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Survey to Evaluate the Effects of Glyphosate and Other Pesticides on Human Health in PECIG Influence Zones

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Bureau for International Narcotics and Law Enforcement Affairs
Washington, DC
January 1, 2003


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The Government of Colombia's National Institute of Health
Bogota, Colombia

  Republic of Colombia                                     
National Health Institute
    Ministry of Social Protection   Epidemiology Subdirectorate and NRL     
                              Research Sub-directorate
I. GENERAL DATA                                            
Provincial Department:                     Municipality:                        
Rural:     Settlement-Farm:                                      
Urban:     Neighborhood:                 Address:                  
Health Institution (IPS):                                          
II. PATIENT'S DATA                                            
Fulll Name:                             Age:     Gender:   M   F
Identification in SGSSS: (Col. ID Card or Medical Chart) #                                  
Type of SGSSS User:           1 Contributory     2 Subsidized              
                    3 Associated     4 Private                
Education: 1 Illiterate             Occupation:                        
      2 Incomplete Elementary School                                      
      3 Complete Elementary School         During the last 15 days, you were:  
      4 Incomplete High School         1 Employed           6 Living Off Income    
      5 Complete High School         2 Day Worker           7 Living Off Retirement    
      6 Technical           3 Freelance Worker           8 Studying        
      7 University           4 Unemployed           9 Doing Housework    
                        5 Non-remunerated Worker       10 Others        
III. MEDICAL EXAM DATA                                        
Main Diagnosis:                                              
Secondary Diagnosis 1:                                          
Secondary Diagnosis 2:                                          
Secondary Diagnosis 3:                                          
Area Where Attended:         1 Out-patient Clinic   2 Hospital       3 E.R.    
Date Admitted:           Time (International)                            
Date Left:                                                
Patient's Condition upon Leaving:                                      
1 Alive         2 Deceased                                  
IV. CHARACTERIZATION OF THE EXPOSURE                                      
Type of Exposure:                                            
1 Direct Spraying     2 Through the Air (via the respiratory tract)                        
3 Contaminated Drinking Water (orally)                                      
  Where does the drinking water come from?       3.1 Waterworks                        
                      3.2 Well                          
                      3.3 Rainwater                        
                      3.4 River                          
                      3.5 Stream or Brook                        
                      3.6 Other           Which?            
4 Contaminated Food (orally)               What or Which?                
5 Other Type of Exposure:     Which?                                
Date of Exposure:           Time (International):                        
Activity Being Carried Out at the Time of the Exposure (check one or more)                        
    Farming                     During a Recreational Activity          
    Doing Housework                                          
    While Doing Usual Work               Others (Which?)                  
Date of Spraying             Time (International):                        
V. OCUPATIONAL HISTORY                                        
  Do you use pesticides when you work?     No     Yes                          
  If you answered "Yes", answer the following questions:                                  
  How long have you been using pesticides?               Months                    
  How often do you fumigate?           Daily       Once a Week     Twice a Week    
  How many hours a day do you fumigate?                                      
  What work do you do when you are not fumigating?                                  
  What was the last date on which you fumigated?                                    
  Have you received training on safe handling of pesticides?             Yes     No            
  List the pesticides that you use on your crop.                                    
  Are you using the pesticide Roundup?               Si     No                
  Where do you store the pesticides that you use?       Inside the House                        
                          Outside the House                        
                          Exclusive Area (storeroom, warehouse)                
                          Near the Food                        
  What do you do with the pesticide containers that are empty?                              
    Burn Them                                            
    Bury Them                                            
    Reuse Them to Store Other Pesticides                                      
    Reuse Them to Store Water                                      
    Reuse Them to Store Food                                      
  Do you use personal protection articles when applying pesticides?             No     Yes        
  If you answered "yes", check which ones you use.                                  
  Plastic or Cloth Apron             Mask with a Double Tank                      
  Street Clothes or Everyday Clothes         Disposable Mouthguards                      
  Uniform                   Face Shield                        
  High-top Boots               Short Gloves                        
  Low-top Boots               Long Gloves                        
  Tennis Shoes               Visor                          
  Leather Shoes               Goggles                          
