Section 325.68. Pesticide poisoning analysis report form.

Rule 8. The pesticide poisoning report form reads as follows:

MICHIGAN DEPARTMENT OF COMMUNITY HEALTH PESTICIDE POISONING REPORT

DATA/INFORMATION REQUIRED BY ADMINISTRATIVE RULE R 325.62

I.  CLIENT INFORMATION

Last name                                                      First name                             M.I.

Sex     (M/F)                     Race     (White/Black/Asian/Pacific       Islander/American Indian/Alaskan/mixed)

(        )

Ethnicity (Hispanic Y/N)               Birth date                              Phone number

Street address                                City                                        State/Zip Code/County Name and address of parent or guardian if individual is a minor

Employer

Employer street address                 City                                        State/Zip Code/County

II. PHYSICIAN/PROVIDER INFORMATION (       )

Provider last name                                         First name              Phone number Name of medical facility of requesting physician/provider

Facility street address     City                                       State/Zip Code

III. LABORATORY INFORMATION (          )

Name of testing laboratory                                                          Phone number

Laboratory street address              City                                        State/Zip Code Date sample taken                                                  Date sample analyzed

Results

Test                                                                Laboratory normal range

Acetylcholinesterase                        U/g hemoglobin     -                 U/g hemoglobin Pseudocholinesterase                       U/L                                        -                 U/L

MDCH - Bureau of Epidemiology, Division of Occupational and Environmental Epidemiology 3423 N. M.L. King, Jr. Blvd., Lansing, MI 48909 o Fax Number [phone] o Phone number [phone]

History: 2005 AACS.