Pesticide Spraying Incident Report for
Davis, CA
Incident Report pdf
(To document the adverse health and environmental effects of the SYMVCD
mosquito spraying of Evergreen 60-6.)
Today's Date______________________ Date/s SYMVCD
sprayed your neighborhood__________________________
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 SYMVCD's pesticide spraying.
Include signs, symptoms, adverse effects, dates,
when they began and how long they lasted. Indicate if they sprayed at
times other
than the announced times (morning times
were 5 to 8 AM, and evening times were 8 to midnight). You may
attach additional
statements, medical documentation,
diagrams or pictures to this page.
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Did the injured party (animal) see a physician (veterinarian) 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______.
______________________________________________________
Signature.............. Date
Return to: Stop West Nile Spraying Now, 129 C Street, Suite 2, Davis,
CA 95616
Phone: (530) 758-6796, E-mail: smccarth@dcn.org, Fax: (530)
758-7169