Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-4967

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: NEW BRUNSWICK

6. Date incident was first observed.

28-JUL-11

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. 27487      PMRA Submission No.       EPA Registration No.

Product Name: ROUNDUP WEATHERMAX WITH TRANSORB 2 TECHNOLOGY LIQUID HERBICIDE

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

Préciser le type: Outdoor

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

Nous ne savons pas. c'est le proprietaire voisin qui a engager un monsieur durant que mon pere et son petit chien etaient dehors. Il ne les a pas averti et a utilise le produit durant que mon pere age, moitie aveugle, etait chez son pere avec le petit chien qui aboyait pres du monsieur. Le proprietaire: (company).

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.

2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• General
  • Symptom - Death

• Gastrointestinal System
  • Symptom - Sore throat

• Cardiovascular System
  • Symptom - Chest pain

• Gastrointestinal System
  • Symptom - Loss of appetite

• General
  • Symptom - Malaise
  • Specify - not feeling good
  • Symptom - Cancer
  • Specify - colon cancer

• Renal System
  • Symptom - Renal failure
  • Specify - kidney failure

4. How long did the symptoms last?

>2 mos and <=6mos />2 mois et <=6mois

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

Yes

6. a) Was the person hospitalized?

Yes

6. b) For how long?

Unknown

7. Exposure scenario

Non-occupational

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

Other

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

None

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.)

My dad heard something being sprayed and even with his poor eyesight could determine that someone was spraying something, maybe he even felt something on his face. My dad came in and told my mom he was going to bed, that he felt a soar throat coming and pain in his chest. When my mom woke him up if he wanted to eat, he told her that he wasn't feeling good and didn't feel like eating, soar throat, thinking it was a flu. My dad passeed away (date) to colon cancer. He never said anything and his body was getting infected day by day from bowel obstruction. He had kidney failure...and never said anything that he was feeling ill, would even hide the fact that he was throwing up. The doctor told us that he would have had the cancer for about 10 years.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.

Subform III: Domestic Animal Incident Report

1. Source of Report

Witness

2. Type of animal affected

Dog / Chien

3. Breed

American eskimo (miniature)

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

5

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Skin

Eye

Oral

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

• General
  • Symptom - Death

• Blood
  • Symptom - Anemia

• General
  • Symptom - Other
  • Specify - diabetes

• Respiratory System
  • Symptom - Burning throat

• Gastrointestinal System
  • Symptom - Abdominal distension
  • Specify - enlarged abdomen
  • Symptom - Other
  • Specify - Adnormal rectal glands
  • Symptom - Abnormal tongue colour
  • Specify - tongue turned blue purple

• Respiratory System
  • Symptom - Irritated throat
  • Symptom - Choking
  • Specify - on water

• Gastrointestinal System
  • Symptom - Anorexia

• General
  • Symptom - Malaise
  • Symptom - Weakness

• Nervous and Muscular Systems
  • Symptom - Ataxia
  • Specify - fell down
  • Symptom - Confusion

• Liver
  • Symptom - Other
  • Specify - difficulty with liver

• Gastrointestinal System
  • Symptom - Other
  • Specify - difficulty with pancreas
  • Symptom - Vomiting
  • Specify - vomiting black material

• Skin
  • Symptom - Pale mucous membrane colour
  • Specify - gums were pale

• General
  • Symptom - Polydipsia

12. How long did the symptoms last?

Persisted until death

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

Yes

14. a) Was the animal hospitalized?

Yes

14. b) How long was the animal hospitalized?

Unknown

15. Outcome of the incident

Died

16. How was the animal exposed?

Other / Autre

specify bystander

17. Provide any additional details about the incident

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

Le petit chien est entre a la maison pour avaler de l'eau a grande vitesse. Ma mere dit qu'il s'emblait s'etouffer. Mon pere lui avait toute la gorge et l'esophage d'irriter. Puis mon pere et le chien ont tombe malade. Ils etaient tous les deux au lit, mal de gorge, ne mangeait pas et se sentait pas bien. Le petit chien lui a commencer a etre faible, il tombait et semblait tout meler. Par inhalation (respirer) puis il avait manger l'herbe pres de l'arrosage. Il a ete expose en meme temps que l'arrosage. Le monsieur n'a jamais cesser quand meme que mon pere et le chien etaient dehors. Ils sont tellement pres un de l'autre peut etre 3 pieds de distance. Le chien avait de l'amnemie cause par ce pesticide, puis il le traitait pour une maladie mais moi je leur disais que c'etait cette poison et ils avaient lu les effets de ce pesticide et voulait me rassurer que ce n'etait pas mortel. Mais ils se sont tromper. Le chien a commencer a developper des difficultes avec ses glandes ranales, puis le foi, puis son pancreas, puis il etait devenu diabetique et le meme matin commenca a vomir de la matiere noir. Le veterinaire avait de la difficulte a admettre qu'ils s'etaient tromper, Non plus une maladie mais plutot une suite a la poison mais ne voulait rien dire par peur. Je suis temoin de la souffrance de ce chien, il a tellement souffert, c'est vraiment criminel. Et mon pere, il est a l'hospital avec un cancer d'intestin. Le medecin affirma que le cancer serait de 10 ans mais 5 ans auparavant mon pere avait eu un CT scan de l'abdomen et rien, alors c'est quoi cette affaire. Moi je pense que cette poison activer des cellules pour causer un cancer aggressive. Ils arrosent le parc chaque annee droit devant mes parents. Tous leurs chiens sont morts de cancer leurs chats. Ma tante voisine est morte de cancer. Toute la region entourante, chaque maison ou deux, meme moi-meme, mes animaux mort de cancer. Le parc est arrose chaque annee avec le Round Up. Les barbeaux meurent sur le bord du lac...La preuve est ce que j'ai temoigne suite a cette poison. Moi je pense que cette poison attaque l'oxygene de la plante et detruit alors c'est la seule chose en commun avec l'humain puis cela attaque les cellules d'oxygene chez les animaux et humains.

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To be determined by Registrant

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

Not Applicable

19. Provide supplemental information here