Health Canada
www.hc-sc.gc.ca
Common menu bar links
Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-2355
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.
13-AUG-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: Round-up
- Active Ingredient(s)
- GLYPHOSATE
PMRA Registration No. PMRA Submission No. EPA Registration No.
Product Name: Arsenal
- Active Ingredient(s)
- IMAZAPYR
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: Other / Autre
Préciser le type: Rail line
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
Caller called to express concerns regarding the application of pesticide to a rail line running behind her back yard. She alleges spraying of pesticide took place early June/13 and again that day (Aug 16/13) although she did not witness the spraying. . she advised pesticide warning signs are in place along the rail line. she advised the rail line and adjacent grassed area/ditch are owned by the City of Port Colborne and that the spraying of the pesticide was done by the City.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
- Respiratory System
- Symptom - Asthma
- Specify - aggravated her asthma
- Symptom - Dyspnea
- Specify - difficult to breath
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)
None
10. Route(s) of exposure.
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.)
She advised that on both occassions, the spraying caused a pesticide odour and aggravated her asthma and respiratory condition which she has making it difficult to breath and forcing her to stay in her home with the windows closed. She advises she has expressed these concerns to City bylaw and engineering staff but no action has been taken. XXXXX advised her to have any health impact due to the spraying events documented by her medical doctor.
