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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-2349
2. Registrant Information.
Registrant Reference Number: x
Registrant Name (Full Legal Name no abbreviations): x
Address: x
City: x
Country: 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: ONTARIO
6. Date incident was first observed.
23-JUL-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: Headline EC Fungicide
- Active Ingredient(s)
- PYRACLOSTROBIN
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: Agricultural-Outdoor/Agricole-extérieur
Préciser le type: Arial, Corn field
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
Caller reports they were driving on Hwy XX around 08:10 this morning and a helicopter oversprayed a corn field and the material they were spraying was sprayed onto their car.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.
Other
2. Demographic information of data subject
Sex: Unknown
Age: Unknown / Inconnu
3. List all symptoms, using the selections below.
System
- Respiratory System
- Symptom - Scratchy throat
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
Occupational
8. How did exposure occur? (Select all that apply)
Other
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.
Respiratory
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 the material instantly gave them a scratchy throat. Caller could not describe the odour as it was not something that he has smelled before. Caller was concerned that the material was a pesticide. Caller did not know who owned the corn field that was sprayed. The spraying was taking place on a wheat and corn field and he could taste the spray. His windows were up in the vehicle at the time. XXXXX said the helicopter looked dark blue or black. There was no spray boom on either side of the helicopter.
