Emergency Pesticide Application Notification Exemption Reporting Form

March 30, 2002

The complete Emergency Pesticide Application Notification Exemption Reporting Form is available as an Adobe Portable Document Format (PDF, 28 KB, 2pg).

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
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  
Address of emergency pesticide application:
(Street address, City, State, Zip, Phone No., County)
 Property type (e.g., school, private residence,
daycare facility, etc.)
Specific location of application on property
(e.g., backyard by sandbox)
 Approximate area covered by application
(e.g., 100 square feet)
Product name(s) of
pesticide(s) applied
U.S. Environmental
Protection Agency
registration number(s)
of product(s)
Active ingredient(s)
in product(s)
Amount of product(s)
applied, expressed as
undiluted material

Description of situation that required the emergency application



Description of any notification provided in this case to persons in the vicinity of the application and to other persons




New York State Department of Health
Bureau of Toxic Substance Assessment
Attention: Emergency Notification Exemption Staff
547 River Street, Room 330
Troy, NY 12180-2216
Fax - (518) 402-7819


Date Recieved:____________________

Method of transmission:____________________

Incident number:____________________

DOH-4212 (9/01)