Pesticide Reporting Form for Providers
It’s the Law!
Pursuant to N.C. 10A NCAC 41F .0101-.0103, physicians (to include physician assistants and nurse practitioners) are required to report confirmed or suspected cases of acute pesticide-related illness or injury within 48 hours of diagnosis, immediately for cases resulting in death. Please complete the information requested on the form for cases which fit the above description. Enter any additional information that you feel is relevant in the comment section. Examples include factors contributing to exposure, activities performed during time of exposure, tests conducted, etc. Instructions for submitting the form are included.
All information reported is considered confidential, identifying information is protected within the confidentiality guidelines for the Epidemiology Section, NCDHHS. Physicians may call Carolinas Poison Center to report a case to fulfill reporting requirements @ 1-800-222-1222 Option 5.
The North Carolina Pesticide Illness and Injury Surveillance Program monitors pesticide-related illness and injury. Reporting ensures that incidents are recorded and enhances prevention of pesticide-related illnesses and injuries. The reports may initiate investigations to identify factors contributing to hazardous exposures and to then make recommendations about safe handling practices.