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Get the free Pesticide-Related Illness Form - CA.gov

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Human Pesticide Exposure Report Form For Health Departments and Health Care ProvidersPlease send to: Environmental Surveillance and Toxicology Branch Attn: PEST Program Fax Number: 5127767249 Phone:
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How to fill out pesticide-related illness form

01
Obtain a pesticide-related illness form from a healthcare provider or public health department.
02
Fill out all personal information such as name, address, contact number, and date of birth.
03
Provide specific details about the incident including the date and time of exposure, type of pesticide involved, and any symptoms experienced.
04
Attach any relevant documents such as medical records or witness statements.
05
Submit the completed form to the appropriate authorities for review and follow-up.

Who needs pesticide-related illness form?

01
Individuals who have been exposed to pesticides and are experiencing symptoms of illness.
02
Healthcare providers who are treating patients with suspected pesticide-related illnesses.
03
Public health departments who are monitoring and investigating cases of pesticide exposure.
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The pesticide-related illness form is a document used to report any illnesses or health issues caused by exposure to pesticides.
Any individual or organization who has experienced or observed pesticide-related illness is required to file the form.
The form can be filled out by providing details of the illness, including symptoms, date of exposure, type of pesticide, and contact information.
The purpose of the form is to track and monitor pesticide-related illnesses, identify trends, and take appropriate actions to prevent future cases.
Information such as symptoms, date of exposure, type of pesticide, location of exposure, and contact information must be reported on the form.
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