Submit the completed form to the following addresses: Office of Environmental Health Hazard Assessment Pesticide and Environmental Toxicology Branch P.O. Box 4010, Sacramento, CA 95812-4010 Fax: (916) 327-7320 Department of Pesticide Regulation Worker Health and Safety Branch P.O. Box 4015, Sacramento, CA 95812-4015 Fax: (916) 322-8577 Department of Industrial Relations Division of Labor Statistics and Research P.O. Box 420603, San Francisco, CA 94142-0603 Fax: (415) 703-3029 Advice: Ensure all required fields are completed and submit the form within the specified timeframe to avoid penalties.

Important dates for submission in 2024 and 2025 include January 1st for the new reporting guidelines and December 31st for annual submissions.

The purpose of this form is to ensure proper reporting and documentation of pesticide-related illnesses in California. Healthcare providers are required to submit this form within 24 hours of diagnosing a known or suspected pesticide-related illness. This helps ensure timely investigations by the relevant authorities and facilitates necessary follow-up actions.

• 1. Patient's Last Name: Enter the patient's last name as it appears on legal documents.
• 2. Social Security Number: Provide the patient's Social Security Number for identification purposes.
• 3. First Name: Enter the patient's first name.
• 4. Birth Date: Provide the patient's date of birth including month, day, and year.
• 5. Address: Enter the patient's current address including street, city, state, and ZIP Code.
• 6. Home Telephone: Provide the patient's home telephone number for contact purposes.
• 7. Reporting Provider - Last Name: Enter the last name of the healthcare provider reporting the illness.
• 8. Health Care Facility Name: Provide the name of the healthcare facility where the patient was treated.
• 9. Illness Onset Date: Record the date when the symptoms of the illness began.
• 10. Gender: Select the patient's gender from the available options.
• 11. Ethnicity: Select the patient's ethnicity from the available options.
• 12. Race: Select the patient's race from the available options.
• 13. Signs and Symptoms: Check all applicable signs and symptoms experienced by the patient.
• 14. Diagnostic or Laboratory Tests: Indicate whether diagnostic or laboratory tests were conducted.
• 15. Pesticide Exposure Date: Provide the date when the pesticide exposure occurred.
• 16. Name of Pesticide(s) or Active Ingredient(s): Enter the name(s) of the pesticide(s) or active ingredient(s) involved in the exposure.
• 17. Location of Exposure: Provide the location details where the pesticide exposure occurred.
• 18. Describe Exposure: Describe how the patient was exposed to the pesticide, e.g., drift, spray, spill.
• 19. Examination Date: Enter the date of the initial examination of the patient.
• 20. Treatment Rendered: Describe the treatment that was provided to the patient.
• 21. Reporting Date: Provide the date when the report is being submitted.

Failure to submit this form within the required timeframe can result in penalties and delayed investigations.

• Penalties: Physicians may face civil penalties for failing to report within 24 hours.
• Delayed Investigation: Late submissions can impede timely investigations by relevant authorities.
• Incomplete Documentation: Failure to submit can result in incomplete or missing records of pesticide-related illnesses.

• 1. Pesticide Exposure: Report any illness suspected to be caused by pesticide exposure.
• 2. Work-Related Illness: Include cases of pesticide-related illnesses occurring in the workplace.
• 3. Residential Exposure: Report pesticide-related illnesses resulting from residential exposure.
• 4. Non-occupational Settings: Use for incidents occurring in non-occupational settings requiring medical treatment.
• 5. Unknown Source: Document illnesses where the source of pesticide exposure is unknown.