Health Canada
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Consumer Product Safety
Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-2311
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.
Environment
4. Date registrant was first informed of the incident.
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
05-JUN-12Product 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.
Active(s)PMRA Registration No. PMRA Submission No. EPA Registration No.
Product Name: Round up
- Active Ingredient(s)
- GLYPHOSATE (PRESENT AS ISOPROPYLAMINE SALT OR ETHANOLAMINE SALT)
7. b) Type of formulation.
Application Information
8. Product was applied?
Unknown
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).
Caller reports her neighbour has caused a pesticide over-spray resulting in veg and tree die off on her property. She noted that her garden has died off in the past 2 wk and she believes it is due to her neighbour's over-spray of pesticides. She also stated that they have not seen the spray activity go on at any time. She requested to call her husband to obtain further details on suspected pesticide. He reported that he has not seen the spray activity. He is aware of pesticide on plants - which he believes that his evergreen and plants are dead as a result of over-spray.To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
Unknown
Subform IV: Environment (includes plants insects and wildlife)
1. Type of organism affected
Trees or shrubs / Arbre ou arbuste
2. Common name(s)
Evergreen
3. Scientific name(s)
Unknown
4. Number of organisms affected
5. Description of site where incident was observed
Fresh water
Terrestrial
Residential
Salt Water
6. Check all symptoms that apply
Death
7. Describe symptoms and outcome (died, recovered, etc.).
His evergreen and plants are dead as a result of overspray.
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?
Unknown
9. b) Up to 3 days after application?
Unknown
10. a) Was there a buffer zone?
Unknown
10. b) What type?
Aquatic
10. c) What was the size of the buffer zone?
11. a) Were environmental samples collected and analysed?
No
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
Subform IV: Environment (includes plants insects and wildlife)
1. Type of organism affected
Herbaceous Plants / Plante herbacée
2. Common name(s)
Garden plants
3. Scientific name(s)
Unknown
4. Number of organisms affected
5. Description of site where incident was observed
Fresh water
Terrestrial
Residential
Salt Water
6. Check all symptoms that apply
Death
7. Describe symptoms and outcome (died, recovered, etc.).
Vegetation and tree die off. She noted the vegetation in her garden has died off in the past 2 weeks.
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?
No
9. b) Up to 3 days after application?
No
10. a) Was there a buffer zone?
No
10. b) What type?
Aquatic
10. c) What was the size of the buffer zone?
11. a) Were environmental samples collected and analysed?
No
