Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-4418

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: ALBERTA

6. Date incident was first observed.

01-MAY-13

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.       PMRA Submission No.       EPA Registration No.

Product Name: Round-Up

• Active Ingredient(s)
  • GLYPHOSATE

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

Product Name: unknown

• Active Ingredient(s)
  • 2,4-D (PRESENT AS AMINE SALTS : DIMETHYLAMINE SALT, DIETHANOLAMINE SALT, OR OTHER AMINE SALTS)

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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).

4 x from May to Sept 2013. Several applications from May-Sept 2012 neighbors yard, Round-Up over 1/2 backyard (where garden was) over dirt (little vegetation) + flower beds in front yard. Spray nozzle from container. 2,4-d over lawn on front, back and side lawn. hose end sprayer.

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

• Gastrointestinal System
  • Symptom - Diarrhea

• Nervous and Muscular Systems
  • Symptom - Headache
  • Symptom - Dizziness

• Respiratory System
  • Symptom - Coughing

• Skin
  • Symptom - Hair loss

• General
  • Symptom - Swelling
  • Specify - swelling around mouth and strange sensations

4. How long did the symptoms last?

>6 mos / > 6 mois

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

Yes

6. a) Was the person hospitalized?

No

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)

None

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.)

May - Nov 2012. Diarrhea and headaches following application for 2 - 3 days. (including dizziness and falls). Cough that persisted until the end of Nov (needed an inhaler to stop). Loss of hair. Swelling around mouth and strange sensations (almost gone 1yr later). As a competitive runner I am now 2min/mile slower than before this exposure. All other health issues rules out by the doctor including allergies. When aware would close all windows and stay inside - living next door and home a lot during this time. Would wait several days before being out in "our" yard.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.