) Brief description of incident circumstances.16 

### Voluntary Industry Reporting Form for 6(a )(2) Incident Information Involving Humans
Provide all known, required information. If required data field informa tion is unknown, designate as such in appropriate area. Page# of

Demographic information: Age_____ Sex_______ Occupation (if relevant) Exposure route: Skin___ Eye___ Oral___ Respiratory___ Unknown___
Other: Was adverse effect result of suicide/homicide or attempted
suicide/homicide?

If female, pregnant? Yes___ No___ Unknown___ Was exposure occupational? Yes___ No___ Unknown___ If yes, days lost due to illness: Time between exposure and onset of symptoms: Was protective clothing worn (specify)?

Type of medical care sought: (examples include none, clinic, hospital emergency department, private physician, PCC, hospital inpatient).

Exposure data: Amount of pesticide:

Exposure duration:

Victim weight: ____lb ____kg ____unknown

Human severity category___ List signs/symptoms/adverse effects If lab tests were performed, list test names and results (If available, submit reports)

This box can be used to provide any explanatory or qualifying in formation surrounding the incident. (add additional pages if n ecessary)

Internal ID #17 

### Voluntary Industry Reporting Form for 6(a)(2) Incident Informati on Involving Fish, Wildlife, Plants or Other Non-Target Org. Provide all known, required information. If required data field informa tion is unknown, designate as such in appropriate area. Page# of List species affected and numb er of individuals per species.

List symptoms or adverse effects.

Magnitude of the effect: (Examples include miles of streams, square area of terrestrial habitat).

If plant, plant type: (Examples include crop, forest, forage, orchard, home garden, ornamental). Pesticide application rate, intended use site (examples: corn, turf), and application method

If lab test(s) performed, list name of tests and re sults (submit laboratory report(s) if available).

Description of the habitat and the circumst ances under which the incident occurred.

Distance from treatment site. Fish, wildlife, plant, other non-target organism severity categories:______:______:______ Include all categories that apply, ex. W, P, ONT

This box can be used to provide any explanatory or qualifying information surrounding the incident (add additional pages if nec essary).

Internal ID#18 

### Voluntary Industry reporting form fo r 6(a)(2) Incident Information

If incident involves domestic animals use this form to collect info rmation to be reported on the aggregate form. Page# of

Type of animal: (Examples include livestock, bird, fish, poultry, pet (specify)). Exposure route: (Examples include skin, eye, oral, respiratory, unknown).

Domestic animal severity category___ Breed/species (name, no./adv.Effect)

Time between exposure and onset of
symptoms:

List sign/symptoms/adverse effects. Was animal treated (optional)?

If lab test(s) performed, list name of tests and re sults (submit laboratory report(s) if available)

This box can be used to provide any explanatory or qualifying in formation surrounding the incident (add additional pages if nec essary).

Internal ID#19 

### Voluntary Industry Reporting Form fo r 6(a)(2) Incident Information
Detections of Pesticides in Surface Water Provide all known information. If required data field information is unknown, designate as such in appropriate area. Page# of

Pesticide/degradates analyzed for, methods of analysis, corresponding detection limits and amount detected:

Pesticides Degradates Method of analysis Detection limit Amount detected

Sampling times/frequency Sample type: (Grab, composite, other)

If raw water samples, water bodies sampled and approximate locations in each water body. If raw water samples, proximity of sampling locations to drinking water supply intakes and identities of systems supplied

If finished water samples, wa ter supply systems sampled

Water severity category If finished water samples, percent surface water source by specific surface water sources to water supply system(s)

Additional space for answers or explanatory information in this box.

Internal ID#20 

### Voluntary Industry Reporting Form fo r 6(a)(2) Incident Information
Detections of Pesticides in Groundwater Provide all known information. If required data field information is unknown, designate as such in appropriate area. Page # of

Pesticide/degradates analyzed for, methods of analysis, corresponding detection limits and amount detected:

Pesticides Degradates Method of analysis Detection limit Amount detected

Date sample collected Depth to groundwater Well use/well identifier

Screened interval Soil series and texture: (sand, clay, silt, other) Latitude/longitude

Aquifer description: Confined ____ Unconfined ____ Hydrologic group. Hydraulic conductivity.

pH of water. Organic matter/organic ca rbon (percent). Maximum rainfall and date

Annual cumulative rainfall Cumulative irrigation (inches). Years Pesticide used.

