Request For Pesticide Registry Or Pesticide Application Information - New York State Department Of Health Page 6

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Project Director (last name, first initial):_____________________________________________________
III.
INFORMATION BEING REQUESTED FROM THE PESTICIDE REGISTRY OR PESTICIDE
APPLICATOR(S): Specify the data being requested in terms of time frame, geographic area,
and pesticide description with as much detail as possible. Attach additional pages as needed.
A.
TIME FRAME
Check one:
All years available OR
�
Specific years
From:___________ To: __________ OR
�
�
Specific dates or range of dates (describe below or attach)
Description: ________________________________________________
__________________________________________________________
B.
GEOGRAPHIC AREA
Check one:
�
Entire state OR
Specific counties (describe below or attach) OR
�
�
Specific 5-digit ZIP codes (describe below or attach) OR
�
Combination of counties and 5-digit ZIP codes (describe below or attach)
Description: ________________________________________________
__________________________________________________________
C.
PESTICIDE DESCRIPTION
Check one:
�
All pesticides OR
Specific pesticide category (e.g., all insecticides or all herbicides) OR
�
�
Specific EPA registration numbers or product names (describe below or
attach)
Description: ________________________________________________
__________________________________________________________
D.
Not all studies require data linked to individual applicators or businesses. If you are
requesting data categorized in this way, check the box below and attach an explanation
of why this is needed for your research. (When data are released, applicator and
business identification numbers are obscured with unidentifiable replacement numbers.)
�
Data linked to individual applicators or businesses are needed (attach
explanation)
__________________________________________
____________________
Signature
Date
Send completed form to:
Director, Bureau of Environmental and Occupational Epidemiology
New York State Department of Health
Flanigan Square, Room 200
547 River Street
Troy, New York 12180-2216
Phone Number: (518) 402-7950, Fax Number: (518) 402-7959
6

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