Occupational Illness and Injury
Reporting Illnesses & Injuries
Choose one of 3 reporting methods:
See our brochure on the Physician's Reporting Responsibilities Under State Public Health Law (PDF).
Using the North Carolina reporting form (DHHS 4077) (PDF or fillable PDF)*, report the following:
Physicians, physician assistants, and nurse practitioners. Reports from exposed persons, witnesses and other concerned citizens will be accepted.
Patients' names are confidential and are not released without consent. Only aggregate, non-identifying information is provided to the public.
Pesticide use is widespread, and potentially unhealthy for adults and children when products are not used as directed. The Pesticide Illness and Injury Surveillance Program monitors pesticide-related illness and injury, and receiving information from physicians is an important first step in the process. Reporting ensures that incidences are recorded and enhances prevention of pesticide-related illnesses. When we learn about your patient, we can offer resources to help prevent further exposure. Your reports also help Public Health to initiate investigations to identify factors contributing to hazardous exposures and to then make recommendations about safe handling practices. Through collaboration, we can help protect the health of those who live and work in our state.
*To download, you need to have Adobe Acrobat Reader. The PDF or the fillable PDF with the added content can be saved and faxed/mailed later.