Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2019-3333
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
Domestic Animal
4. Date registrant was first informed of the incident.
5. Location of incident.
Country: CANADA
Prov / State: QUEBEC
6. Date incident was first observed.
02-JUL-19
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. 32515
PMRA Submission No.
EPA Registration No.
Product Name: WILSON LAWN WEEDOUT ULTRA
- Active Ingredient(s)
- 4-CHLOROINDOLE-3-ACETIC ACID, PRESENT AS POTASSIUM SALT
7. b) Type of formulation.
Liquid
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).
The following was reported/Ce qui suit a été rapporté: la compagnie (NAME)...a répandue ce produit...malgré la chaleur...le propriétaire n a prévenu personne autour....moi je suis la locataire en haut au deuxième...j ai sorti sur mon balcon arrière et j ai vu un homme arroser avec une ose un liquide....je lui ai demandé si c étais des pesticides il m a répondu ne pas le savoir....ensuite il a appliqué des graines....et m a dit que après une heure mes chats pouvaient sortir...j ai téléphoné à la compagnie ils m ont assuré qu e moi et mes animaux pouvions sortir sur le terrain après une heure....mais elle fait appliquer des produits depuis 22 ans.. sans raison ...juste en prévention...j ai demandé à la proprio d arroser...m a dit comme pas....parce l an dernier elle a fait encore mettre des pesticides biologiques...et ils ont encore appliqué dans les temps records de chaleur et ce encore une fois sans prévenir...
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: Female
Age: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Nervous and Muscular Systems
- Eye
- Symptom - Burning eye
- Specify - especially the eyelids/les paupieres surtout
- Symptom - Irritated eye
- Specify - feeling of sand in the eye/impressions de sable dans les yeux
- Respiratory System
- Symptom - Runny nose
- Symptom - Burning nose
- Symptom - Burning throat
- Symptom - Burning lungs
- Skin
- Symptom - Burning skin
- Symptom - Irritated skin
- Nervous and Muscular Systems
- Cardiovascular System
- Symptom - Arrhythmia
- Symptom - Chest pain
- Nervous and Muscular Systems
- Gastrointestinal System
- Symptom - Loss of appetite
- Nervous and Muscular Systems
- Skin
- Symptom - Hair loss
- Symptom - Other
- Specify - eczema
4. How long did the symptoms last?
>24 hrs <=3 days / >24 h <=3 jours
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)
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
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.)
The following was reported/Ce qui suit a été rapporté: j ai commencé à avoir pendant trois jours des gros maux de tête....yeux brûlaient....les paupières surtout...impressions de sable dans les yeux...nez qui coulent et qui brûlent...gorge...poumons...peau qui pique et qui brûle...tremblement...arythmie...mal au coeur....douleurs musculaires...perte d appétit ... étourdissement....et mon chat a perdu tout ses poils en dessous du corps et des pattes et queues...et moi aussi j ai perdu beaucoup de cheveux...et ja i eu beaucoup de problème cutané...genre eczéma...et arythmie...
To be determined by Registrant
14. Severity classification.
15. Provide supplemental information here.
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Cat / Chat
3. Breed
unknown
4. Number of animals affected
1
5. Sex
Unknown
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Respiratory
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
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?
Unknown
15. Outcome of the incident
Unknown/Inconnu
16. How was the animal exposed?
Other / Autre
specify unknown
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
The following was reported/Ce qui suit a été rapporté: mon chat a perdu tout ses poils en dessous du corps et des pattes et queues
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Not Applicable
19. Provide supplemental information here