‘SUM’THINGS UP – MINNESOTA Fall Harvest-Time Injuries

There’s still time to achieve a safer fall harvest this year among Minnesota farmers and ranchers.  One way is renewed focus on preventing what has contributed to fatalities in the past.  Like many other fatal events, preventing deaths in production agriculture often involves hardware and behavior.  For example, rollover protection is the hardware to have if your tractor overturns; following safe operating practices on an ATV helps keep them right side up. 

The US Bureau of Labor Statistics (BLS) categorizes fatalities in production agriculture for each state using data from the Census of Fatal Occupational Injuries (CFOI)1.  There were 81 production agriculture deaths in Minnesota during the four-year period 2007-10; 2011 data is not yet published.  Minnesota experienced 14% of the 561 production agriculture deaths in the 7-state CS-CASH 2 region (ND, SD, NE, KS, MO, IA, and MN).  The following breakdown provides historical perspective (note the percentages) for production agriculture deaths in Minnesota based on pooled data for the four-year period. 

BLS CFOI Production Agriculture Fatalities, Minnesota 2007-10  

(Numbers in parentheses (#) below are the CFOI count of fatalities for Minnesota for the four-year period.) 

    43%        Transportation (35) – Events including collisions between farm equipment and motor vehicles (4) (see note below), non-collision events on the road (8) including tractor overturns, plus other overturns not on the roadway (12), and non-highway non-collision falls and struck by events (4) 

NOTE:  According to data from the Farm Equipment – Motor Vehicle Crash Prevention Conference website (agsafetyandhealthnet.org/femvcpc) 3, there were 569 such collisions between farm equipment and motor vehicles in Minnesota resulting in 274 injuries and 12 deaths over the five-year period 2005-2009. 

   43%        Contact with Objects and Equipment (35) – Sample events include being struck by equipment or objects (15), caught in it (9), or crushed in collapsing materials (11

   8%       Assaults and Violent Acts (6) – Attacked by an animal (6), such as a bull 

   4%       Falls (3) to a lower level (3

Newspaper press clippings do not report on all of these fatal events, but when they do they add to an understanding that is not presented in the numbers alone.  A review of five year’s press clippings for Minnesota during the 3-month Sep-Oct-Nov harvest period identified 46 deaths4

  • 27 transportation:  Tractor overturns in field or farmstead (13) including 4 carrying front-end loads, 3 while mowing, and 1 tugging equipment mired in mud;  Collision between farm truck and train or motor vehicle (4);  motor vehicle rear-ended or side-swiped equipment behind a tractor (4);  ATVs working (3)
  • 6 engulfments:  Engulfments occurred inside bins (4) or while loading or unloading trailers (2)
     
  • 6 struck by objects or equipment:  Equipment tipped or parts fell (3);  moving machinery or objects entangled (2);  chain broke and recoiled while jerking mired machine (1)
     
  • 3 other:  Scaffold failed painting barn;  fell, wedged partway down silo ladder chute;  overcome in tractor cab while fighting spreading grass fire 

TIPS TO AVOID INJURY 

Road transport collision prevention includes functional lighting and marking:  the behavior part is turning lights on whenever on the road.  Of course, both equipment and motor vehicle operators must be alert, patient, and have what they are driving under control.  

A hardware part of the increasing number of farm trucks on farm-to-market roads involves inspecting and ensuring brakes, lights, steering, etc., work:  an important behavior is traveling at a safe speed given conditions and the load.  

Part of overturn injury prevention, especially with tractors, is getting a rollover protective structure (ROPS) installed and using the seatbelt that comes with it:  a behavior component is to prefer not to use tractors without ROPS, especially those with tricycle front wheels and/or front-end loaders, to perform tasks where they are more likely to overturn.  

Run over prevention involves maintenance and proper functioning of the starting system and interlocks:  a behavioral contribution is always starting equipment from the operator station and never starting it at the starter or ignition while standing on the ground. 

Staying out of grain that can shift or flow is high on the list of vital precautions.  Entry into bins should be planned to include proper hardware and attendants.  

But, safe operating practices do not end with these few.  Among others are keeping extra riders off equipment to help prevent run over incidents and stopping equipment, disengaging all power, before leaving it or approaching moving machinery parts to help prevent both run over incidents and entanglements.  Review the operator’s manual for a complete presentation of how to use each piece of machinery safely at least before the use or harvest season. 

FOR ADDITIONAL INFORMATION 

ATV safety – Contact your local ATV dealer for safety training and personal protective equipment.  Visit the ATV Safety Institute website.

Grain Handling Safety –See “The Dangers of Flowing Grain” by W E Field and “Caught in the Grain” by G G Maher.  View a “Grain Bin Safety Video”.

Lighting and marking – See a local equipment dealer.  Visit the Great Plains Center for Agricultural Health.

Rollover protection – See “Your Guide to Affordable Retrofit ROPS for Agricultural Tractors”.  Visit your local agricultural tractor dealer or call your local cooperative extension service office.  Contact your insurance provider:  they may have a ROPS retrofit incentive. 

Truck inspection – See your local truck dealer, service or repair center.

Need more information?  Contact CS-CASH at (402-559-4998) or call your local Cooperative Extension Service office.  Access the National Agricultural Safety Database.  See the National Safe Tractor and Machinery Operation Program task sheets. 

REFERENCES 

1Dept. of Labor Bureau of Labor Statistics Census of Fatal Occupational Injuries (CFOI).  Available here. Regional data provided in personal communications with author. 

2CS-CASH (Central States – Center for Agricultural Safety and Health) at the University of Nebraska Medical Center is federally funded by CDC National Institute for Occupational Safety and Health under agreement 5U54OH010162-02. 

3FEMVCPC  (Farm Equipment – Motor Vehicle Crash Prevention Conference) Composite data (excerpts).  Available here.

 4FAIMS – Farm and Agricultural Injury Monitoring Service (press clippings) is a current project of the UNMC CS-CASH funded by CDC National Institute for Occupational Safety and Health under agreement 5U54OH010162-02.   Prior press clippings data for 2007-2010 as captured and reported by GPCAH (Great Plains Center for Agricultural Health).  The GPCAH is a federally-funded Center at the University of Iowa sponsored by the CDC National Institute for Occupational Safety and Health. 

About the author: 

Murray D. Madsen, MBA, is an independent consultant to CS-CASH at UNMC, current part-time Program Manager and former Associate Director for the Great Plains Center for Agricultural Health, and retired product safety engineer for Deere & Company.

‘SUM’THINGS UP – NEBRASKA Fall Harvest-Time Injuries

There’s still time for a safer fall harvest among Nebraska’s farmers and ranchers this year.  One way is a renewed focus on preventing what has contributed to fatalities in the past, whether they occur over the course of the year or during fall harvest times.  Like many other fatal events, preventing deaths in production agriculture often involves hardware and behavior.  For example, rollover protection is the hardware to have if your tractor overturns; following safe operating practices every time you get on an ATV helps keep them right side up.

The US Bureau of Labor Statistics (BLS) categorizes the fatalities in production agriculture for each state using data from the Census of Fatal Occupational Injuries (CFOI)1.  There were 74 such deaths in Nebraska over the four-year period 2007-10, the most recent year of published data:  13% of 561 such deaths in the 7-state CS-CASH 2 region (ND, SD, NE, KS, MO, IA, and MN) over the same period according to a summary email from CFOI staff.  The following breakdown provides an annual profile (see percentages) for production agriculture deaths in Nebraska based on the pooled data for the four-year period. 

BLS CFOI Production Agriculture Fatalities, Nebraska 2007-10  

(Numbers in parentheses (#) in the list below are the CFOI count of fatalities for Nebraska over the four-year period.) 

43%        Transportation (32) – Events including collisions between farm equipment and motor vehicles (4) (see note below), non-collision events on the road (6) including tractor overturns, and other overturns not on the roadway (13)
NOTE:  According to data from the Farm Equipment – Motor Vehicle Crash Prevention Conference website (agsafetyandhealthnet.org/femvcpc) 3, there were 376 such collisions in Nebraska resulting in 202 injuries and 8 deaths over the five-year period 2005-2009. 

   30%        Contact with Objects and Equipment (22) – Sample events include being struck by equipment (9), caught in it (8), or crushed in collapsing materials (5

   8%       Assaults and Violent Acts (6) – Includes being attacked by an animal (4), such as a bull 

   8%       Exposure to Harmful Substances or Environments (6), e.g., contact with electricity (3

   7%       Falls (5), mainly to a lower level (4

   4%       Fire and Explosion (3), including forest, brush or other outdoor fires

Newspaper press clippings do not report on all of these fatal events, but when they do they add to an understanding that is not presented in the numbers alone.  A review of Farm and Agricultural Injury Monitoring Service (FAIMS)4 press clippings from Nebraska compiled by the Great Plains Center for Agricultural Health (GPCAH)5 2007-Oct2011 and CS-CASH for Oct2011-Nov2011 for the fall harvest months (September through November) identified press clippings for the following 15 deaths: 

  • 6 road transport:  Head-on collision between a tractor and motor vehicle;  motor vehicle rear-ended equipment behind a tractor (2);  farm truck crash, blew through intersection (2) ;  high-speed van swerved then collided with a combine header in transport stopped at intersection
     
  • 4 run over:  Backed over by tractor with engine not running;  working on truck duals when co-worker moved truck;  run over by forage harvester;  unspecified vehicle pinned operator who had exited to open farm gate
  • 1 entanglement:  Operator climbed inside hay grinder while it was running
     
  • 1 engulfment:  Entrapped and engulfed inside bin while unloading corn into truck
     
  • 1 overturn:  ATV driven off embankment overturned while checking cattle
     
  • 2 other:  Skid steer went over bank into creek;  unspecified event involving a youth in farm shop

 TIPS TO AVOID INJURY 

Road transport collision prevention includes functional lighting and marking:  the behavior part is turning lights on whenever on the road.  Of course, both equipment and motor vehicle operators must be alert, patient, and have what they are driving under control. 

A hardware part of the increasing number of farm trucks on farm-to-market roads involves inspecting and ensuring brakes, lights, steering, etc., work:  a important behavior is traveling at a safe speed given conditions and the load. 

Part of overturn injury prevention, especially with tractors, is getting a rollover protective structure (ROPS) installed and using the seatbelt that comes with it:  a behavior component is to prefer not to use tractors without ROPS, especially those with tricycle front wheels and/or front-end loaders, to perform tasks where they are more likely to overturn. 

Run over prevention involves maintenance and proper functioning of the starting system and interlocks:  a behavioral contribution is always starting equipment from the operator station and never starting it at the starter or ignition while standing on the ground. 

Safe operating practices do not end with these.  Among others are keeping extra riders off equipment to help prevent run over incidents and stopping it, disengaging all power, before leaving it or approaching moving machinery parts to help prevent both run over incidents and entanglements.  Review the operator’s manual for a complete presentation of how to use each piece of machinery safely before the use season or more often.

FOR ADDITIONAL INFORMATION

Lighting and marking – Visit a local equipment dealer.  Visit  The Great Plains Center for Agricultural Health.

Rollover protection – View “Your Guide to Affordable Retrofit ROPS for Agricultural Tractors”.  Visit your local agricultural tractor dealer or call your local cooperative extension service office.  Contact your insurance provider:  they may have a ROPS retrofit incentive.

Truck inspection – View Nebraska DMV offical site or call your local truck service department.

ATV safety – Contact your local ATV dealer for safety training and personal protective equipment.  Visit the ATV Safety Institute website.

Want more information?  Access the National Agricultural Safety Database and see the National Safe Tractor and Machinery Operation Program task sheets.

REFERENCES 

1Dept. of Labor Bureau of Labor Statistics Census of Fatal Occupational Injuries (CFOI).  Available here. Regional data provided in personal communications with author.

2CS-CASH (Central States – Center for Agricultural Safety and Health) at the University of Nebraska Medical Center is federally funded by CDC National Institute for Occupational Safety and Health under agreement 5U54OH010162-02.

3FEMVCPC  Composite data (excerpts). Available here

4FAIMS – Farm and Agricultural Injury Monitoring Service managed by M. D. Madsen as a project of the UNMC CS-CASH funded by CDC National Institute for Occupational Safety and Health under agreement 5U54OH010162-02.

5GPCAH (Great Plains Center for Agricultural Health) at the University of Iowa is a federally-funded Center sponsored by the CDC National Institute for Occupational Safety and Health.

About the author: 

Murray D. Madsen, MBA, is an independent consultant to CS-CASH at UNMC, part time Program Manager and former Associate Director for the Great Plains Center for Agricultural Health, and retired product safety engineer for Deere & Company.

