Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-2354

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.

06-AUG-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: Headline

• Active Ingredient(s)
  • PYRACLOSTROBIN

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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

Préciser le type: Areial

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

calller says there was a crop duster flying very low and close to her home and that her husband was sprayed with pesticides while he was out on the lawnmower.in the morning of Aug 6. He said that spraying started on Saturady evening. Plane flew directly over the complainant's house, about 50 - 60 ft above. He said that the plane started spraying over the house and he got spray on him and his clothing; his eyes also stung for awhile; no other ill effects noticed. Clothes have not been washed as yet. The product stung and it was soemwhat sticky. Complainant waved to the aircrft about its flying pattern, i.e. too low and flying over the house. Thereafter he videoed the plane.

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
  • Specify - stung

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

Unknown

8. How did exposure occur? (Select all that apply)

Other

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

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.)

his eyes stung for awhile; no other ill effects noticed

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.