pesticide incident form

Pesticide Compliance Incident Information Form
If you would like to file a pesticide compliance complaint, please fill out the form below. Additionally, complaints can be phoned in to our office during normal operating hours at 575-646-2134, after hours at 575-646-3007, or emailed to pesticidecomplaints@nmda.nmsu.edu. If you would like to fax your complaint, please download the Pesticide Compliance Incident Form.
Submit anonymously?*

YesNo
Your Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Nature of Incident
Date of suspected incident*

MonthDayYear
Suspected direct exposure of human(s) or animal(s) to a pesticide application?

YesNo
Seek medical care immediately if you are feeling ill.
Suspected contamination of food or feed from a pesticide application?

YesNo
Application made by a known person/company/agency?

YesNo
Description of alleged incident:*
If possible, please attached photos or files below.
Cancelof
Name of the alleged person/company/agency (if known)
Address or location of alleged incident*
Name of other known witnesses to the incident.
Have you reported this incident to any other agency?

YesNo
Name of agency
Has there been any discussion with the person/company in attempt to resolve the matter?

YesNo
By reporting this incident, my expectation is...*
Upon receipt of this completed form, staff will review the information and decide if NMDA has statutory authority over this matter. If so, an investigator will contact you for an interview. If not, you will be provided with an explanation.

**Note: Be advised that this agency has no statutory authority regarding efficacy, price, or contractual matters. Pesticide products are registered at the federal level by US EPA and at the state level by NMDA. As such, NMDA has no statutory authority to prohibit the lawful applications of any registered pesticide. If the alleged applicator/company/agency is unknown, NMDA will attempt to identify the person/company/agency. However, based on the information provided, identification may not be possible.
Your name, address and email are no longer required.
However, you can still enter them in case we need to reach out to you for further information.
Should be Empty:

Pesticide Compliance Incident Information Form

Your Information

Nature of Incident