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Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-2378

2. Registrant Information.

Registrant Reference Number: x

Registrant Name (Full Legal Name no abbreviations): xx

Address: x

City: x

Prov / State: x

Country: xx

Postal Code: 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.

05-JUN-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. 28715 PMRA Submission No. EPA Registration No.

Product Name: Pic Plus

Active Ingredient(s)
- CHLOROPICRIN

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: Ginseng

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

Caller reports that a Chemical Chlorapicton( correct name might be Chloropicrin) was sprayed onto 2 Ginseng fields. The second field where a complaint from a resident was received is at XXXXX. The same pesticide is believed to be involved. Caller reports they believe that a co-op sprayed the field. The chemical was applied to 40 acres all afternoon ended at 19:00. The FD did not have the total volume applied. Caller reports they applied the chemical to 30 acres of land at 250 lbs per acre. The chemical comes out as a liquid and gasifies in the soil. The chemical is injected into the ground at approximately 8-10 inch depth and the machine packs down the soil behind it. Caller reports they have not had an incident like this in the past. The conditions this evening allowed extra moisture to come up to surface and the heavy air did not allow the chemical to dissipate. Caller was aware of the second incident but reports that the other field (XXXX) was farmer applied. The next steps will be to monitor the area and ensure that the fumes dissipate. Caller will likely be on site all night. The road is now opened and it will not be long till everyone leaves. At the XXX site, treated area was about 10 hectares and was within 3 to 4 metres from neighbouring back yards. The second field where a complaint from a resident was received is at XXXXX. The same pesticide is believed to be involved. Caller reports they believe that a co-op sprayed the field. Caller was advised that the chemical was legally applied. Seven people have been taken to hospital several of them are firefighters. Approximately 25 homes have been evacuated and the FD is ensuring that the evac zone is clear. The evacuation radius is 0.25km.

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 - Respiratory distress

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

Unknown

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)

Unknown

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.)

1 person was taken to the hospital for respiratory distress. . OPP, fire department, ambulance, were at both of the fields (two sites). 00:59 caller confirmed that approx. 25 homes evacuated and approximately 8-9 people have been taken to hospital. 02:00: Caller reports it is now a voluntary evacuation and some people have returned home. 02:17:The odour has dissipated and many of the people have decided to return home. The roads have been reopened. 06:38: Caller spoke with some of the residents, some of which went to hospital and they have elected to return home later today. 04h30 - If windows wound up, then effects were not noticeable in vehicle, but tearing happened if windows were open.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.

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

Eye
- Symptom - Burning eye

Respiratory System
- Symptom - Coughing

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

Unknown

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)

Unknown

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.)

Adjacent resident XXXX, XXXX, XXXX, experienced burning eyes, coughing, haven't returned home yet. XXXX, XXXX, left about 10pm, returned about 1pm.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.

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

Eye
- Symptom - Burning eye

Respiratory System
- Symptom - Choking

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)

Drift from the application site

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

Unknown

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.)

Visited Mushroom Farm, XXXXX ,. XXXX, XXX, XXXX were harvesting mushrooms at 9:30 pm when impacted by vapour. Burning eyes, choking. Returned at 7am, still irritates eyes. Returned at 9am. Mushroom crop damage.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.

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

Eye
- Symptom - Burning eye

Respiratory System
- Symptom - Coughing

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

Unknown

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)

Unknown

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.)

Additional residents adjacenty to field are at home this afternoon, report experiencing burning eyes, coughing.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.

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

Eye
- Symptom - Burning eye

Respiratory System
- Symptom - Coughing

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?

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)

Unknown

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.)

Adjacent resident XXXX, XXXX, XXXX, experienced burning eyes, coughing, haven't returned home yet. XXXX, XXXX, left about 10pm, returned about 1pm.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.

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

Eye
- Symptom - Burning eye

Respiratory System
- Symptom - Coughing

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)

Unknown

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.)

Adjacent resident XXXX, XXXX, XXXX, experienced burning eyes, coughing, haven't returned home yet. XXXX, XXXX, left about 10pm, returned about 1pm.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.

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

Eye
- Symptom - Burning eye

Respiratory System
- Symptom - Choking

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)

Drift from the application site

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

Unknown

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.)

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.

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

Eye
- Symptom - Burning eye

Respiratory System
- Symptom - Choking

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)

Drift from the application site

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

Unknown

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.)

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.

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

Eye
- Symptom - Burning eye

Respiratory System
- Symptom - Choking

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?

6. b) For how long?

7. Exposure scenario

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)

Unknown

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.)

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)

Sedum, peony, clover, chickweed

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

Visible injury ( eg. chlorosis, necrosis, bleaching)

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

XXXX reports vegetation damage in back yard, XXXX Sedum and peony at garage, shrub in front of house. Grass doesn't appear affected, clover and chickweed in grass is dying/dead. Tough waxy leaves not affected like English ivy. Visual symptoms are bleaching of green tissue consistent with contact herbicide, vinegar, HCl

8. a) Was the incident a result of (select all that apply)

Drift

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

Subform IV: Environment (includes plants insects and wildlife)

1. Type of organism affected

Trees or shrubs / Arbre ou arbuste

2. Common name(s)

Shrub

3. Scientific name(s)

Unknown

4. Number of organisms affected

5. Description of site where incident was observed

Fresh water

Terrestrial

Residential

Salt Water

6. Check all symptoms that apply

Visible injury ( eg. chlorosis, necrosis, bleaching)

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

8. a) Was the incident a result of (select all that apply)

Drift

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

Subform IV: Environment (includes plants insects and wildlife)

1. Type of organism affected

Herbaceous Plants / Plante herbacée

2. Common name(s)

cabbage, peas, chickpeas, peppers, mushroom

3. Scientific name(s)

Unknown

4. Number of organisms affected

Unknown

5. Description of site where incident was observed

Fresh water

Terrestrial

Agricultural

Salt Water

6. Check all symptoms that apply

Visible injury ( eg. chlorosis, necrosis, bleaching)

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

mushroom grower. Garden vegetables leaf damage, cabbage, peas, chickpeas, peppers, pear tree leaves. Mushrooms in barn damaged, Portabello. (photos)

8. a) Was the incident a result of (select all that apply)

Drift

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

Subform IV: Environment (includes plants insects and wildlife)

1. Type of organism affected

Trees or shrubs / Arbre ou arbuste

2. Common name(s)

Pear tree

3. Scientific name(s)

Unknown

4. Number of organisms affected

5. Description of site where incident was observed

Fresh water

Terrestrial

Agricultural

Salt Water

6. Check all symptoms that apply

Visible injury ( eg. chlorosis, necrosis, bleaching)

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

Mushroom grower. Garden vegetables leaf damage, cabbage, peas, chickpeas, peppers, pear tree leaves . Mushrooms in barn damaged, Portabello.

8. a) Was the incident a result of (select all that apply)

Drift