Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2008-4059

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: ONTARIO

6. Date incident was first observed.

18-SEP-08

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)

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PMRA Registration No. 9811      PMRA Submission No.       EPA Registration No.

Product Name: KILLEX LIQUID 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, OR SODIUM SALT)
  • MECOPROP (PRESENT AS DIMETHYLAMINE SALT)

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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).

It was applied by (company). Applied to weeds around the apartment.

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

• Respiratory System
  • Symptom - Sore throat
  • Symptom - Chest congestion
  • Symptom - Difficulty Breathing

• Gastrointestinal System
  • Symptom - Stomach cramps

• Nervous and Muscular Systems
  • Symptom - Confusion
  • Symptom - Difficulty walking
  • Symptom - Difficulty talking
  • Symptom - Trembling

4. How long did the symptoms last?

>1 wk <=1 mo / > 1 sem < = 1 mois

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

Unknown

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

Unknown

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.

Skin

Eye

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>2 hrs <=8 hrs / > 2 h < = 8 h

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.)

Sore throat & Chest - Moderate - still occurs when I am in my apartment. Tight chest & difficulty catching my breath fulltime still 09-30-08 - Moderate. Stomach cramps - about 5 hours - moderate. Very confused & Difficulty speaking and walking - Severe - Until I left and then very strong for 5 hours. Right arm tremors - shaking - one hour after I left my apartment. Went to emergency at (name) Hospital in (city). I am disabled with MCS and I react much more strongly to a number of chemicals since the pesticide exposure. I entered my apartment in the evening. The lawn was sprayed that day. All my windows were open because I was not notified about the spraying.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.