Health Canada
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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-2308

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.


4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.


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.


PMRA Registration No. 29535      PMRA Submission No.       EPA Registration No.


  • Active Ingredient(s)

7. b) Type of formulation.

Application Information

8. Product was applied?


9. Application Rate.


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

Site: Res. - Out Home / Rés - à l'

Préciser le type: Applied to Front lawn

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

Applied to front lawn, back lawn, strawberry plants, raspberry bushes, spearmint (herb), part of pear tree, lemon balm (herb), etc... Method of application: spray equipment as used by Weedman - phone #, Address This was an illegal spraying of the product on my property. Weedman claimed it was a mistake.

To be determined by Registrant

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


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.


  • Respiratory System
    • Symptom - Laboured breathing
  • Skin
    • Symptom - Burning skin

4. How long did the symptoms last?

Unknown / Inconnu

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


6. a) Was the person hospitalized?


6. b) For how long?

7. Exposure scenario


8. How did exposure occur? (Select all that apply)

Contact with treated area

Amount of time between application and contact 1

Hour(s) / Heure(s)

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


10. Route(s) of exposure.




11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

<=30 min / <=30 min

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.)

Health incident: Breathing became laboured. Symptoms laster for a few minutes. Subsided when I came inside. About 1/2 hour later around my ankles started to burn. (I did not wear any socks when I went outside.) Advised by Telehealth Ontario to wash the area with warm water and change all clothing. Walking on the lawn for about 1 minute. Amount of pesticide - unknown how much was sprayed.I saw the Weedman's representative leaving my property and went outside to ask him what he was doing. He stated that he had finished spraying my property as per order. I advised him that I had not made any such order and only my neighbours at # and # spray their property. I asked the representative to show my where he had sprayed. Unfortunately, he was very untruthful as the dying plants etc. proved that he had sprayed more than he advised. Lawn was finally mowed on 2011-05-23 - I wore gloves, socks, and a face mask. (Occassionally topped mowing to allow pedestrians to pass on the sidewalk.)

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.