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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-2339
2. Registrant Information.
Registrant Reference Number: x
Registrant Name (Full Legal Name no abbreviations): x
Address: xx
City: x
Country: x
3. Select the appropriate subform(s) for the incident.
Human
Environment
4. Date registrant was first informed of the incident.
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
09-MAY-13Product 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. PMRA Submission No. EPA Registration No.
Product Name: Touchdown
- Active Ingredient(s)
- GLYPHOSATE
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).
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
Caller says that neighbour (XXXXX) sprayed pesticides about 2 weeks agoTo 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: Unknown
Age: Unknown / Inconnu
3. List all symptoms, using the selections below.
System
- Nervous and Muscular Systems
- Symptom - Headache
4. How long did the symptoms last?
Unknown / Inconnu
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)
Drift from the application site
9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)
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.)
Caller says that neighbour (XXXXX) sprayed pesticides about 2 weeks ago - they had headaches then
To be determined by Registrant
14. Severity classification.
15. Provide supplemental information here.
Subform IV: Environment (includes plants insects and wildlife)
1. Type of organism affected
Trees or shrubs / Arbre ou arbuste
2. Common name(s)
Plum Tree
3. Scientific name(s)
4. Number of organisms affected
2
5. Description of site where incident was observed
Fresh water
Terrestrial
Residential
Salt Water
6. Check all symptoms that apply
Death
Visible injury ( eg. chlorosis, necrosis, bleaching)
7. Describe symptoms and outcome (died, recovered, etc.).
Two plum trees also dying. Caller advised that he had the bylaw (XXXXX) there recently. This spring tress healthy again and Caller has pictures of two weeks ago when all healthy. Caller advised that the same person approached Caller (or callers co-worker at work place?) last year to ask if he "knew how to kill plum trees" and then sprayed last fall. The trees are struggling to put out some small shoots but very stressed and should be replaced.
8. a) Was the incident a result of (select all that apply)
Application
8. b) i) How many times has the product been applied this year?
Unknown
8. b) ii) What was the date of the last application?
Unknown
9. Did it rain
9. a) During application?
Unknown
9. b) Up to 3 days after application?
Unknown
10. a) Was there a buffer zone?
Unknown
10. b) What type?
10. c) What was the size of the buffer zone?
11. a) Were environmental samples collected and analysed?
Unknown
To be determined by Registrant
12. Severity classification (if there is more than one possible classification, select the most severe)
13. Please provide supplemental information here
Subform IV: Environment (includes plants insects and wildlife)
1. Type of organism affected
Herbaceous Plants / Plante herbacée
2. Common name(s)
grass
3. Scientific name(s)
4. Number of organisms affected
Unknown
5. Description of site where incident was observed
Fresh water
Terrestrial
Residential
Salt Water
6. Check all symptoms that apply
Death
Visible injury ( eg. chlorosis, necrosis, bleaching)
7. Describe symptoms and outcome (died, recovered, etc.).
Grass died and trees became droopy but Police said they would have to wait and see if the trees were ok before proceeding. This spring tress healthy again and Caller has pictures of two weeks ago when all healthy. Grass is regrowing in most spots.
8. a) Was the incident a result of (select all that apply)
8. b) i) How many times has the product been applied this year?
8. b) ii) What was the date of the last application?
9. Did it rain
9. a) During application?
No
9. b) Up to 3 days after application?
No
10. a) Was there a buffer zone?
No
10. b) What type?
Aquatic
10. c) What was the size of the buffer zone?
11. a) Were environmental samples collected and analysed?
No