Application frequency per year. Application method

Date of last application Water severity category

Additional space for answers or explanatory information in this box.

Internal ID#21 

### Voluntary Industry Reporting Form for 6(a)(2) Incident Information Incident involving property damage with risk of human injury. Page# of

Describe property damage (if any).

PD - A

Additional space for answers or explanatory information in this box

Internal ID#22 

### Voluntary Industry Reporting Form for 6(a)(2) Incident Information
Unauthorized Residue in Food and Feed

Provide all known information. If required data field info rmation is unknown, designate as such in appropriate area. Page# of

Pesticides/degradates analyzed for and corresponding detection limits

Amount of Pesticide detected

Sample type Sampling times/frequency

Method of analysis Tolerance Level

This box can be used to provide any explanatory or qualifying in formation surrounding the incident (add additional pages if nec essary).

Internal ID#23 

## FIFRA 6(a)(2) Aggregate Inci dent and Effect Information

Submission Form Instructions

Under 6(a)(2) aggregate reporting, the registrant is required to provide an aggregate summary of adverse incidents reported to the registrant that are outside of serious incidents which require individual reports. The attached form is a reporting template developed by industry representatives, in cooperation with the EPA, to facilitate this aspect of 6(a)(2) reporting. Use of this specific form is voluntary and other methods of reporting to achieve the same goal are also acceptable. The instructi ons for filling in the fields on this form are as follows:

Product Identification : In order for the incident to be a reportable event the product must be identified in at least one of two ways. In order of preference by the agency, they are: 1) EPA Product Registration Number or, 2) Active Ingredient. The product name must also be included, if known, but must be accompanied by either EPA Product Registration Number or Active Ingredient.

Internal ID # : The Internal ID # is an optional field reserv ed for use by the registrant to reference that particular summary.

Submission Date : The Submission Date refers to the regist rant’s date of submission for this report.

Time Period Covered : Although some registrants may elect to report more frequently, data may be accumulated for a maximum of 90 days (interpreted by EPA as 3 months) then repo rted within 60 days (interpreted by EPA as 2 months). The registrant should state the time period this aggregate report covers. Considering maximums, an example would be accumulating data for the months of July, August and September, then submitting the aggregate report to the Agency on or before the last day of November.

Total Incidents : This field represents the total number of incidents which resulted in one or more of the “Exposure types and Category Designations.”

Exposure Types and Severity Category Designations : There are a total of 12 exposure types and severity category designations included in aggregate reporting to describe a given type of exposure and reported effects (see definitions on attached page). Each incident will involve a minimum of one exposure type and severity category designation but could involve multiple designa tions. When an exposure type and severity category designation is reported it is counted only once per incident, regardless of the number occurring in that incident. As an example, one incident involving 5 humans each ha ving effects that would be categorized as H-D would result in category H-D being counted just once in the aggregate report. If that same incident also included 3
occurrences of a B effect in domes tic animals then the “D-B” category designation would have a 1 placed in that box also. It should be noted that in the exposure types involving wildlife or plants the number of organisms affected is reflected in the level of the category.

Additional Information : Registrant may use this optional area to provide supplemental information that may explain, qualify, or otherwise aid in the interpretation of information provided in the aggregate summary. There is no limit as to the amount of information that can be provided in this area. Please note that this information will not appear in the EPA database but will be made available to the scientific review
committees.

These forms contain fields for reporting of information which may or may not be required to be reported to EPA under FIFRA 6(a)(2) and the regulations at 40 CFR 159.152 et.seq.. Use of this form is voluntary and is not intended to infer that any designated fields should be submitted to EPA or to mandate reporting of any specific information to EPA. Registrants/or applicants should consult their own legal counsel or FIFRA 6(a)(2) Reporting Officers before responding.24 

## SUMMARY OF EXPOSURE TY PES & SEVERITY CATEGORIES
INCLUDED IN AGGREGATE REPORTING*

H-D (Human) If the person alleged or exhibited some symptoms, but they were minimally traumatic. The symptoms resolved rapidly and usually involve skin, eye or respiratory irritation.

H-E (Human) If symptoms are unknown, unspecified.

