Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-4304

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.

Human

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: SASKATCHEWAN

6. Date incident was first observed.

24-JUL-13

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.

Active(s)

---

PMRA Registration No. 27884      PMRA Submission No.       EPA Registration No.

Product Name: PAR III TURF HERBICIDE

• Active Ingredient(s)
  • 2,4-D (PRESENT AS AMINE SALTS : DIMETHYLAMINE SALT, DIETHANOLAMINE SALT, OR OTHER AMINE SALTS)
  • DICAMBA (PRESENT AS ACID, AMINE SALT, ESTER, POTASSIUM SALT, OR SODIUM SALT)
  • MECOPROP-P (PRESENT AS DIMETHYLAMINE SALT)

---

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

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

Airborne. Next door neighbour at (address) in (city) Saskatchewan hired Weed Man 2 do his front and back lawn just next to us. The chemicals are airborne and is obviously drifting towards us even though they try to deny it or say it isn't. You could smell it in the air and evident by the fact I am STILL sick with symptoms manifestations from it even days after, the physical manifestations during and after days they were spraying. Days they sprayed were approximately July 24-28. Today is July 29 and I am still getting mroe symptoms. Someone needs to be accountable. Why is it ok to impose a bio-hazard to someone's health who is already compromised without any regard for its implications

To 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.

Data Subject

2. Demographic information of data subject

Sex: Male

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Itchy skin
  • Symptom - Hives

• Gastrointestinal System
  • Symptom - Burning throat
  • Symptom - Tongue swelling
  • Specify - tongue is red and inflamed

• Nervous and Muscular Systems
  • Symptom - Headache

• Gastrointestinal System
  • Symptom - Nausea

• Nervous and Muscular Systems
  • Symptom - Muscle twitching

• Ear
  • Symptom - Ear irritation
  • Specify - itchy ears inside

• Gastrointestinal System
  • Symptom - Mouth Irritation
  • Specify - tongue is sore

• Eye
  • Symptom - Watery eye
  • Symptom - Burning eye

• General
  • Symptom - Other
  • Specify - itchy mucous membranes

• Eye
  • Symptom - Itchy eye

4. How long did the symptoms last?

>3 days <=1 wk / >3 jours <=1 sem

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.

Skin

Eye

Oral

Respiratory

11. What was the length of exposure?

>3 days <=1 wk / >3 jours <=1 sem

12. Time between exposure and onset of symptoms.

>24 hrs <=3 days / >24 h <=3 jours

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.)

Itchy skin, itchy mucous membranes, tongue, inside ears, itchy hives on skin, burning throat, end of my tongue is red and inflamed and sore, watery itchy burning eyes, headache, and nausea, muscle twitches all day on Saturday to Sunday July 27 and July 28.I don't know what they were exactly by name brand, but apparently they felt it was ok to risk my health and impose a health hazard (if not on others as well in the neighborhood) even WITHOUT WARNING that they were even coming to do what they lawfully felt was 'RIGHT', without any care or concern for us with what they were doing and even after I told them if they do this they area just going to make me very ill, but in return showed no regard or care for my concern and just told me to just leave our own property while they contaminate the area as it will just somehow disappear from the air/environment miraculously! Please make them stop poisoning us while they or whoever party to these chemical companies just play oblivious to it. They exposed me to harmful chemicals I am still suffering from that just keep compounding everytime they or whoever party to thesechemical companies feel it is somehow ok to keep selling this crap that poisons others let alone feel it was somehow ok to poison us. I am sorry I am not a guinea pig for someone else's laboratory experiment they feel they need to profit on. The government needs to stop being complacent regarding this matter. I even tried to call the owner who said he would call me back in 20 minutes, after he was done something he was doing but failed to do so.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.