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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-2340

2. Registrant Information.

Registrant Reference Number: x

Registrant Name (Full Legal Name no abbreviations): xx

Address: x

City: x

Country: 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. 28738      PMRA Submission No.       EPA Registration No.

Product Name: Infinity Herbicide

  • Active Ingredient(s)

PMRA Registration No. 29615      PMRA Submission No.       EPA Registration No.

Product Name: Puma Advance Herbicide

  • Active Ingredient(s)

PMRA Registration No. 27528      PMRA Submission No.       EPA Registration No.

Product Name: Stratego 250EC Fungicide

  • Active Ingredient(s)

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

Product Name: Buctril_M

  • Active Ingredient(s)

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

Product Name: Crimson

  • 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: Agricultural-Outdoor/Agricole-extérieur

Préciser le type: Barley field

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

Caller reports that the farmer (name unknown) who works the farm field to the west of her property was spraying an unknown liquid from his tractor on Sat June 1 at 14:00. Caller believes the crop is soy beans or corn. The wind speed was brisk on Saturday. The field immediately west of the XXXXX residence was planted in what appears to be barley. Rate: Infinity 0.33L/ac, Puma Advance 0.412L/ac, Stratego 0.2L/ac, Crop Booster 1L/ac, Crimson 0.5L/ac, BB5.

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.


2. Demographic information of data subject

Sex: Female

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.


  • General
    • Symptom - Taste altered
    • Specify - Sour taste in mouth

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)

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.



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 was in her yard and the liquid sprayed on herself and her property. The caller said she did not notice an odour or a colour to the mist, but it left a sour taste in her mouth. later she stated she was working in her garden (which is approx. 100 ft from the barley field) on Saturday June 1, 2013 when the field immediately west of her residence was being sprayed. She could feel a mist and had a sour taste in her mouth after the spraying was initiated. She ran to the house and took a shower.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.