Form Doh-4212 - Emergency Pesticide Application Notification Exemption Reporting Form - New York State Department Of Health


Emergency Pesticide Application
Notification Exemption Reporting Form
Bureau of Toxic Substance Assessment
March 30, 2001
Recent legislation (L. 2000, c. 285) amends the Environmental Conservation Law (“ECL”), the Education Law (“Ed. Law”) and the
Social Services Law (“SSL”) with respect to notification relating to commercial and residential lawn pesticide applications, and
pesticide applications at schools and daycare facilities. Prior notification requirements established by the legislation do not apply
to, among other things, “emergency application[s] of a pesticide when necessary to protect against an imminent threat to human
health.” ECL § 33-1004(1)(b)(ii)(L); Ed. Law § 409-h(2)(e)(x); SSL § 390-c(2)(c)(x).
This form was developed for use by applicators who make “emergency applications” without providing the 48-hour prior notification
to persons in the vicinity of the application and others as required by law. When emergency applications are made, the applicator
is required to make a written report to the New York State Department of Health. To comply with this requirement, applicators
must provide the following information in as complete a form as possible. The completed form should be sent to the address at
the end of the form within three business days of the application. Additional pages may be attached if needed.
Once the submitted form (and any attached pages) is reviewed, the applicator and/or the person who determined that an emergency
application was warranted may be contacted for further information. The Department of Health will then determine if an emergency
application was justified and distribute its determination to other interested parties such as the New York State Department of
Environmental Conservation and county authorities. If it is determined that an emergency application was unwarranted, a penalty
may be imposed on the applicator.
Name of person who applied the pesticides
Pesticide business registration number or
certified applicator identification number
Name and address of applicator’s business
Telephone number of applicator’s business
Fax number and e-mail address (if available)
Date and time of emergency pesticide application _________________________________________________________________
Name of person who determined the need
for an emergency pesticide application
Telephone number of this person
DOH-4212 (9/01)


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