Health Canada
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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-2357
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.
24-SEP-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: unknown
- Active Ingredient(s)
- 2,4-D (PRESENT AS ACID)
- DICAMBA (PRESENT AS ACID, AMINE SALT, ESTER, POTASSIUM SALT, OR SODIUM SALT)
- MECOPROP P-ISOMER (PRESENT AS ACID)
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: lawn
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
her and her husband saw her neighbours lawn (XXX XXXXX St) get a pesticide application. They did not put up signs after the application,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
- Gastrointestinal System
- Symptom - Nausea
- Nervous and Muscular Systems
- Symptom - Headache
- Respiratory System
- Symptom - Irritated throat
- Specify - Hurt her throat
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.)
They did not put up signs after the application, and then there was a very strong odour that lasted all day coming from the lawn and she believed it was 2-4 D. XXXs Landscaping is a difficult company to deal with and she does not want her information provided to anyone. She just had her lawn sprayed with Fiesta by xxs Landscaping today, and signs were posted. She found the odour coming from her neighbours property very nauseating, it also gave her a headache and hurt her throat. She is very concerned about the situation.
