Pesticide Exposure Incident Report Form

Why Do We Have a Pesticide Incident Complaint Form on the Beyond Toxics web site?

You have a right to have your pesticide poisoning or pesticide damage incident investigated by State of Oregon authorities, namely the Pesticide Analytic Response and the Oregon Health Authority. Beyond Toxics has found that the majority of people who file complaints with the State are dissatisfied with the quality of the investigation itself and questionable professional and ethical conduct on the part of some agency staff. Beyond Toxics is not an agency or State authority but we do collect data on pesticide poisoning or pesticide damage incidents for research and to help our members. We are here to connect you with a growing movement of Oregonians who want redress and legislative reform on chemical policies, and we hope to help you receive a just and respectful response from the agencies you connect with.

More resources for pesticide exposure reporting

Pesticide Exposure Incident Form

Please fill out this form as thoroughly as you can. We will get in touch with you shortly. PART A: Disclosure Approval (below); please check one...

- I give my permission to release this form and/or the information contained herein to the media, policy makers, and other victims.
- I will only permit the release of this form if it is done anonymously. However, you may use my city and state only for reference purposes.
May we contact you again?
- Yes
- No
Today's Date
MM slash DD slash YYYY
Name*
First Last
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Approximate Time of Incident

:
Date of Incident
MM slash DD slash YYYY
Name of Injured Person or Type of Animal/Plant
Age of Injured Person
Please enter a number from 0 to 120.
Gender
- Female
- Male
Your Relationship to Injured Person
Injured Person’s Contact Information, if different from above
Is this a single exposure or a recurring exposure?*
- One time
- Recurring
PLACE(S) OF EXPOSURE (check all that apply)
- Indoors—Please Specify (home, school, workplace, etc.)
Indoors exposure - details
- home
- school
- workplace
PLACE(S) OF EXPOSURE continued (check all that apply)
- Outdoors - Please specify (yard, farm, golf course, park, etc.)
Outdoors - details
- yard
- farm
- golf course
- park
PLACE(s) OF EXPOSURE continued (check all that apply)
- Food Residues and/or Water - Please list consumable item below
Food Residues and/or water - consumable item detail
PLACE(S) OF EXPOSURE continued (check all that apply)
- Drift or volatization - please list possible sources below
Possible Sources of Drift or Volatization
PESTICIDE(S) EXPOSED TO (IF KNOWN)
Please include the product name and/or active ingredient. If you have a label, please send us a copy: Beyond Toxics | P.O. Box 1106 | Eugene, OR 97440
PESTICIDE APPLICATOR
- Self
- Neighbor
- Farmer
- Golf Course
- Utility Company
- School
- Public (local or state government)
- Commercial
- Other
PESTICIDE APPLICATOR - if commercial, name of company
PESTICIDE APPLICATOR - if other, please list
METHOD OF APPLICATION
- Aerial
- Aerosol
- Fogger
- Wood Preservative
- Fumigation/Tenting
- Other
METHOD OF APPLICATION - if other, please detail below
ROUTE OF EXPOSURE(S)
- Inhalation
- Dermal (through the skin)
- Ingestion
- Other (see below)
ROUTE OF EXPOSURE(S) - if other, please detail below
Were you notified in advance that a pesticide was used?
- Yes
- No
If notified in advance how and when were you notified?
If NOT notified in advance, how did you discover that the pesticide had been applied?
EXPOSURE INCIDENT - Please provide an account of the incident below.
Did you notify a public authority or agency about this incident?
- Yes
- No
If Yes, please elaborate on what took place (Was there an investigation? Was any action taken? Were any tests conducted?)
If No, do you plan to do so?
- Yes
- No
- Uncertain
Did you see a doctor?
- Yes
- No
Did you test for pesticides?
- Yes
- No
Describe briefly
Did you obtain lab results?
If Yes, please elaborate on what took place (Was there an investigation? Was any action taken? Were any tests conducted?)
Were you satisfied with the response from the agency that received your complaint?
- Yes
- No
- Not sure
Is there anything you wish to add about what help you need, or what next steps you think should be taken?

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For questions about how to fill out this form, feel free to contact Beyond Toxics: info@beyondtoxics.org / 541-465-8860. Thank you!

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Back to Pesticide Exposure Reporting Resources page

Safe Public Places Resources page
Read our Safe Public Places flyer
Back to Safe Public Places project home page
Chemical trespass stories (text and audio only)
Chemical trespass and human rights (pesticide exposure stories on video)
See three video clips from an exclusive 2011 interview with Sandra Steingraber on the topic of chemical trespass and human rights

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Pesticide Exposure Incident Form

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