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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-2356

2. Registrant Information.

Registrant Reference Number: x

Registrant Name (Full Legal Name no abbreviations): x

Address: x

City: xx

Country: x

3. Select the appropriate subform(s) for the incident.


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.


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.       PMRA Submission No.       EPA Registration No.

Product Name: Round-up

  • 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: corn field

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

Caller reported person who rents the field around the farm that complainant rents was sprayed with possible poisonous pesticide on Friday 20th September. Owner rents the farmhouse with his daughter and they have a garden at the back of their house. While they were in the garden the person sprayed. The complainant stated he took pictures while the person sprayed but they never stopped. He stated that farmer sprayed right uip to the edge of the adjacent to his sweet corn crop. he stated that the corn crop was also sprayed. He was standing in the Sweet corp patch when the farmer turned on the sprayer and was sprayed. At that time XXXXX says was standing in the sweet corn patch directly behind the sprayer and that he was trying to get the attention of the farmer to stop him from spraying his corn. He showed us the area where he was standing which would have been 10-15 feet behind the sprayer. According to XXXXX the wind carried the spray directly toward him and drifted as far as the house. XXXXX stated that water at the farm smelled and that he was concerned that that was a result of the appliaiton.

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: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.


  • Gastrointestinal System
    • Symptom - Nausea
    • Symptom - Diarrhea
  • Nervous and Muscular Systems
    • Symptom - Headache
  • Respiratory System
    • Symptom - Difficulty Breathing

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.)

When the person sprayed he was within 100 feet of the complainant. Caller has been ill since that day. When caller visited the doctor the doctor stated he may have been poisoned since his lungs were impacted. had a headache, acres and pains, was vomitting and had diarreha.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.