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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2009-1102

2. Registrant Information.

Registrant Reference Number: x

Registrant Name (Full Legal Name no abbreviations): x

Address: x

City: x

Prov / State: x

Country: x

Postal Code: X

3. Select the appropriate subform(s) for the incident.


4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA


6. Date incident was first observed.


Product Description

7. a) Provide the active ingredient and, if available, the registration number and product name (include all tank mixes). If the product is not registered provide a submission number.


PMRA Registration No.       PMRA Submission No.       EPA Registration No.

Product Name: a

  • Active Ingredient(s)

7. b) Type of formulation.

Application Information

8. Product was applied?


9. Application Rate.

10. Site pesticide was applied to (select all that apply).

Site: Unknown / Inconnu

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

Unknown. Carcasses were collected along a creek bank. Site visit conducted by field technician at the (location), survey of surrounding land use was not documented.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?


Subform IV: Environment (includes plants insects and wildlife)

1. Type of organism affected

Bird - Songbird / Oiseau - Chanteur

2. Common name(s)

Northwestern Crows

3. Scientific name(s)


4. Number of organisms affected


5. Description of site where incident was observed

Fresh water



Salt Water

6. Check all symptoms that apply


7. Describe symptoms and outcome (died, recovered, etc.).

Unknown. Carcasses were collected along a creek bank. Site visit conducted by field technician at the (location); survey of surrounding landuse was not documented. Twelve crows were collected: total number of birds was not documented. There may have been additional mortalities as sick/dead birds are preyed upon/scavenged quckly & dark coloured birds may be difficult to locate in landscape. RHV called Environment Canada, as part of the BC Interagency Wild Bird Mortality Investigation; carcasses submitted to the BC Min of Agriculture and Lands Animal Health Centre for post-mortem exam; stomach analyzed at Contract Lab for pesticides. BCMAL Animal Health Centre Case [number] significantly reduced brain cholinesterase (average: 6.1 umol/min/g; range: 3.2-11.4 umol/min/g, n=12). Environment Canada examined stomach contents from 11 individuals, crows & identified: beige mush, with white granules 1mm diameter, small round pieces of grit 2mm diameter, thin cartilage pieces 1-4mm in lenght and some dark flecks, black & shiny, under 1mm in lenght. Stomach contents/lining were split - half submitted to Maxxam Analytical for organophosphates & half submitted to Can Test for carbamates. CanTest (ID:number) detected 19.0 ppm methomyl.

8. a) Was the incident a result of (select all that apply)


8. b) i) How many times has the product been applied this year?


8. b) ii) What was the date of the last application?


9. Did it rain

9. a) During application?


9. b) Up to 3 days after application?


10. a) Was there a buffer zone?


10. b) What type?

10. c) What was the size of the buffer zone?

11. a) Were environmental samples collected and analysed?


To be determined by Registrant

12. Severity classification (if there is more than one possible classification, select the most severe)

13. Please provide supplemental information here