Mich. Admin. Code R. 325.68
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 (517) 335-9775 o Phone number (517) 335-8350
Mich. Admin. Code R. 325.68