Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-2344

2. Registrant Information.

Registrant Reference Number: x

Registrant Name (Full Legal Name no abbreviations): x

Address: x

City: x

Country: 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: ONTARIO

6. Date incident was first observed.

14-JUN-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. 28217      PMRA Submission No.       EPA Registration No.

Product Name: Manzate Pro-Stick Fungicide

• Active Ingredient(s)
  • MANCOZEB

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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: Agricultural-Outdoor/Agricole-extérieur

Préciser le type: Ginseng farm

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

ginseng operation close to his home (within 100feet) was spraying pesticides when it was windy

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.

Other

2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Eye
  • Symptom - Irritated eye

• Respiratory System
  • Symptom - Respiratory irritation
  • Specify - Lung problems

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?

Unknown

7. Exposure scenario

Unknown

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.

Eye

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.)

called to complain about pesticide drift. spraying pesticides when it was windy and it entered his home causing eye irritation and lung problems. XXXXX told XXXXX that is an ongoing issue, and that last Saturday XXXXX called the OPP. OPP showed up and tried to speak to the worker spraying the pesticide, however there was a language barrier. The OPP grabbed the info for the pesticide and gave it to XXXXX.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.