Incident Report pdf
(To document the adverse health and environmental effects of the Metro Health Department's mosquito spraying of Anvil 2+2.)Today's Date______________________ Date/s Metro sprayed your neighborhood________________________________ Zone (circle one, if known) 1 2 3 4 Name of Injured Person or Type of Animal/Plant_________________________________________________ Name of Person Filling Out this Form, if different_________________________________________________ Relationship to the Injured Person____________________________________________________________ Injured Person's Address__________________________ City_______________________ Zip____________________ Phone______________________E-mail_______________________________________________________________ Your Address, if different____________________________ City_____________________ Zip_____________________ Phone________________________ E-mail_________________________________________________________________ Place where the incident occurred_________________________________________________________________________ Describe the incident that took place with Metro Health Department's pesticide spraying. Include signs, symptoms, adverse effects, dates, when they began and how long they lasted. (You may attach additional: statements, medical documentation, diagrams or pictures to this page.) ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Did the injured party see a physician or other health care provider? What was done?_______________________________________ _______________________________________________________________________________________________________ If you reported this incident to any local, state or federal agencies, please give the agency name (s), key contact, phone numbers and referral numbers____________________________________________________________________________________________________ _____________________________________________________________________________________________________________ Was an investigation done? Yes ____ No_____ If yes, who conducted the investigation_______________________________________ _____________________________________________________________________________________________________________ Disclosure Approval: I, _________________________________________, hereby give my permission to release this form and/or the information contained herein to (check which) the media _____ policy makers _____ and other victims______.
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