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


Other Releases
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
SURVEY TO EVALUATE THE EFFECTS OF GLYPHOSATE AND OTHER PESTICIDES ON HUMAN HEALTH IN PECIG INFLUENCE ZONES
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    
EPS-ARS-ARP:                                              
   
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  
  Which?              
   
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):        
Place:                
   
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    
  Which?                
   
  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