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State of California - Environmental Protection Agency Office of Environmental Health Hazard Assessment CONFIDENTIAL REPORT OF KNOWN OR SUSPECTED PESTICIDE-RELATED ILLNESS Please provide as much information as possible.
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Document Date: 2014-03-11 14:08:54

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File Size: 222,11 KB

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City

San Francisco / Sacramento / /

Currency

USD / /

Facility

Laboratory Tests Conducted / /

IndustryTerm

state law / pesticide application equipment / /

MedicalCondition

incoordination / allergies / Edema Confusion Erythema / acute pesticide illness / disease / shortness of breath / Dermatologic Neurologic/Sensory Blistering Anxiety/Irritability Burns Ataxia / Rhinitis / pesticide illness / runny nose / pesticide poisoning / injury / pesticide-related illness / Photophobia Other_____________________ Respiratory Cough Dyspnea / Irritation / suspected pesticide illness / Pruritis (itching) Dizziness Rash Fasciculation / Miosis / asthma / /

Organization

Environmental Protection Agency office of Environmental Health Hazard Assessment Pesticide Exposure Date Name / office of Environmental Health Hazard Assessment Pesticide / Department of Pesticide Regulation / Department of Industrial Relations Division of Labor Statistics / Environmental Protection Agency office of Environmental Health Hazard Assessment CONFIDENTIAL REPORT OF KNOWN OR SUSPECTED PESTICIDE-RELATED ILLNESS Please / Department of Pesticide Regulation Worker Health / /

Person

Civil Code / /

/

Position

Supervisor / Governor / county agricultural commissioner / physician / local health officer / /

ProvinceOrState

Alaska / Code County / Latino Unknown Year Day County / California / /

Technology

cellular telephone / /

URL

http /

SocialTag