D-A (Domestic Animal) If the domestic animal died or was euthanized.

D-B (Domestic Animal) If the domestic animal exhibited or was alleged to have exhibited symptoms which may have been lifethreatening or resulted in residual disability.

D-C,D,E (Domestic Animal) D-C : If the domestic animal exhibited or was alleged to have exhibited symptoms which are more pronounced, more prolonged or of a more systemic na ture than minor symptoms. Usually some form of treatment would have been indicated to treat the animal. Symptoms were not life threatening and the animal has returned to its pre-exposure state of health with no additional residual disability.

D-D : If the domestic animal was alleged to have exhibited symptoms, but they were minimally bothersome. The symptoms resolved rapidly and usua lly involve skin, eye or respiratory irritation.

D-E : If symptoms are unknown or not specified.

W-B (Wildlife) Use W-B if none of the following criteria are met: (A) Involves any incident caused by a pesticid e currently in Formal Review for ecological concerns. (B) Fish: Affected 1,000 or more individuals ofa schooling species or 50 or more individuals of a nonschooling species. (C) Birds: Affected 200 or more individuals of a flocking species, or 50 or more individuals of a songbird species, or 5 or more indi viduals of a predatory species. (D) Mammals, reptiles, amphibians: Affected 50 or more individuals of a re latively common or herding species or 5 or more individuals of a rare or solitary species. (E) Involves effects to, or illegal pesticide treatme nt (misuse) of a substantia l tract of habitat (greater than or equal to 10 acres, terrestrial or aquatic). (F) Involves a major spill or discharge (great er than or equal to 5,000 gallons) of a pesticide. (G) Involves adverse effects cau sed by a pesticide, to federally listed endangered or threatened species.

P-B (Plant) If an alleged effect involves damage to plants, label the incident P-A if the single criterion listed in (A) of this section is met, or P-B if the criterion is not met: (A) The effect is alleged to have occurred on more than 45 percent of the acreage exposed to the pesticide.

ONT (Other non Target Organism) If an alleged effect involves damage to non-target organisms other than fish, wildlife or plants (for example, beneficial insects), label the incident ONT

.

G-B(Groundwater) If a pesticide is alleged to have been detected in groundwater, surface water or finished drinking water, label the incident in accordance with the following criteria:
G-B : If the pesticide was detected at levels greater than 10 percent of the MCL, HAL or a criterion for ambient water quality but does not exceed the MCL or other applicable level.

G-C(Groundwater) If the pesticide was detected at levels less than 10 pe rcent of the MCL, HAL, or ot her applicable level, or
there is no established level of concern.

*See 40 CFR Part 159.184 for full text and definitions.FIFRA 6(a)(2) Aggregate Incident and Effect InformationSubmission Form(Suggested Format)Submission Datepage #_____ of_____Product Registration #Time Period Covered:Total Incidents =Active Ingredient(s)Product Name (if known)Exposure Types and Severity Category DesignationsH-D H-E D-A D-B D-C,D,E W-B P-B ONT G-B G-CInternal IDAdditional Information:

## FIFRA 6(a)(2) Aggregate Incide nt and Effect Information
Submission Form (Suggested Format) Submission Date Page # _____ of

_____ Product Registration # Time Period Covered Total Incidents =

Active Ingredient(s) Product Name (if known)

Exposure Types and Severity Category Designations
H-D H-E D-A D-B D-C,D,E W-B P-B ONT G-B G-C Internal ID

Additional information:

Product Registration # Time Period Covered Total Incidents =

Active Ingredient(s) Product Name (if known)

Exposure Types and Severity Category Designations
H-D H-E D-A D-B D-C,D,E W-B P-B ONT G-B G-C Internal ID

Additional information:

Product Registration # Time Period Covered Total Incidents =

Active Ingredient(s) Product Name (if known)

Exposure Types and Severity Category Designations
H-D H-E D-A D-B D-C,D,E W-B P-B ONT G-B G-C Internal ID

Additional information:

Product Registration # Time Period Covered Total Incidents =

Active Ingredient(s) Product Name (if known)

Exposure Types and Severity Category Designations
H-D H-E D-A D-B D-C,D,E W-B P-B ONT G-B G-C Internal ID

Additional information: