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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-2368

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.

Domestic Animal

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

07-MAY-12

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.       PMRA Submission No.       EPA Registration No.

Product Name: Traxion

  • Active Ingredient(s)
    • GLYPHOSATE (PRESENT AS POTASSIUM SALT)

7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

1.1

Units: L

Other Units: 10gal/acre

10. Site pesticide was applied to (select all that apply).

Site: Agricultural-Outdoor/Agricole-extérieur

Préciser le type: wheat

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

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Unknown

Subform III: Domestic Animal Incident Report

1. Source of Report

Other

2. Type of animal affected

Horse / Cheval

3. Breed

n/a

4. Number of animals affected

3

5. Sex

Unknown

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Unknown

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

  • General
    • Symptom - Malaise
    • Specify - ill, in distress
  • Nervous and Muscular Systems
    • Symptom - Recumbent

12. How long did the symptoms last?

Unknown / Inconnu

13. Was medical treatment provided? Provide details in question 17.

Unknown

14. a) Was the animal hospitalized?

Unknown

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Unknown/Inconnu

16. How was the animal exposed?

Other / Autre

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

XXXX called to report that she observed her neighbouring farmer, XXXX spraying his field on Sunday, May 6th where he sprayed right up to the very edge of the property (the fenceline). Ms. XXXX believed that he sprayed on Friday May 4th as well. She observed that 10 feet in from the fenceline her grass is all dead and this morning (May 7th) two of her horses were found very ill laying on the ground in the area adjacent to the portion of XXXX's field which was sprayed on May 7th. Ms.XXXX is in touch with her Vet who indicated that without knowing what product was sprayed, she cannot provide an antidote to the horses. The horses were found laying down near adjacent wheat field ,XXXX stated that all three horses went down at the same time and were in distress.


To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Not Applicable

19. Provide supplemental information here