and Integrated Pest Management - part - usaid

318 PESTICIDJE MANAGIB-ENT AND IPM IN SOUTIIEAST ASIA
APPENDIX I
Abstract of form used to report pesticide poisoning (English translation)
REPORT ON PESTICIDE POISONING
Directions -Tick ('I) in the appropriate box. One form for one patient.
1. BASIC INFORMATION
1) Name of patient:
2) Identity card no. (if any):
3) Address (home):
4) Age:
5) Sex: J Male [ I Female
6) Race: [ ] Malay [ ] Indian
Chinese [ I Others (Specify):
7) Occupation: Permanent worker [ ] Temporary worker
Contract worker
8) Name of person interviewed (if not the patient):
Relationship to patient:
11. PARTICULARS OF POISONING
9) Date of incident:
10) Where incident happened:
11) How incident happened (accident, suicide, occupational, unknown)
12) If answer to (11) is "accident" or "suicide", answer the following
questions:
12(a) How did accident/suicide happen? (swallowed/drank, splashed on
skin, inhaled vapor/spray, others)
12(b) If "swallowed/drank", how much ?
12(c) Name(s) of pesticides involved:
13) If answer to (11)is "occupational", then answer the following:
13(a) State work done when poisoning occurred (spraying pesticide,
mixing pesticide, working in pesticide store, others)
13(b) Name(s) of pesticides involved:
13(c) How did poisoning occur (inhaled, spilt/splashed on skin, sprayer
leaked, others)
13(d) Equipment used at time of incident (knapsack sprayer, motor
blower sprayer, spinning disc sprayer, motorized power sprayer,
others):
13(e) Type of clothing worn at time of incident:
13(0 , ,'hen was equipment first provided by employer?
13(g) Is worker supervised while working?