Health Canada
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Consumer Product Safety
Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-2322
2. Registrant Information.
Registrant Reference Number: x
Registrant Name (Full Legal Name no abbreviations): x
Address: x
City: x
Prov / State: x
Country: xx
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.
03-AUG-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: unknown
- Active Ingredient(s)
- 2,4-D (PRESENT AS AMINE SALTS : DIMETHYLAMINE SALT, DIETHANOLAMINE SALT, OR OTHER AMINE SALTS)
7. b) Type of formulation.
Application Information
8. Product was applied?
Yes
9. Application Rate.
10. Site pesticide was applied to (select all that apply).
Site: Res. - Out Home / Rés - à l'ext.maison
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
Caller says the neighbour used to be a farmer and has some leftover 2,4-D and uses it in his residential yard. He applied it to the grass between the fences and into her yard and its dying in her yard too. She cannot smell it and it appears to be working at killing the grass. Caller is concerned about her children playing in the yard where its been sprayed. Caller is also upset the he has killed the grass into her yard. Caller did not know exactly when the spray occurred.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
Herbaceous Plants / Plante herbacée
2. Common name(s)
Grass
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.).
Killed the grass in her yard.
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
