Name
Location
Personal Particulars
Sex:	Age:	Race:
Marital Status:	Occupation of Spouse:	Length of Service:
No: of children:	Nature of work:	Salary:

Are you a:
Permanent worker	Contract worker	Migrant Worker
Working Hours
Per day	Per week	Per month

Pesticide Use
Are you a pesticide user?	Yes	No
Date of last exposure to pesticide:

1. What class of persticide used in the field?
Weedicide	Insecticide	Fungicides	Others

2. What pesticide so you use?
Common name:	Brand name:
What it is used for

Do you spray throughout the year?	Yes	No
Is there a break given?	Yes	No
If there is a break, for how long?
What type of task are you assigned?
How long after spraying are you assigned to another task?
Frequency in a month:
No. of hours per spray:

3. Equipment

Method of spray (equipment used):

What was the condition of the equipment?

How is it stored?

Was training provided on use?

4. Protective clothing
Was protective clothing/equipment supplied?	Yes	No

If yes, what are they?
Cover-alls	Gloves	Eye and face protection
Aprons and coats	Protective boots	Respiratory equipment

5. Mixing of Pesticides
Do you mix the pesticidesbefore spraying?	Yes	No
If not, who mixes?
What is the pesticide mixed with?
What are the quantities?
Do you mix it with other pesticides?	Yes	No
If yes, what are they?
What are the quantities?

6. Effects of the Pesticide
After spraying, do you suffer from:
Nausea	Tremors
Giddiness	Lower abdominal pains
Headache	Vaginal pains
Vomiting	Burning sensation during urination
Difficulty in breathing	Fatigue/tiredness
Tight feeling in chest	Back pains
Itchiness/skin irrirtation	Discoloration of the nails/inflamation and irritation
White patches on skin/red spots
Bleeding through the nose	Swelling of the knee joints
Vomiting	Others
Blurred vision

How have you  been exposed/come in contact with pesticides?
Through inhalation	Yes	No
On the skin	Yes	No
Accidentally consumed it	Yes	No

7. Medical
Who do you go when you have any effects of poisoning?
What treatment is given?
Types of medicine	Cream	Drugs/tablets
	Liquid form
Do you go for regular check-ups?
Where do you go for check-ups?
Who conducts the medical examination?
Is there a policy in the plantation on sending sprayers for regular check-ups?

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