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2. If you have been exposed to a pesticide, please call 911.
4. Name:*
6. Address:
8. City:
9. Zip:
11. Phone Number:*
13. Email:
15. When did pesticide incident happen?*
    Please include date and time when incident occurred.
17. Where did the pesticide incident occur?*
    Physical address or nearest cross streets. Did this happen indoors or outdoors? If indoors, was it at home, school, work or another place? If outdoors, was it in your yard, on your street, along a road, at a school, in an agricultural field or other place?
19. Description of what happened?*
    What did you see happen? For example: was the pesticide application nearby? Was there a spill or leak? Was the pesticide being sprayed, being mixed or transported? How far away were you? What type of equipment was used (tractor, hand-held or back pack sprayer). Did you see any dust or particles? What were the effects you experienced? Did you smell or taste anything unusual? Did anyone go to the hospital?
21. Pictures of pesticide incident?
Leave This Blank:


23. 1. Receive an email copy of this form.
24. Email address

    This field is not part of the form submission.

25. Submit Submit and Print

* indicates a required field