Industry’s 

Voluntary 6(a)(2) Incident 

Reporting Forms 

& 

Guidance Documents 

August 4, 1998 
 

 2 

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 26 
 

 3 

Information Regarding the Use of the 

Voluntary 6(a)(2) Incident Reporting Forms 

Introduction 

A number of industry trade organizations, registrants, 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 requirements under 6(a)(2). Use of 

these specific forms for required reporting is voluntary. 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 individually. 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 appropriate method of reporting that incident to the EPA 

can then be determined. 

The single incident forms are divided into two specific areas. The first area describes “administrative 

data” or general demographic and product information that is gathered for any incident. There are seven 

supplemental addenda relating to the seven incident types i.e., human, domestic animal, 

fish/wildlife/plant/other non-target organisms, groundwater, surface water, food and feed, and property 

damage with risk of human injury. After collecting 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 individually 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 document 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 Pesticide Registration Notice (PR Notice) 98-3. 

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.
 

 4 

General Considerations: 

• Due to the nature of incidents and how they are typically reported through the 6(a)(2) process, 

Registrants do not guarantee the authenticity or accuracy of information contained in the reports 

required to be submitted to the Agency. 

• The forms contain some fields of data that are optional. These fields are used to aid the Registrant in 

general data collection purposes. In some cases these fields represent data that are not required but 

can be submitted to document important information 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 related 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 information that has been provided. No investigation or 

follow-up is required, but may be useful if further 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 notice (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 humans 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 development of delayed symptoms should be considered 

when classifying severity. For example, human cases may report developing common 

symptoms like headaches, general weakness, memory 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 rash, 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 description of severity categorization for humans 

and domestic animals. 
 

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• The following table provides a quick reference 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 2nd 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 finalized 
 

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• 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 closely involved in the form development process and 

serve as a valuable resource to their constituents and others interested in 6(a)(2) related efforts. 

American Crop Protections Association Chemical 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 Association 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 Data
 

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KEY TO DATA FIELDS ON INDIVIDUAL INCIDENT FORMS 

Administrative, Pesticide and Incident 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 detections 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 must also be included, if known, but must be 

accompanied by either EPA Product Registration 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 intended for dilution and the incident involves the 

concentrate prior to being diluted, indicate so here. 

Formulation Identify the formulation if known. Examples could 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 circumstances of the incident indicate so here. 

Applicator certified PCO If the individual applying the pesticide is a certified 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, surface 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 exposure occurred. Examples could include 

mixing/loading, reentry, application, transportation, repair/ maintenance 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. 
 

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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 individual 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 pregnancy status is known, indicate here. 

Occupational exposure status 

and workdays lost 

For those incidents occurring in the 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 the 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 incident. 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. 
 

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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 generally 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 incident. 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.
 

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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 incident. Registrant may use this space to record 

this information and, attach additional pages if necessary. 
 

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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 incident. 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 the 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 incident. 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 incident. 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 Incident Information 

Provide all known, required information. If required data field information 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 information 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 information surrounding the incident. (add additional pages if necessary) 

Internal ID # 
 

 17 

Voluntary Industry Reporting Form for 6(a)(2) Incident Information Involving Fish, Wildlife, Plants or Other Non-Target Org. 

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

List species affected and number 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 results (submit laboratory report(s) if available). 

Description of the habitat and the circumstances 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 necessary). 

Internal ID# 
 

 18 

Voluntary Industry reporting form for 6(a)(2) Incident Information 

If incident involves domestic animals use this form to collect information 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 results (submit laboratory report(s) if available) 

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

Internal ID# 
 

 19 

Voluntary Industry Reporting Form for 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, water 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 for 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 carbon (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 information 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 information surrounding the incident (add additional pages if necessary). 

Internal ID# 
 

 23 

FIFRA 6(a)(2) Aggregate Incident 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 instructions 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 reserved for use by the registrant to reference that 

particular summary. 

Submission Date: The Submission Date refers to the registrant’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 reported 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 designations. 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 having 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 domestic 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 TYPES & 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 nature 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 usually 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 pesticide currently in Formal Review for ecological concerns. 

 (B) Fish: Affected 1,000 or more individuals of a 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 individuals of a predatory species. 

 (D) Mammals, reptiles, amphibians: Affected 50 or more individuals of a relatively common or herding 

species or 5 or more individuals of a rare or solitary species. 

 (E) Involves effects to, or illegal pesticide treatment (misuse) of a substantial tract of habitat (greater 

than or equal to 10 acres, terrestrial or aquatic). 

 (F) Involves a major spill or discharge (greater than or equal to 5,000 gallons) of a pesticide. 

 (G) Involves adverse effects caused 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 percent of the MCL, HAL, or other 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 Information

Submission Form (Suggested Format)

Submissio

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 

Internal ID Additional Information: 
FIFRA 6(a)(2) Aggregate Incident 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: