Form PR-ENF-128 "Pesticide Episode Investigation Non-occupational Exposure Supplement" - California

What Is Form PR-ENF-128?

This is a legal form that was released by the California Department of Pesticide Regulation - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2003;
  • The latest edition provided by the California Department of Pesticide Regulation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form PR-ENF-128 by clicking the link below or browse more documents and templates provided by the California Department of Pesticide Regulation.

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Download Form PR-ENF-128 "Pesticide Episode Investigation Non-occupational Exposure Supplement" - California

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State of California
Department of Pesticide Regulation
Enforcement Branch
PESTICIDE EPISODE INVESTIGATION NON-OCCUPATIONAL EXPOSURE SUPPLEMENT
PR-ENF-128 (Est. 12/03)
Page 1 of 2
NAME OF PERSON INTERVIEWED
ADDRESS (Number and Street, City, State, ZIP Code)
TELEPHONE NUMBER (Include Area Code)
COUNTY
DATE OF EXPOSURE
TIME OCCURRED
AM
PM
EXPOSURE SITE
IS EXPOSURE ONGOING?
NUMBER EXPOSED OUTDOORS
HOUSE
APARTMENT
SCHOOL
VEHICLE TYPE
YES
NO
NUMBER EXPOSED INDOORS
RETAIL
OPEN AREA
OTHER
DID ANYONE SEE A DOCTOR?
HOW MANY SAW A DOCTOR?
NAME OF DOCTOR/MEDICAL FACILITY
YES
NO
ADDRESS OF DOCTOR/MEDICAL FACILITY (Number and Street, City, State, ZIP Code)
TELEPHONE NUMBER (Include Area Code)
WAS ANYONE HOSPITALIZED? IF "YES", HOW MANY PERSONS? IF "YES", LENGTH OF STAY (DAYS)
DATE(S) PERSONS SAW A DOCTOR
YES
NO
LOCATION OF EXPOSURE - BE SPECIFIC. USE PAGE 2, IF NEEDED; ATTACH A MAP, IF DESIRED.
DESCRIBE HOW EXPOSURE OCCURRED. DESCRIBE LOCATION, ACTIVITIES, WHAT HAPPENED, WHAT WAS SEEN, HEARD, SMELLED, TASTED, AND FELT. USE PAGE 2, IF NEEDED.
NAME OF PERSONS EXPOSED IN BUILDING
GENDER
DATE OF BIRTH
HAVE SYMPTOMS
SYMPTOMS EXPERIENCED
(CONTINUE LIST ON PAGE 2, IF NECESSARY)
(M/F)
(OR AGE)
RESOLVED?
EYES BURN/TEAR
NOSE IRRITATION
COUGH
DIZZY
(SPACE 1 IS FOR PERSON BEING INTERVIEWED)
YES
SORE THROAT
SHORT BREATH
RASH/ITCH
ODOR
NO
1
HEADACHE
VOMIT/NAUSEA
OTHER
EYES BURN/TEAR
NOSE IRRITATION
COUGH
DIZZY
YES
SORE THROAT