Five Strategies for a Safer Summer on Farms and Ranches in the CS-CASH1 Region

U.S. Department of Labor (DoL) data for 2007-2010 and records of over 125 press clippings about deaths in production agriculture from the summers of 2007 through 2011 suggest five strategies for a safer summer on farms and ranches in the CS-CASH7-state region (IA, KS, MN, MO, ND, NE, and SD):

  • Prevent overturns and prefer ROPS-equipped tractors for mowing and roadside maintenance;
  • Practice safe transport of farm equipment and watch for it when you drive a motor vehicle;
  • Secure raised loads, equipment and parts that can move or shift during repair or maintenance;
  • Shut-off power to all moving machinery before going near it;
  • Stay out of flowable materials that can entrap and engulf a person.

Analysis of annual data compiled from the U.S. DoL Bureau of Labor Statistics Census of Fatal Occupational Injuries2 for 2007-2010 (2011 data not available) show transportation incidents were the leading fatality event; they accounted for over 50% of 561 production agriculture deaths in the region during the 4-year period.  Being struck, caught in or compressed by equipment or objects, or in collapsing materials, contributed to 35% of the deaths.  Falls and exposures to harmful substances or environments each added 4% to the toll.  Attacks by animals plus self-inflicted injuries caused 5%.  Only 1% of the deaths in production agriculture in the CS-CASH 7-state region from 2007 through 2010 were the result of fires or explosions.

The first key strategy for the region continues to be preventing overturns (whether on an ATV, tractor, or other self-propelled machine) and protecting the operator with rollover protection and seat belt.

The 280-plus fatal transportation incidents were split two-thirds non-highway and one-third highway.  The non-highway category was nearly 90% non-collision events, of which over 70% (109 of 151) were overturns.  A sample of fatalities from the Farm and Agricultural Injury Monitoring Service3 can be found in table 1 (PDF).

Included in the highway incidents (83 of 280) are collisions, crashes with stationary objects, and non-collision incidents.  Examples can be found in table 2 (PDF).

Many collision deaths involve trucking commodities by persons employed on farms and ranches.  Collisions between “farm-equipment-other-than-trucks” and motor vehicles, however, (about 700 per year in the CS-CASH region4) do not add greatly to the death toll for production agriculture since there are few fatal collisions between “farm-equipment-other-than-trucks” and motor vehicles, and most often those fatally injured were occupants of the motor vehicle, not performing production agricultural work at the time.  Safer transport is, nevertheless, a key strategy because it’s important for agricultural producers AND the motoring public which also includes farmers, ranchers, farm workers and their family members operating motor vehicles.

Fatal contact with objects or equipment (187 of 561 deaths) was 3/6ths “struck by”, 2/6ths “caught in or compressed”, and 1/6th “collapsing materials”.  Securing raised loads (like objects in loader buckets and round bales in front-end bale handlers) as well as blocking or otherwise securing equipment and portions of it that can shift or fall during maintenance or repair is another key strategy.  Examples of incidents can be found in table 3 (PDF).

Many incidents also illustrate the importance of shutting off power to moving machinery before approaching and potentially becoming entangled in it.  Not only is it vital to stay out of moving machinery, it is also critically important to stay out of confined spaces without proper training, equipment, and personnel, and out of materials like grain that can give way, avalanche or flow entrapping and engulfing a person in seconds.  More examples can be found in table 4 (PDF).

Producers and others are working toward a safer summer for those engaged in production agricultural activities on our region’s farms and ranches.  These 5 strategies can help meet that goal:

  • Prevent overturns and prefer ROPS-equipped tractors for mowing and roadside maintenance;

For information on rollover protection available for your tractors, refer to “Your Guide for Available Retrofit ROPS for Agricultural Tractors”.

  • Practice safe transport of farm equipment and watch for it when you drive a motor vehicle;

Contact your local equipment dealer for recommended lighting and marking for farm equipment.  For information about collisions between farm equipment and motor vehicles, visit this website and contact the CS-CASH.

For additional information on the following topics, visit the National Agricultural Safety Database

  • Secure raised loads, equipment and parts that can move or shift during repair or maintenance;
  • Shut-off power to all moving machinery before going near it;
  • Stay out of flowable materials that can entrap and engulf a person.

