FAO  POISONING INCIDENT FORM  (Locust control)

Fill out this form for each (suspected) poisoning incident, and send it to the National Locust Unit in your country

1

DATE & LOCATION OF POISONING INCIDENT

1-1

date of the incident:

1-2

location of the incident (name; latitute/longitude):

1-3

reference to Spray Monitoring Form (if relevant; page number):

2

INSECTICIDE DATA (of product involved in poisoning case)

2-1

trade name:

2-2

common name:

2-3

concentration (g a.i./l or %):

2-4

formulation type:

2-5

batch number:

2-6

production and/or expiry date:

2-7

solvent and mixing ratio (if relevant):

3

PERSONAL DETAILS (of suspected poisoned person)

3-1

name:

3-2

sex:

o  male

o  female

3-3

age (years):

3-4

staff position (e.g. applicator, flag man, driver):

4

INCIDENT DETAILS

4-1

activity while exposed to insecticide (e.g. spraying, filling aircraft hopper, etc):

4-2

personal protective equipment used (tick one or more boxes):

o  boots

o  hat

o  apron

o  coveralls

o  face shield / goggles

o  respirator

o  gloves

o  dust mask

o  other (specify):

4-3

way of exposure (tick one or more boxes):

o  on skin

o  by ingestion

o  by inhalation

4-4

estimate of quantity of exposure (e.g. spray cloud droplets, coveralls entirely drenched, drank 1-litre bottle, etc.):

4-5

duration of exposure (hours until decontamination / treatment):

4-6

other persons also exposed to insecticide:

o  yes

o  no

4-7

other relevant details about the incident (describe):

5

SIGNS AND SYMPTOMS

5-1

observed signs and symptoms of poisoning (tick one or more boxes):

o  skin irritation / rashes

o  tingling or numbness of face or hands

o  abdominal pain (stomach, belly)

o  sweating

o  headache

o  nausea, vomiting

o  tearing of eye(s)

o  confusion, disorientation, incoordination

o  diarrhea

o  double vision

o  muscle twitching, tremor

o  respiratory failure, coma

o  contraction of pupils

o  runny nose

o  seizures, convulsions

o  salivation

o  abnormal breathing

o  death

5-2

first onset of symptoms (hours or days after last exposure):

5-3

cholinesterase measurement carried out:

o  yes

o  no

5-4

type of cholinesterase measurement carried out (tick one box):

o  plasma

o  red blood cells

o  whole blood

6

TREATMENT

6-1

treatment given:

o  yes

o  no

6-2

type of treatment or antidote given (provide details):

6-3

person taken to hospital or medical post:

o  yes

o  no

6-4

period that person will be taken off insecticide application (days):

7

REPORTING

7-1

name of person who filled out this form:

7-2

staff category (tick one box):

o  medical

o  paramedical

o  non medical (specify)

hvdv 07.02