Occupational Injury and Illness Intake Form


Other Languages: Version en espaņol

East Carolina University

PI Chart # _____________________ Date of Birth __________ Age ________ Gender Male / Female
Health Center ID __________ Collector's Initials _____________ Married/have a partner Yes / No
Data Source and date: Health Center Visit _________ Outreach Visit _________ ER Visit________ Other ___________
Current job status(circle one): migrant seasonal H2A
year round 		other (explain) _______________________________

Origin (circle one):

AA
Asian Caucasian		 Latin American Mexican
Native American 		other (explain) ______________

S
U
B
J
E
C
T
I
V
E

Are you having pain or discomfort? When did it start? What caused it?


When Started:

__ last 24 hours
__ last 2-3 days
__ last week
__ > 1 month
__ > 3 months
__ other _____________________

Contact with Allergens/Irritants:
__ poison ivy/oak/
poison sumac
__ pollen
__ mold
__ water/moisture
__ plant(s) ___________________
__ other _____________________

Where pt was when injured/became ill:

__ on farm
__ away from farm
__ living quarters
__ work site
__ other

Type of Injury/Illness :

__ strain/sprain
__ contusion
__ skin related
__ internal infection/ illness
__ other

Exposure to Chemicals:

__ pesticides
__ cleaning agents
__ fertilizers
__ fuels/solvents/vapors_________
__________________________
__ other _____________________

Who talked to?

__ boss/supervisor
__ co-worker(s)
__ spouse/partner
__ relatives
__ friends
__ no one
__ other ___________

Cause of Injury/Illness:

__ bitten/stung (by) ______________
__ caught in Machinery___________
__ crushed (by) _________________
__ cut (by) _____________________
__ burned (by) __________________
__ fell (from) ___________________
__ pierced (by)__________________
__ rubbed (by) __________________
__ struck (by):
__ tree branch___________­­­___
__equipment_______________
__ vehicle ________________
__ tool ___________________
__ bucket/bin ______________
__ other __________________
__ sexual contact ________________
__ other _______________________

How exposure/contact occurred

 __ eyes
__ mouth/hand to mouth
__ skin
__ breathing
__ other _____________________

Others experiencing same symptoms?

__ spouse/partner
__ children
__ friends
__ co-workers
__ boss/supervisor
__ other ___________

Filing Worker's Comp?

__ Yes
__ No


Check where working DOI/# years worked:

__construction _______________
__ field crops:
__ beans __________________
__ blueberries ______________
__ cabbage ________________
__ cucumbers ______________
__ peppers ________________
__ grapes _________________
__ strawberries _____________
__ sweet corn ______________
__ sweet potatoes ___________
__ tobacco _________________
__ tomatoes ________________
__ watermelons _____________
__ white potatoes ____________
__ other ___________________
__ forestry:__________________
__ Christmas trees __________
__ fisheries: _________________
__ livestock: _________________
__ manufacturing ____________
__ nursery plants: ____________
__ orchard crops:
__ apples _________________
__ peaches________________
__ other __________________
__ other _____________________


Objective Findings :

For Office Use Only

AS
&
PLN

DX : ___________________________________ DX/ICD9 code : _______________

TX Plan : __ meds: ________________________ Notes/ Comments :


__ referral(s): ____________________
__ FU visit: ___________
__ Pt. Education: _________________________________________________________________

Disclaimer and Reproduction Information: Information in NASD does not represent NIOSH policy. Information included in NASD appears by permission of the author and/or copyright holder. More

Reviewed for NASD: 03/2005