Pest treatment record – Redbridge eforms

1Customer details

2Appointment details

3Risk assessment

4Pest & treatment details

5Treatment details

6Details of 1st visit

7Details of 2nd visit

8Details of 3rd visit

9Details of 4th visit

10Details of 5th visit

11Details of 6th visit

12Details of 7th visit

13Details of 8th visit

14Details of 9th visit

15Details of 10th visit

16Details of 11th visit

17Details of 12th visit

18Feedback

Reference number*

Customer details

First name*

Last name*

Do they live in Redbridge*

Yes

Enter Postcode*

Find addressSelected address

Address*

Address Line 1 Address Line 2 City County Postcode

Telephone Number

Appointment details

First appointment date*

DD slash MM slash YYYY

Time (24 hrs)*

Operative Details

Operative First name*

Operative Last name*

Operative email address*

Risk assessment

Presence of pest confirmed*

Yes

Please specify the pests

Risk assessed & acceptable for treatment*

Yes

Presence of animals*

Yes

Please specify the animals

Risk assessed & acceptable for non-target animals/pets*

Yes

Presence of children*

Yes

Please specify about children

Risk assessed & acceptable for children*

Yes

Other*

Yes

Please specify if other

Risk assessed & acceptable*

Yes

Additional Information

Pest & treatment details

Premises type*

Domestic

Commercial

Pest*

Rats

Mice

Cockroaches

Bed bugs

Black ants

Pharaoh ants

Wasps

Other

If other pests, please specify*

Rodenticides

Raccumin Foam

Sakarat D Whole Wheat

Contrac Super Blox

Solo Super Blox

Rodilon Wheat Tech.

Rat / mouse bait

Ratimor brodifacoum block

Ratimor difenacoum block

Ratimor bromadiolone soft block

Rodolin difethialone soft block

Other

If other Rodenticides, please specify*

Insecticides

Cimetrol Super EW

Biopren 6 EC

Effect Ultimum Pro

Effect Microtech CS Pro

K-Othrine Partix

Cytrol Forte WP

Maxforce Platin Gel

Advion Cockroach Gel

Bayer Flying Insect Killer

Biopren BMS

Advion Ant Gel

Maxforce Quantum Gel

Ficam D

Vulcan PS DP.

Other

If other Insecticides, please specify*

Was occupier advised and given safety information*

Yes

Treatment details

Can you proceed with the treatment?*

Yes

Please specify the reasons for not proceeding with the treatment

No infestation present

Operator safety

Housekeeping/Husbandry

Different species found

Pre spray preparation not of an acceptable standard

No one at present at the time of appointment - No Access Card left

Treatment area not prepared as required – Customer pretreatment advice given again.

Tenant/Occupier refused access.

Other

If other reason, please specify

Proofing and Housekeeping details

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Max. file size: 10 MB.

Details of 1st visit

First appointment date

DD slash MM slash YYYY

Initial visit – areas treated/number of baiting points*

Operative*

Proofing done*

Yes

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Drop files here or

Max. file size: 10 MB.

2nd visit requested*

Yes

Details of 2nd visit

Second appointment date

DD slash MM slash YYYY

2nd visit*

Operative*

Proofing done*

Yes

Pesticide removed

Yes

Reason for not removing pesticide*

Refusal by customer

No bait to take away

Further visit required

Please upload any photos here. You can upload multiple photos

Drop files here or

Max. file size: 10 MB.

3rd visit requested*

Yes

Details of 3rd visit

Third appointment date

DD slash MM slash YYYY

3rd visit*

Operative*

Proofing & housekeeping advice followed*

Yes

Pesticide removed*

Yes

Reason for not removing pesticide*

Refusal by customer

No bait to take away

Further visit required

Please upload any photos here. You can upload multiple photos

Drop files here or

Max. file size: 10 MB.

4th visit requested*

Yes

Details of 4th visit

Forth appointment date

DD slash MM slash YYYY

4th visit*

Operative*

Proofing & housekeeping advice followed*

Yes

Pesticide removed*

Yes

Reason for not removing pesticide*

Refusal by customer

No bait to take away

Further visit required

Please upload any photos here. You can upload multiple photos

Drop files here or

Max. file size: 10 MB.

5th visit requested*

Yes

Details of 5th visit

Fifth appointment date

DD slash MM slash YYYY

5th visit*

Operative*

Proofing & housekeeping advice followed*

Yes

Pesticide removed*

Yes

Reason for not removing pesticide*

Refusal by customer

No bait to take away

Further visit required

Please upload any photos here. You can upload multiple photos

Drop files here or

Max. file size: 10 MB.

6th visit requested*

Yes

Details of 6th visit

Sixth appointment date

DD slash MM slash YYYY

6th visit*

Operative*

Proofing & housekeeping advice followed*

Yes

Pesticide removed*

Yes

Reason for not removing pesticide*

Refusal by customer

No bait to take away

Further visit required

Please upload any photos here. You can upload multiple photos

Drop files here or

Max. file size: 10 MB.

7th visit requested*

Yes

Details of 7th visit

Seventh appointment date

DD slash MM slash YYYY

7th visit*

Operative*

Proofing & housekeeping advice followed*

Yes

Pesticide removed*

Yes

Reason for not removing pesticide*

Refusal by customer

No bait to take away

Further visit required

Please upload any photos here. You can upload multiple photos

Drop files here or

Max. file size: 10 MB.

8th visit requested*

Yes

Details of 8th visit

Eigth appointment date

DD slash MM slash YYYY

8th visit*

Operative*

Proofing & housekeeping advice followed*

Yes

Pesticide removed*

Yes

Reason for not removing pesticide*

Refusal by customer

No bait to take away

Further visit required

Please upload any photos here. You can upload multiple photos

Drop files here or

Max. file size: 10 MB.

9th visit requested*

Yes

Details of 9th visit

Ninth appointment date

DD slash MM slash YYYY

9th visit*

Operative*

Pesticide removed*

Yes

Reason for not removing pesticide*

Refusal by customer

No bait to take away

Further visit required

Please upload any photos here. You can upload multiple photos

Drop files here or

Max. file size: 10 MB.

10th visit requested*

Yes

Details of 10th visit

Tenth appointment date

DD slash MM slash YYYY

10th visit*

Operative*

Pesticide removed*

Yes

Reason for not removing pesticide*

Refusal by customer

No bait to take away

Further visit required

Please upload any photos here. You can upload multiple photos

Drop files here or

Max. file size: 10 MB.

11th visit requested*

Yes

Details of 11th visit

Eleventh appointment date

DD slash MM slash YYYY

11th visit*

Operative*

Pesticide removed*

Yes

Reason for not removing pesticide*

Refusal by customer

No bait to take away

Further visit required

Please upload any photos here. You can upload multiple photos

Drop files here or

Max. file size: 10 MB.

12th visit requested*

Yes

Details of 12th visit

Twelveth appointment date

DD slash MM slash YYYY

12th visit*

Operative*

Pesticide removed*

Yes

Reason for not removing pesticide*

Refusal by customer

No bait to take away

Further visit required

Please upload any photos here. You can upload multiple photos

Drop files here or

Max. file size: 10 MB.

Feedback

Please complete the Customer feedback form after you submit this form.