Health Canada
Symbol of the Government of Canada
Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-7005

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

Prov / State: ONTARIO

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: 2,4-D

  • Active Ingredient(s)
    • 2,4-D (PRESENT AS ACID)

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

Product Name: Folpan

  • Active Ingredient(s)
    • FOLPET

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

Product Name: Polyram

  • 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: Agricultural-Outdoor/Agricole-extérieur

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

Caller reports herbicide drift damage to his grape crop at his winery (XXXXX Estate). They believe the damage occurred as a result of spraying approx 2 weeks ago by the farmer located to the east of his property, who has a young corn crop which shows evidence of herbicide application.

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

Herbaceous Plants / Plante herbacée

2. Common name(s)


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

Visible injury ( eg. chlorosis, necrosis, bleaching)

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

Impact area is estimated at 8 acres, with 1300 plants per acre damaged. The caller stated this will result in a major financial loss for him for which he intends to seek legal compensation. He said they are seeing the spray effects now. He said there is a drainage ditch that goes N-S along the east side of their property. There is a tree row along that drainage ditch but where there is a gap in the trees they noticed the most damage to the vines. He said there is wheat in the field now but ahead of that is a corn field. said he scouts the vineyards every Friday and he noticed damage on May 24th, but not the previous Friday. The leaves were curling and there were pale veins on the leaves closest to the gap in the tree line along the eastern boundary of the vineyard adjacent to the wheat field. XXXXX said the wheat field looked sick 2 weeks ago but looks very lush now. There were vehicle tracks in the wheat field indicating that something was sprayed there. XXXXX said XXXXX sprays fungicide about every 2 weeks. The use Folpan and Polyram (sp?). He said the vines were sprayed after this happened. XXXXX thinks it is 2, 4-D damage.

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