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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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