"Incident Report Form" - California

Incident Report Form is a legal document that was released by the California Department of Pesticide Regulation - a government authority operating within California.

Form Details:

  • The latest edition currently provided by the California Department of Pesticide Regulation;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the California Department of Pesticide Regulation.

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Incident Notes
Form to record notes about a pesticide incident
This form will help you record your notes about a pesticide incident or illness.
The information can help investigators find out what happened.
GENERAL INFORMATION
You do not need to provide personal information if you do not want to. You can file a
complaint without giving your name or the name of anyone else.
Your name ________________________________________________________________________________
Your address ______________________________________________________________________________
__________________________________________________________________________________________
Do you want a copy of the incident report mailed to you?
Yes
No
Your phone number ________________________________________________________________________
Names of other witnesses (if you know them) __________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
DESCRIBE WHAT HAPPENED
Where the incident happened (please write in the street address or the general location) _____________
__________________________________________________________________________________________
__________________________________________________________________________________________
The date and time of the incident _____________________________________________________________
Was it:
Indoors
Outdoors
If it was indoors, was it:
At home
At a school
At work
Other (please specify)______________________________
If it was outdoors, was it:
In your back yard
On your street
In a park
In your front yard
At a school playground
Along a road
In an agricultural field
Other _________________________________________________________
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Recognizing & RepoRting pesticide pRoblems
Incident Notes
Form to record notes about a pesticide incident
This form will help you record your notes about a pesticide incident or illness.
The information can help investigators find out what happened.
GENERAL INFORMATION
You do not need to provide personal information if you do not want to. You can file a
complaint without giving your name or the name of anyone else.
Your name ________________________________________________________________________________
Your address ______________________________________________________________________________
__________________________________________________________________________________________
Do you want a copy of the incident report mailed to you?
Yes
No
Your phone number ________________________________________________________________________
Names of other witnesses (if you know them) __________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
DESCRIBE WHAT HAPPENED
Where the incident happened (please write in the street address or the general location) _____________
__________________________________________________________________________________________
__________________________________________________________________________________________
The date and time of the incident _____________________________________________________________
Was it:
Indoors
Outdoors
If it was indoors, was it:
At home
At a school
At work
Other (please specify)______________________________
If it was outdoors, was it:
In your back yard
On your street
In a park
In your front yard
At a school playground
Along a road
In an agricultural field
Other _________________________________________________________
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Recognizing & RepoRting pesticide pRoblems
Incident Notes
How far away were you? ____________________________________________________________________
What did you see? Describe what happened. For example, did you see a pesticide application nearby?
Was there a spill or a leak? Was the pesticide being sprayed? Being mixed? Transported? _______________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
If you saw it, describe the equipment being used to apply the pesticide
A tractor. Was the tractor spraying up or down?
Up
Down
A hand-held or backpack sprayer
A helicopter
An airplane
Other ______________________________
Use this space to makes notes about the color, license number, or other markings on the equipment
used to apply the pesticide: __________________________________________________________________
__________________________________________________________________________________________
Did you see any dust or particles?
Yes
No
Describe the weather:
Wind
Wind direction from the:
Skies
No wind
North
Clear
Light breeze
South
Cloudy
Medium wind
East
Foggy
Strong wind
West
Raining/drizzling
Gusty winds
From direction of this landmark: __________________________
If you know, what was the name of the pesticide? ______________________________________________
If you know the name of the company, utility, or government agency doing the application (for
example, you saw their truck), write it here: ___________________________________________________
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Recognizing & RepoRting pesticide pRoblems
Incident Notes
WHAT WERE THE EFFECTS?
Did you smell or taste anything unusual? If so, describe it as best you can. Try to associate the odor with
something familiar, like rotten eggs, sweet or sour chemicals, garlic, or chlorine. Some other descriptions
are oily, metallic, sharp, burning, light or heavy.
__________________________________________________________________________________________
__________________________________________________________________________________________
Did you feel anything on your skin, eyes, or clothing?
Yes
No
Did you inhale fumes?
Yes
No
Did you eat contaminated food?
Yes
No
If yes, what was it?_________________________
Was anyone injured?
Yes
No
If yes, when did they start feeling sick? _______________________________________________________
__________________________________________________________________________________________
Name of the injured person, or the type of animal or plant injured. _______________________________
(You don’t have to provide names or other personal information, if you do not want to.)
Address of injured person ___________________________________________________________________
__________________________________________________________________________________________
(If you know the names of other people who were injured, you can write them below)
What were their symptoms? What part of the body was affected? How long did the symptoms last?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Did the injured person go to the doctor or to the hospital? If so, please list the name of the doctor or
hospital, and phone number if you have it. ____________________________________________________
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Recognizing & RepoRting pesticide pRoblems
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