Child's First Name Child's Middle Initial Child's Last Name

Reporting Person's First Name Reporting Person's Last Name

Child's Date of Birth Child's Gender: MaleFemale

Street address where incident occurs

City Zip code Telephone Number

Date of exposure to poison

Date symptoms began Duration of symptoms

Observed symptoms

Type of poison (if known) Amount

Manner in which the child was poisoned (injested, inhaled, etc.)

Was the child taken to the emergency room? Yes No Was a poison center contacted? Yes No

Thank you!