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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-2345
2. Registrant Information.
Registrant Reference Number: x
Registrant Name (Full Legal Name no abbreviations): x
Address: xxx
City: x
Country: x
3. Select the appropriate subform(s) for the incident.
Human
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.
29-MAY-13Product 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: Grass&Weed Killer
- Active Ingredient(s)
- GLYPHOSATE
7. b) Type of formulation.
Application Information
8. Product was applied?
Yes
9. Application Rate.
Unknown
10. Site pesticide was applied to (select all that apply).
Site: Res. - Out Home / Rés - à l'ext.maison
Préciser le type: apartment building
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
caller reports suspected spraying of illegal pesticide by landlord in multiple apartment complex areas at XXX XXXXX Street East, eastward to XXXXX Boulevard. Residents had headaches, grass is dead. No signs were posted. Residents don't want pesticide sprayed againTo be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
Unknown
Subform II: Human Incident Report (A separate form for each person affected)
1. Source of Report.
Other
2. Demographic information of data subject
Sex: Unknown
Age: Unknown / Inconnu
3. List all symptoms, using the selections below.
System
- Nervous and Muscular Systems
- Symptom - Headache
4. How long did the symptoms last?
Unknown / Inconnu
5. Was medical treatment provided? Provide details in question 13.
Unknown
6. a) Was the person hospitalized?
Unknown
6. b) For how long?
7. Exposure scenario
Non-occupational
8. How did exposure occur? (Select all that apply)
Drift from the application site
9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)
None
10. Route(s) of exposure.
Unknown
11. What was the length of exposure?
Unknown / Inconnu
12. Time between exposure and onset of symptoms.
Unknown / Inconnu
13. Provide any additional details about the incident (eg. description of the frequency and severity of the symptoms, type of medical treatment, results from medical tests, outcome of the incident, amount of pesticide exposed to, etc.)
caller reports suspected spraying of illegal pesticide by landlord in multiple apartment complex areas at XXX XXXXX Street East, eastward to XXXXX Boulevard. Residents had headaches. No signs were posted. Residents don't want pesticide sprayed again
To be determined by Registrant
14. Severity classification.
15. 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)
Grass
3. Scientific name(s)
Unknown
4. Number of organisms affected
Unknown
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.).
grass is dead.
8. a) Was the incident a result of (select all that apply)
Unknown
8. b) i) How many times has the product been applied this year?
Unknown
8. b) ii) What was the date of the last application?
Unknown
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?
10. c) What was the size of the buffer zone?
11. a) Were environmental samples collected and analysed?
Yes
