Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-2371

2. Registrant Information.

Registrant Reference Number: x

Registrant Name (Full Legal Name no abbreviations): x

Address: x

City: x

Prov / State: x

Country: x

Postal Code: X

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

Domestic Animal

Environment

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

12-JUL-12

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: Sevin

• Active Ingredient(s)
  • CARBARYL

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

Product Name: Daconil

• Active Ingredient(s)
  • CHLOROTHALONIL

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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

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

caller reporting the indiscriminate spraying of chemicals on an almost 2 acre sized residential lot (XXXX.) which is located adjacent to caller; caller would like this stopped. -caller also lives on a 2 acre property with neighbours on each side. -the neighbour/owner in question never lives there but comes a couple times/year from the u.s. to visit -owner has hired a company to spray pesticides -but they spray not only the lawn but every single shrub, tree, plant, etc. with a large spray gun -this occurs 4-5 times/year -when they spray the pesticide it drifts over the property line onto caller's lot

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Unknown

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

• General
  • Symptom - Other
  • Specify - allergies

• Skin
  • Symptom - Hair loss
  • Specify - bald

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

caller has a vegetable garden close to property line which he does not want to have sprayed. caller's dog has developed severe allergies to the spraying; it's getting bald after spraying; -caller even had to rent a hotel room for the night once after the spraying occurred.

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To be determined by Registrant

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

Not Applicable

19. Provide supplemental information here

Subform IV: Environment (includes plants insects and wildlife)

1. Type of organism affected

Terr. Invrtbrt-Honey Bee/Inv.Ter-Abeille

2. Common name(s)

Bees

3. Scientific name(s)

Unknown

4. Number of organisms affected

100

5. Description of site where incident was observed

Fresh water

Terrestrial

Residential

Salt Water

6. Check all symptoms that apply

Death

7. Describe symptoms and outcome (died, recovered, etc.).

-caller also has bees; there are 100's of bees dead in front of entrance after neighbouring lot is sprayed -caller's other neighbour also has bees which are dying - he has lost two bee colonies due to the spraying

8. a) Was the incident a result of (select all that apply)

Drift

8. b) i) How many times has the product been applied this year?

Unknown

8. b) ii) What was the date of the last application?

Unknown

9. Did it rain

9. a) During application?

No

9. b) Up to 3 days after application?

No

10. a) Was there a buffer zone?

No

10. b) What type?

10. c) What was the size of the buffer zone?

11. a) Were environmental samples collected and analysed?

No

To be determined by Registrant

12. Severity classification (if there is more than one possible classification, select the most severe)

13. Please provide supplemental information here