 About the author:

Murray D. Madsen, MBA, is an independent consulting contractor to CS-CASH at UNMC, former Associate Director for the Great Plains Center for Agricultural Health, and product safety engineer for Deere & Company.  He currently maintains the FAIMS – Farm and Agricultural Injury Monitoring Service, which captures and records press clipping information from all periodicals in the region.

 

1CS-CASH (Central States – Center for Agricultural Safety and Health) is federally funded by the CDC National Institute for Occupational Safety and Health under agreement 1U54OH0101612-01.
2DoL Bureau of Labor Statistics Census of Fatal Occupational Injuries.  Available at http://www.bls.gov/iif/oshstate.htm.
3FAIMS – Farm and Agricultural Injury Monitoring Service data (Press Clip Records) from the Great Plains Center for Agricultural Health (GPCAH) at the University of Iowa, Iowa City, IA.
4FEMVCPC  Composite data (excerpts). Available at http://www.agsafetyandhealthnet.org/FE%20-%20MV%20Upper%20Midwest%20FE%20vs%20MV%20Crashes%202005-9.pdf

 

 

 

Pasture Safety at Calving Time

Articles about pasture safety often address the welfare of animals, but not this one.  This one’s about your safety as a rancher, or livestock producer.  In particular, the focus is on helping you safely through the calving season when your time in the pasture is both “on demand” as well as part of your daily routine. 

Pasture Safety at Calving Time

Annually for the past five years, about 36 million calves were born in the US according to USDA National Agricultural Statistics Service estimates.  More than one-in-four calves were born in the CS-CASH* 7-state region (about 20% of the region’s calves were born in Nebraska).1   That’s a lot of new “doggies” and many were born on pasture!  It’s a good thing cows typically take care of the birthing process pretty well on their own, though their choice of location isn’t always so good. 

The hormones in livestock at calving (and breeding) times, however, make them as unpredictable as spring weather.  A livestock producer can be surprised by either, or both.  It makes sense to consider a feeding strategy that results in more calves born in daylight.  Ensure expectant cattle (especially heifers more likely to have trouble calving) are pastured where they can be observed easily and are near facilities to safely handle them, such as a squeeze chute.2 

In remote pastures some producers do their new-calf processing from the back of a pick-up truck, which affords some protection against an aggressive cow or sympathetic member of the herd.  An extra hand can provide a heads-up for trouble as well as assist in processing.  But, don’t bring “fido”.   Cattle with newborns sense dogs to be predators and will aggressively protect their calf whether you’re in the way or not. 

During the 2003-2008 period, deaths in production agriculture in the 7-state CS-CASH region totaled 829 according to US Department of Labor Census of Fatal Occupational Injuries figures.3    Assaults by animals were the main event in one of approximately every 14 deaths; cattle (~80%) and horses (~20%) were primary sources in these fatal injuries.  But there’s more to this story than aggressive cows or bulls, the rider injured by a horse or thrown while scouting cattle in the pasture.

Ranchers have hopped from their pick-up truck to open a gate only to be run over by the pick-up as it continued to roll.  Other times a tractor used in bad weather, to traverse difficult pasture terrain, or to pull a dead animal overturns.  Less speed, more attention to the terrain and safe hitching practices, plus a rollover protective structure could have saved their life.  Increasingly, however, the ATV (all-terrain vehicle) or a similar utility work machine for off-road work has become a modern workhorse during calving season.  It is paramount, just as for tractors, to follow all precautions for safe ATV use and be extra careful in bad weather or urgent times during calving season. 

For additional information, contact the CS-CASH* at UNMC in Omaha and consider how to prevent these incidents by other livestock producers as reported in media across our region:

