Pennsylvania Department of Health Natural Gas Drilling Report CONFIDENTIAL Date of initial report: Record Number: Staff member who fielded initial call: Name/Organization: ______________________________________________________________________ Citizen’s request - What are you hoping the Department of Health can do for you? Role of DEHE – The Division of Environmental Health Epidemiology at the Department of Health evaluates possible connections between the environment someone lives in and their health outcomes. The Division compares medical information it collects with environmental data provided by sister agencies, like the Department of Environmental Protection. While the Division and our toxicologist who evaluate your concerns are not able to provide specific medical advice and/or medical care, we are able to collaborate with your medical provider and federal, state, county and local officials to address environmental health issues and protect communities. Citizen provided information ______________________________________________________________________ Public nature of reports It is also important to note that the information you provide and the records we keep related to your report are subject to the provisions of both the Health Insurance Portability and Accountability Act of 1996 (HIPPA) and Pennsylvania’s Right to Know law (RTK). This means all the medical information and personal identifying information you provide is protected and remains confidential but we may be obligated to release some of your record as part of our complaint log. Citizen provided information ______________________________________________________________________ Address: City: Zip Code: County: Phone Number: O Home ______________ O Cell ______________ O Work ______________ 1 Pennsylvania Department of Health Natural Gas Drilling Report CONFIDENTIAL Email: ______________________________________________________________________ Referral (How did you find out about us/reach us?) O O O O DEP referred Called 877-PA-Health Emailed RA-DHENVHEALTH@pa.gov Other: Concern/Issue: Health concerns: No___ Yes _______________________________________________________________ Non-health concerns: Air quality/odor, dust, ground water/well water, spills/soil contamination, light, noise, traffic, waste management/dumping, property damage, other Family or household members that live in household (those with a health concern only): Name: Age: Race: Gender: Relationship: self, child, spouse or other Industry/Occupation: Employer 1: Number of Years: Location Employer 2: Number of Years: Location Employer 3: Number of Years: Location Chemicals used? Hobbies, type and chemicals used: 2 Pennsylvania Department of Health Natural Gas Drilling Report CONFIDENTIAL Add Family Member Name: Date of Birth: Race: Relationship: Occupation: Employer 1: Number of Years: Location Employer 2: Number of Years: Location Employer 3: Number of Years: Location Chemicals used? Hobbies, type and chemicals used: 3 Pennsylvania Department of Health Natural Gas Drilling Report CONFIDENTIAL Symptoms (for each individual): This is an open ended question Neurological/Musculoskeletal O O O O O O O O O O Headaches Tremors Numbness/tingling Confusion Memory loss Difficulty concentrating Muscle aches/cramps Painful joints Falls/balance problems/dizziness Other Date of Onset Description How often they have the symptoms, and if they are getting better, worse or the same ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ ___________ ___________ ___________ ___________ ___________ ___________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ Dermatological O O O O O O Skin rash Hives Skin irritation Dry skin Hair loss Other Eyes, Ears, Nose, Throat O O O O O O O Nosebleeds ___________ Eye irritation/burning ___________ Ringing in ears/hearing loss ___________ Sore throat/irritated throat ___________ Sinus irritation/congestion/runny nose___________ Dry or irritated mouth ____________ Other ____________ Respiratory and Cardiac O Lung irritation/pneumonitis O Cough O Shortness of breath O Worsen asthma O New onset asthma/wheezing O Palpitations/racing/irregular heart O Chest pain O Hypertension O Other ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ 4 Pennsylvania Department of Health Natural Gas Drilling Report CONFIDENTIAL Gastro-Instestinal/Urinary O Nausea O Vomiting O Abdominal pain O Diarrhea O Urinary problem O Other ___________ ___________ ___________ ___________ ___________ ___________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ Reproductive O Pregnant O Not pregnant O Not sure ___________ ___________ ___________ ______________________ ______________________ ______________________ Emotional Status O Anxiety/stress O Difficulty sleeping O Depressed or angry O Lack of energy/tired O Other ___________ ___________ ___________ ___________ ___________ ______________________ ______________________ ______________________ ______________________ ______________________ Immune System Condition Date of Diagnosis ___________ ___________ ______________________ ______________________ Type or site Date of Diagnosis ___________ ___________ ______________________ ______________________ Adverse Birth Outcomes Condition Date of Diagnosis ___________ ___________ ______________________ ______________________ ___________ ___________ ___________ ______________________ ______________________ ______________________ Cancer Pre-existing condition(s) Allergies (list) ______________________________________________________________________ Medication(s) Type/frequency/how used: _____________________________________________________ Type/frequency/how used: _____________________________________________________ Type/frequency/how used: _____________________________________________________ Folk or alternative medicine(s): Type/frequency/how used: _____________________________________________________ Type/frequency/how used: _____________________________________________________ Type/frequency/how used: _____________________________________________________ 5 Pennsylvania Department of Health Natural Gas Drilling Report CONFIDENTIAL Has complainant sought medical care for concern? O Yes O No Describe outcome/diagnosis (with authorization given to contact doctor) _____________________________________________________________________________ Clinical tests: O No O Yes, describe______________________________________________________________ Primary Care Physician/Health Care Provider: Name: ___________________________________ Address: _________________________________ _________________________________ Phone: _________________________________ Specialist: Type: __________________________________ Name: ___________________________________ Address: _________________________________ _________________________________ Phone: _________________________________ Other Provider: Type: __________________________________ Name: ___________________________________ Address: _________________________________ _________________________________ Phone: _________________________________ Exposure history: What do you think contributed to this health concern? In what location were you/they exposed? When did this exposure begin? How often did/does this exposure occur? Have you noticed anything else related to when the exposure occurs? Exposure location ________________________________________ Exposure frequency_______________________________________ Exposure other __________________________________________ 6 Pennsylvania Department of Health Natural Gas Drilling Report CONFIDENTIAL Source of concern o Natural gas well Name: o o o o o o Distance: Onset of activity: Pipeline Name: Distance: Onset of activity: Compressor Station Name: Distance: Onset of activity: Impoundment Name: Distance: Onset of activity: Processing plant Name: Distance: Onset of activity: Truck traffic Name: Distance: Onset of activity: Other:___________________________________________________________ Water source O Public water O Well water Treatment system, describe:______________________________________________ How used: o Drinking o Cooking o Shower Change in taste, appearance, or odor? o Yes o No If yes, onset _________________ description_________________________________________________________ O Bottled water How long?_______ O Refillable Water Tank How long? _______ O Other Water Testing O Yes O No If yes: Date ___________ Date ___________ Date: __________ Laboratory___________ Laboratory___________ Laboratory___________ 7 Pennsylvania Department of Health Natural Gas Drilling Report CONFIDENTIAL Odors O Yes O No If yes: Onset_________ Frequency________________________________________________________ Describe__________________________________________________________ Other____________________________________________________________ Visible emissions O Yes O No If yes: o Flaring o Dust o Other, describe____________________________________________________ Garden vegetable/fruits o Yes o No If yes, O type and amount consumed____________________________________ O source of water, if watered____________________________________ Noise o Yes o No If yes, describe_____________________________________________________ Lights o Yes o No If yes, describe____________________________________________________ Sleep disturbance o Yes o No If yes, describe____________________________________________________ Other Concerns:__________________________________________________________ __________________________________________________________ __________________________________________________________ ___________________________________________________________ 8 Pennsylvania Department of Health Natural Gas Drilling Report CONFIDENTIAL Housing: Year Home built: __________ How long at this address? ___ Years Source of heat: Primary ____________ Secondary ____________ Remodeling, describe ______________________ Pesticide or Insecticide Use: O Yes O No If yes, type____________ Radon test: O Yes O No If yes, result: _____________ Vapor extraction system? Other Environmental Sampling Air: O Yes If yes, Type____________ Date_______________________ Laboratory_________________ O No Soil: O Yes If yes, Type____________ Date_______________________ Laboratory_________________ O No Other: O Yes If yes, Type____________ Date_______________________ Laboratory_________________ O No 9 Pennsylvania Department of Health Natural Gas Drilling Report CONFIDENTIAL Animals or Pets: O Yes O No If yes, type____________ If any problems or concerns, describe_____________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Neighbors with a similar problem or concern? Name_________________________________________ Address________________________________ ________________________________ Phone__________________________________ Action Taken to Date/Result: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Referrals: O DEP Date__________________ Contact________________ O OSHA Date__________________ Contact________________ O Environmental Medicine Date__________________ Contact________________ O Primary care provider Date__________________ Contact_______________ O Agriculture Date__________________ Contact_______________ O Other Date:_________________ Contact_______________ 10 Pennsylvania Department of Health Natural Gas Drilling Report CONFIDENTIAL Next Steps: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Were these steps relayed to resident? O Yes O No Date of next scheduled follow up/update to resident: ______________________________________________________________________ Executed Action with dates: Case outcome: ________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Case outcome communicated to citizen by: O Letter O Email O Phone call Date complaint closed: Date complaint closed letter sent: 11