  Mask with a Tank               Others                      
  Do you use the same clothing for your usual work and for fumigating?                 Yes     No    
  Do you change from your workclothes when you finish your day's work?   Yes     No                
  How often do you change your workclothes?       Daily     Once a Week     Twice a Week    
  Others   Which?                                          
  Where do you wash your workclothes?     In the Fields     At Home                  
  Others   Which?                                          
  If you wash them at home, do you mix them in with the rest of the clothes?     Yes     No              
  Do you eat out in the fields?       Yes     No                        
  How often do you eat in the fields?             Always       Occasionally     Never    
  Do you wash your hands before eating in the fields?         Always       Occasionally     Never    
  Do you shower after work?             Always       Occasionally     Never    
  Have you ever smoked? Yes     No                                
  How long have you been smoking?                                      
  Do you or have you smoked in the fields? Yes     No                              
  How many cigarettes do you or did you smoke in the fields?                                
  Do you drink alcohol?   Yes     No                                
  How often do you drink alcohol?     Daily     Once a Week       Twice a Week        
  Others   Which?                                            
  How long have you been drinking alcohol?                 Years                  
  Have you ever gotten intoxicated from pesticides before?     No     Yes     How long ago?       Months
  If you answered "yes", what did you do?           Consulted a doctor                        
                          I took medicine on my own                    
                          I used home remedies                      
                          I did not do anything                      
  What pesticide caused the intoxication?                                      
VI. SOCIAL BACKGROUND                                        
  The person surveyed moved here.       No     Yes                        
  If you answered "yes", answer the following questions.                                  
  Where did you and your family live before you moved here?         Provincial Department:              
  How long ago did you move here?     Months                                  
  What motivated you to move here?                                      
  1 Economic or work reasons                                      
  2 Personal or family safety (threats)                                      
  3 Family or friends are here                                      
  4 Settled down                                            
  5 Because of social support organizations here (State, religious or community)                        
  6 Doesn't know or doesn't answer                                      
  7 Others                                              
VII. ATTITUDE TOWARDS THE ICEPG                                      
  What do you think about aerial spraying?       It is a State policy that must be carried out.         Yes     No  
  Why don't you agree?       It affects the economy.                          
                  It is harmful to your health.                        
                  It affects legal crops.                          
                  It affects animals.                            
                  it affects the environment.                        
                  Doesn't know or doesn't answer.                        
  What did you feel after the spraying was done in your area?         I was indifferent.                
                              I rejected it.                  
                              I was sad.                  
                              I felt dispair.                  
                              I felt desolation.                
                              I felt anxiety.                  
                              I was depressed.                
                              I was afraid.                  
                              I wanted to move.                
                              Other feelings. Which?              
VIII. MEDICAL CHART                                          
Signs and Symptoms Date Symptoms Started:                                    
  Dermal Erythema     Vomiting           Tachicardia           Miosis          
  Pruritus         Nausea           Involuntary Micturition         Mydriasis        
  Skin Ulcers       Hematemesis            Dysuria             Blurred Vision      
  Blebs         Abdominal Pain           Hematuria         Tearing          
  Burns         Diarrhea           Pollakiuria         Reddened Eyes      
  Paleness       Constipation           Fatigue             Conjunctival Hemorrhage    
  Dysnea         Melena           Weakness           Burning Eyes      
  Coughing       Precordial Pain           SM Paresthesias           Epistaxis        
  Rhonchi       Palpitations           IM Paresthesias           Profuse Sweating      
  Wheezing       Hypertension           Fasciculations           Chills          
  Hemoptysis       Hypotension           Convulsions           Fever          
  Dysphagia       Bradycardia           Loss of Consciousness                      
  Others         Which?                                      
Exposure through:                                            
  Respiratory Tract   Mouth   Skin         Eyes       Unknown            
IX.LABORATORY RESULTS                                        
Glyphosate in Urine:         ug/l    OC in Serum                        
AMPA in Urine:           ug/l   Heptachlor           Oxichlordane        
Ache Activity in Blood:       %   p-p, -DDT           Epoxied Heptachlor      
                      Aldrin             Hexachlorbencene      
                      Chlordane-gama         p-p, -DDD          
Name of Physician in Charge:                                      

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