  • ND livestock producer repeatedly rammed by a mothering cow (Feb ‘07)
  • 47-year-old NE man crushed to death in corner of pen by cow with calf (Mar ‘07)
  • NE man pushed from behind and stepped on by cow while tagging calf (Mar ’07)
  • KS man, age 26, suffered a broken back herding cattle (Jun ’07)
  • 15-year-old IA youth died working cattle in pasture when ATV overturned (Nov ’07)
  • 48-year-old IA man died herding cattle in picked corn field when ATV overturned (Nov ’07)
  • 37-year-old MN man crushed to death by cow while assisting with calving (Feb ’08)
  • MN man, 71, died when rammed by a cow while herding cattle in pasture (Apr ’08)
  • IA man, 49, died when tractor overturned pulling dead livestock for washout (Mar ’08)
  • SD man was thrown from his horse when it slipped working cattle in mud/snow (Apr ’08)
  • NE man, age 81, died when assaulted by a cow in pen (May ’08)
  • KS man, 71, died when his horse fell while checking cattle (Mar ’09)
  • 64-year-old MO man checking cattle drowned in small creek that had swollen (Apr ’09)
  • KS man, 20, on horseback chased runaway cow and drowned with horse in pond (May ’09)
  • 59-year-old MO man fractured bones when attacked while teaching cow to nurse (Sep ’09)
  • 49-year-old MO man received minor injuries when ATV overturned herding cattle ( Oct ’09)
  • MO man attacked by cow held onto horn to avoid being gored (Mar ’10)
  • NE man fractured ribs when knocked backwards by cow while moving cattle (Nov ’10)
  • NE man, age 32, died when ATV overturned helping move cattle (Mar ’11)
  • NE man, 50, died when ATV went off embankment while checking on sick calf (Sep ’11)

1 Data compiled from USDA NASS survey information available at http://quickstats.nass.usda.gov/.  Accessed 2Apr12.

2 Ringwall K.  Beeftalk: Heads up it’s calving time.  NDSU Ag News.  Available at http:www.ag.ndsu.edu/news/columns/beeftalk/beeftalk-heads-up-2013. Access 5Apr2012.

3 US Department of Labor, Bureau of Labor Statistics, Census of Fatal Occupational Injuries data available at http://www.bls.gov/iif/oshstate.htm.

* CS-CASH (Central States – Center for Agricultural Safety and Health) is a CDC National Institute for Occupational Safety program funded under cooperative agreement 1U54OH01062-01 at the University of Nebraska Medical Center, Omaha, NE.

Motor Vehicles Clash with Farm Equipment on Rural Roads

The traffic mix of motor vehicles and farm equipment in rural America is once again growing as planting season unfolds across the Midwest.  Crashes between motor vehicles and farm equipment continue to occur on rural roadways.  Recent crashes in the news include: 

  • 24Jan2012       Stockton, IA     Southbound van collided with northbound self-propelled fertilizer  spreader that turned left in front of the oncoming van
  • 22Feb2012      Octavia, NE     Auto rear-ended eastbound tractor with white light to the rear
  • 27Feb2012      Brunswick, NE SUV rear-ended eastbound hay feeder without rear lighting towed  by tractor with lights
  • 02Mar2012     Columbus, NE  Van rear-ended eastbound tractor on roadway at 6:50 p.m. 

The 7-state CS-CASH1 region experienced over 3500 such crashes between farm equipment (excluding trucks) and motor vehicles 2005-2009.  Nearly 1/3rd of those crashes resulted in nonfatal injuries.  Over 70% of the 1677 persons injured were occupants of the motor vehicle:  44% of the 86 deaths in the 5-year period were operators of farm equipment.2

Whether the trip is business or pleasure, every motor vehicle driver whether from an urban or rural community has a responsibility to share rural roadways safely, and so does every farm equipment operator.  That means not only ensuring that proper equipment is in place (seatbelts, wipers, lighting, marking and more), that it functions properly and is used, but also that safe operating practices are followed by both motorists and equipment operators.

For an internet video on this topic in general, entitled “Rural Road Crashes – They’re Preventable”, visit www.iowadot.gov/mvd/ods/RuralRoadCrashes.html.

For more information on lighting and marking for farm equipment and safety precautions to be followed, visit the Centers for Disease Control National Agricultural Safety Database at www.nasdonline.org and search on the word “collisions”.     

For specific help with lighting and marking for particular equipment, see your local farm equipment dealer.  Additional information regarding lighting and marking can be found by copying each of the following links into your web browser:

1 CS-CASH (Central States – Center for Agricultural Safety and Health) is National Institute for Occupational Safety and Health (NIOSH), federally-funded, center at the University of Nebrasks Medical Center in Omaha to serve the states of NE, KS, MO, IA, MN, ND, and SD.

2 “Comprehensive data for 2005-9” FEMVCPC (Farm Equipment – Motor Vehicle Crash Prevention Conference) accessed at http://www.agsafetyandhealthnet.org/Current%20FEMVCPC%20Data.htm.