SHORT BREATH
RASH/ITCH
ODOR
NO
2
HEADACHE
VOMIT/NAUSEA
OTHER
EYES BURN/TEAR
NOSE IRRITATION
COUGH
DIZZY
YES
SHORT BREATH
RASH/ITCH
SORE THROAT
ODOR
NO
3
HEADACHE
VOMIT/NAUSEA
OTHER
EYES BURN/TEAR
NOSE IRRITATION
COUGH
DIZZY
YES
SHORT BREATH
RASH/ITCH
SORE THROAT
ODOR
NO
4
HEADACHE
VOMIT/NAUSEA
OTHER
EYES BURN/TEAR
NOSE IRRITATION
COUGH
DIZZY
YES
SHORT BREATH
RASH/ITCH
SORE THROAT
ODOR
NO
5
HEADACHE
VOMIT/NAUSEA
OTHER
EYES BURN/TEAR
NOSE IRRITATION
COUGH
DIZZY
YES
SORE THROAT
SHORT BREATH
RASH/ITCH
ODOR
NO
6
HEADACHE
VOMIT/NAUSEA
OTHER
EYES BURN/TEAR
NOSE IRRITATION
COUGH
DIZZY
YES
SORE THROAT
SHORT BREATH
RASH/ITCH
ODOR
NO
7
HEADACHE
VOMIT/NAUSEA
OTHER
EYES BURN/TEAR
NOSE IRRITATION
COUGH
DIZZY
YES
SORE THROAT
SHORT BREATH
RASH/ITCH
ODOR
NO
8
HEADACHE
VOMIT/NAUSEA
OTHER
PESTICIDE ALLEGEDLY INVOLVED
REGISTRATION NUMBER FROM LABEL
COMMODITY/SITE TREATED
PERSON/FIRM ALLEGEDLY RESPONSIBLE
OWNER OR OPERATOR OF PROPERTY TREATED
INVESTIGATOR'S NAME (PRINT)
INVESTIGATOR'S SIGNATURE
TITLE
DATE
(Over)
State of California
Department of Pesticide Regulation
Enforcement Branch
PESTICIDE EPISODE INVESTIGATION NON-OCCUPATIONAL EXPOSURE SUPPLEMENT
PR-ENF-128 (Est. 12/03)
Page 1 of 2
NAME OF PERSON INTERVIEWED
ADDRESS (Number and Street, City, State, ZIP Code)
TELEPHONE NUMBER (Include Area Code)
COUNTY
DATE OF EXPOSURE
TIME OCCURRED
AM
PM
EXPOSURE SITE
IS EXPOSURE ONGOING?
NUMBER EXPOSED OUTDOORS
HOUSE
APARTMENT
SCHOOL
VEHICLE TYPE
YES
NO
NUMBER EXPOSED INDOORS
RETAIL
OPEN AREA
OTHER
DID ANYONE SEE A DOCTOR?
HOW MANY SAW A DOCTOR?
NAME OF DOCTOR/MEDICAL FACILITY
YES
NO
ADDRESS OF DOCTOR/MEDICAL FACILITY (Number and Street, City, State, ZIP Code)
TELEPHONE NUMBER (Include Area Code)
WAS ANYONE HOSPITALIZED? IF "YES", HOW MANY PERSONS? IF "YES", LENGTH OF STAY (DAYS)
DATE(S) PERSONS SAW A DOCTOR
YES
NO
LOCATION OF EXPOSURE - BE SPECIFIC. USE PAGE 2, IF NEEDED; ATTACH A MAP, IF DESIRED.
DESCRIBE HOW EXPOSURE OCCURRED. DESCRIBE LOCATION, ACTIVITIES, WHAT HAPPENED, WHAT WAS SEEN, HEARD, SMELLED, TASTED, AND FELT. USE PAGE 2, IF NEEDED.
NAME OF PERSONS EXPOSED IN BUILDING
GENDER
DATE OF BIRTH
HAVE SYMPTOMS
SYMPTOMS EXPERIENCED
(CONTINUE LIST ON PAGE 2, IF NECESSARY)
(M/F)
(OR AGE)
RESOLVED?
EYES BURN/TEAR
NOSE IRRITATION
COUGH
DIZZY
(SPACE 1 IS FOR PERSON BEING INTERVIEWED)
YES
SORE THROAT
SHORT BREATH
RASH/ITCH
ODOR
NO
1
HEADACHE
VOMIT/NAUSEA
OTHER
EYES BURN/TEAR
NOSE IRRITATION
COUGH
DIZZY
YES
SORE THROAT
SHORT BREATH
RASH/ITCH
ODOR
NO
2
HEADACHE
VOMIT/NAUSEA
OTHER
EYES BURN/TEAR
NOSE IRRITATION
COUGH
DIZZY
YES
SHORT BREATH
RASH/ITCH
SORE THROAT
ODOR
NO
3
HEADACHE
VOMIT/NAUSEA
OTHER
EYES BURN/TEAR
NOSE IRRITATION
COUGH
DIZZY
YES
SHORT BREATH
RASH/ITCH
SORE THROAT
ODOR
NO
4
HEADACHE
VOMIT/NAUSEA
OTHER
EYES BURN/TEAR
NOSE IRRITATION
COUGH
DIZZY
YES
SHORT BREATH
RASH/ITCH
SORE THROAT
ODOR
NO
5
HEADACHE
VOMIT/NAUSEA
OTHER
EYES BURN/TEAR
NOSE IRRITATION
COUGH
DIZZY
YES
SORE THROAT
SHORT BREATH
RASH/ITCH
ODOR
NO
6
HEADACHE
VOMIT/NAUSEA
OTHER
EYES BURN/TEAR
NOSE IRRITATION
COUGH
DIZZY
YES
SORE THROAT
SHORT BREATH
RASH/ITCH
ODOR
NO
7
HEADACHE
VOMIT/NAUSEA
OTHER
EYES BURN/TEAR
NOSE IRRITATION
COUGH
DIZZY
YES
SORE THROAT
SHORT BREATH
RASH/ITCH
ODOR
NO
8
HEADACHE
VOMIT/NAUSEA
OTHER
PESTICIDE ALLEGEDLY INVOLVED
REGISTRATION NUMBER FROM LABEL
COMMODITY/SITE TREATED
PERSON/FIRM ALLEGEDLY RESPONSIBLE
OWNER OR OPERATOR OF PROPERTY TREATED
INVESTIGATOR'S NAME (PRINT)
INVESTIGATOR'S SIGNATURE
TITLE
DATE
(Over)
State of California
Department of Pesticide Regulation
Enforcement Branch
PESTICIDE EPISODE INVESTIGATION NON-OCCUPATIONAL EXPOSURE SUPPLEMENT
PR-ENF-128 (Est. 12/03) (Reverse)
Page 2 of 2
NAME OF PERSONS EXPOSED IN BUILDING
GENDER
DATE OF BIRTH
HAVE SYMPTOMS
(CONTINUE LIST ON SEPARATE PAGE,
SYMPTOMS EXPERIENCED
(M/F)
(OR AGE)
RESOLVED?
IF NECESSARY)
EYES BURN/TEAR
NOSE IRRITATION
COUGH
DIZZY
YES
SORE THROAT
SHORT BREATH
RASH/ITCH
ODOR
NO
9
HEADACHE
VOMIT/NAUSEA
OTHER
COUGH
EYES BURN/TEAR
NOSE IRRITATION
DIZZY
YES
SORE THROAT
SHORT BREATH
RASH/ITCH
ODOR
NO
10
HEADACHE
VOMIT/NAUSEA
OTHER
EYES BURN/TEAR
NOSE IRRITATION
COUGH
DIZZY
YES
SORE THROAT
SHORT BREATH
RASH/ITCH
ODOR
NO
11
HEADACHE
VOMIT/NAUSEA
OTHER
EYES BURN/TEAR
NOSE IRRITATION
COUGH
DIZZY
YES
SORE THROAT
SHORT BREATH
RASH/ITCH
ODOR
NO
12
HEADACHE
VOMIT/NAUSEA
OTHER
EYES BURN/TEAR
NOSE IRRITATION
COUGH
DIZZY
YES
SORE THROAT
SHORT BREATH
RASH/ITCH
ODOR
NO
13
HEADACHE
VOMIT/NAUSEA
OTHER
EYES BURN/TEAR
NOSE IRRITATION
COUGH
DIZZY
YES
SORE THROAT
SHORT BREATH
RASH/ITCH
ODOR
NO
14
HEADACHE
VOMIT/NAUSEA
OTHER
EYES BURN/TEAR
NOSE IRRITATION
COUGH
DIZZY
YES
SORE THROAT
SHORT BREATH
RASH/ITCH
ODOR
NO
15
HEADACHE
VOMIT/NAUSEA
OTHER
CONTINUATION OF REMARKS (EXPOSURE LOCATION, HOW EXPOSURE OCCURRED)
INVESTIGATOR'S NARRATIVE
PLOT MAP
Page of 2