Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-2348

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

Domestic Animal

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

16-JUL-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)

---

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

Product Name: Decis

• Active Ingredient(s)
  • DELTAMETHRIN

---

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

Product Name: Sluggo

• Active Ingredient(s)

---

PMRA Registration No. 26612      PMRA Submission No.       EPA Registration No.

Product Name: Ridomil Gold 1G Fungicide

• Active Ingredient(s)
  • METALAXYL-M AND S-ISOMER

---

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

Product Name: Quadris

• Active Ingredient(s)
  • AZOXYSTROBIN

---

PMRA Registration No. 28568      PMRA Submission No.       EPA Registration No.

Product Name: Scholar 50WP Fungicide

• Active Ingredient(s)
  • FLUDIOXONIL

---

PMRA Registration No. 24458      PMRA Submission No.       EPA Registration No.

Product Name: Aliette WDG Systemic Fungicide

• Active Ingredient(s)
  • FOSETYL-AL

---

PMRA Registration No. 20553      PMRA Submission No.       EPA Registration No.

Product Name: Dithane Rainshield Fungicide

• Active Ingredient(s)
  • MANCOZEB

---

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

Product Name: Rovral

• Active Ingredient(s)
  • IPRODIONE

---

PMRA Registration No. 15723      PMRA Submission No.       EPA Registration No.

Product Name: Bravo 500 Agricultural Fungicide

• Active Ingredient(s)
  • CHLOROTHALONIL

---

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

Product Name: Captan

• Active Ingredient(s)
  • CAPTAN

---

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).

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: Female

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Eye
  • Symptom - Irritated eye

• Nervous and Muscular Systems
  • Symptom - Seizure

• Cardiovascular System
  • Symptom - Other
  • Specify - Cavernoma

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.)

Caller feels that she is impacted by pesticides sprayed by ginsing farmer. Irritates eyes and smells bad. She has seizures April 24/13 . Diagnosed with cavernoma in r/s hemi-sphere (of brain). Dog also had seizures. Wonders if there is a correlation to pesticides application. Farmer won't discuss what he uses or give warning of when he sprays. Sprays a fog-like substance is applied on a weekly basis. Videos of applications do not show any spray drift.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.

Subform III: Domestic Animal Incident Report

1. Source of Report

Other

2. Type of animal affected

Dog / Chien

3. Breed

4. Number of animals affected

1

5. Sex

Unknown

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Unknown

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

• Nervous and Muscular Systems
  • Symptom - Seizure

12. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

14. a) Was the animal hospitalized?

Unknown

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Unknown/Inconnu

16. How was the animal exposed?

Spray drift / Dérive de pulvérisation

17. Provide any additional details about the incident

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

Dog also had seizures

---

To be determined by Registrant

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

Not Applicable

19. Provide supplemental information here