PAN International Website

PAN UK Incident and concern report form

Please fill in the form below if you have been exposed to pesticides, or are concerned about pesticides. The incident will be treated in strict confidence and in accordance with the Data Protection Act. Many thanks.

Records you provide, such as this form, and concerns you express, are crucially important. Although you may not see immediate effects, they will form part of a collection on which PAN UK bases its lobbying and policy work, and are vital to future developments. We meet regularly with senior government ministers, and are routinely invited to submit responses to all governmental consultations relating to pesticides. Join PAN UK to keep abreast of pesticide issues and to receive regular news updates and a selection of publications.

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Incident reporting form 

Your Details
Forename / Surname
Gender / Age / Todays date Age Date
Address /
Town / City /
County Postcode
Telephone / Fax
Mobile / Email

Incident Details
Date of the incident
Description of the incident
Who has been affected (give details of all individuals, their gender and age) and any animals, or wildlife, exposed
Address of exposure incident (include a grid reference if in the open country, if possible)
What was the pesticide-user doing?
Did the pesticide-user give any warning?
Application conditions (eg was it a windy day?)

Symptoms
Symptoms of all those affected
Confidential: Does the victim, or do the victims, have any existing medical condition?
Please give details (optional)

Pesticide details
Product name (eg Round-up)
Active ingredient name (eg glyphosate)

Action and response
If you have not reported the incident to your GP, why not? Please give reasons.
Date of reporting the incident to your GP
GP's name and contact details
What did your GP say?
Date of reporting the incident to the HSE
HSE officer's name and local office
What did the HSE officer say?
Date of contacting the Local Authority, or any other enforcement agency
Officer's name and contact details
What did the officer say?
Date of contacting any other organisation about the incident
Name, address and contact detail(s) of witness (or individual you told about the incident) who we can contact  
Person 1
Name, address and contact detail(s) of witness (or individual you told about the incident) who we can contact  
Person 2

Concern about pesticides
Are you concerned about pesticides:  Locally? generally?
Please give details
If you have any comments on this form, or advice recieved
We have made the email address a required field to add credibility to this survey. Your contact details will not be passed on to any other organisation and is only for the purposes of this study. 
    We may contact you to provide further information on the health effects of pesticides in the future. If you do not wish to be contacted by PAN UK please tick this box.