Pesticide applicator

Name: sex:

Age: address:

What type of pesticide are you using in the farm?

 Insecticides (insects)
 Herbicides (plants)
 Rodenticides rodents (rats & mice)
 Bactericides(bacteria)
 Fungicides (fungi)
 Larvicides (Larvae)

What is the product you are using? (name of the product) _______________________

What application methods do you generally use when you apply herbicides? (Mark all that apply.)

 Don’t usually apply herbicides

 Airblast
 Boom on tractor, truck, or trailer
 Hand spray gun
 Backpack sprayer
 Aerial (aircraft application)
 Furrow or banded
 Mist blower/fogger
 Other (indicate what is it) : ___________________________

What application methods do you generally use when you apply crop insecticides? (Mark all that
apply.)

 Don’t usually apply herbicides

 Airblast
 Boom on tractor, truck, or trailer
 Hand spray gun
 Backpack sprayer
 Aerial (aircraft application)
 furrow or banded
 Mist blower/fogger
 Other (indicate what is it) : ___________________________

What application methods do you generally use when you apply fungicides?

 Don’t usually apply herbicides

 Airblast
 Boom on tractor, truck, or trailer
 Hand spray gun
 Backpack sprayer
 Aerial (aircraft application)
 furrow or banded
 Mist blower/fogger
 Other (indicate what is it) : ___________________________

When you personally mix herbicides, what additives do you generally use? (Mark all that apply.)

 Don’t mix herbicides

 Don’t usually use additives
 Solvents (like diesel fuel)
 Fertilizer
 Surfactants, crop oil concentrates
 Other pesticides (indicate what is it) : ___________________________

When you personally mix crop insecticides, what additives do you generally use? (Mark all that apply.)

 Don’t mix herbicides

 Don’t usually use additives
 Solvents (like diesel fuel)
 Fertilizer
 Surfactants, crop oil concentrates
 Other pesticides (indicate what is it) : ___________________________

When you personally mix fungicides, what additives do you generally use?

 Don’t mix herbicides

 Don’t usually use additives
 Solvents (like diesel fuel)
 Fertilizer
 Surfactants, crop oil concentrates
 Other pesticides (indicate what is it) : ___________________________

General information:

Before age 18, did you live at least half your life on a farm?

 Yes
 No

About how much did you weigh when you were age 20? ________________

During the past 12 months about how many times did you visit a medical doctor or medical assistant
about a health concern?

 None
 Once
 More than once
On average, how many hours per week do you spend doing strenuous exercise (heart beats rapidly)
during your leisure time?

 1–2 hours
 3–5 hours
 6–10 hours
 More than 10 hours

How would your skin react the first time each year if you were exposed to strong sunlight for more than
an hour?

 Get a severe sunburn with blisters F Get a painful sunburn, but not blisters
 Get a mild sunburn followed by some tanning
 Become tanned without any sunburn
 No visible reaction

In the growing season when you work in the sun, what type(s) of sun protection do you usually use?

 Sunscreen or sunblock
 Wear baseball-type cap
 Wear other kind of hat with brim
 Almost always wear long-sleeved shirt
 Don’t use any of the above protection

In the growing season, how many hours a day do you generally spend in the sun?
a. Now b. 10 years ago

 Up to 1 hour Up to 1 hour

 1–2 hours 1–2 hours
 3–5 hours 3–5 hours
 6–10 hours 6–10 hours
 More than 10 hours More than 10 hours
 B. IF YES
How old were you when the doctor first told you?
A. Condition

Yes no Younger 60 or
than 20 20-39 40-59 older

a. Rheumatoid arthritis

b. Stroke

c. Myocardial infarction (heart attack)

d. Arrhythmia (irregular heart beat)

e. Angina (chest pain)

f. High blood pressure requiring

medication

g. Diabetes (sugar) (other than while

pregnant

h. Asthma or reactive lung disease

i. Farmer's lung disease

j. Chronic bronchitis

k. Emphysema

l. Hay fever

m. Pneumonia (viral or bacterial)

n. Cataracts

o. Glaucoma

p. Detached retina

q. Retinal or macular degeneration

r. Goiter
88. During the B. C.
past 12 Were the symptoms
months, have How many episodes have worse after smelling
you had ...? you had in the last 12 chemical odors?
months?

More
YES NO One Two 3-6 7-12 YES NO
than 12
a. Stuffy, itchy, or runny
nose

b. Watery, itchy eyes

c. A cold

d. Sinusitis or sinus
problems

e. Flu

f. Pneumonia

approximately how often during the last 12 months have Once Once More than
you experienced the following? A A Once a once a
Never year month week week

a. Dizziness

b. Feeling tense, anxious, or nervous

c. Nausea/vomiting

d. Feeling tired, sleepy, or low energy most of the day

e. Sweating a lot more than usual

f. Difficulty seeing at night

g. Being absentminded, forgetful, or confused

h. Headache

i. Loss of appetite

j. Fast heart rate

k. Difficulty with balance

l. Blurred vision or double vision

m. Difficulty concentrating
n. Numbness or pins-and-needles in your hands or feet

o. Momentary loss of consciousness

p. Feeling excessively irritable or angry

q. Shaking or trembling of your hands

r. Difficulty falling asleep or staying asleep

s. Difficulty speaking

t. Weakness in your arms or legs

u. Changes in your sense of smell or taste

v. Feeling depressed, indifferent, or withdrawn

Twitches, jerks, or involuntary movements of your arms

w.
or legs