Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-2376

2. Registrant Information.

Registrant Reference Number: x

Registrant Name (Full Legal Name no abbreviations): x

Address: xx

City: x

Prov / State: x

Country: x

Postal Code: XX

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.

19-MAY-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: Captan

• Active Ingredient(s)
  • CAPTAN

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PMRA Registration No. 15723      PMRA Submission No.       EPA Registration No.

Product Name: Bravo 500

• 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: Agricultural-Outdoor/Agricole-extérieur

Préciser le type: cherry orchard

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

Yesterday night (May 19, about 10pm) XXXX spayed poison again. The smell of the poison was very intensive (bad smell) Today, late afternoon, XXXX again spayed poison.It is now 9pm and XXX again is spraying. Sprayed on May 6th and finished on May 7th - Bravo500 May 19th - Captan

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: Unknown

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Headache

• Respiratory System
  • Symptom - Dyspnea
  • Symptom - Irritated nose
  • Symptom - Irritated 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.)

The dangerous poisons are coming over to our house/property...2 days and 2 nights of spraying, next to our home, have made us sick. My family, including myself, have developed, headaches, difficulty breathing, irritating nose and throats. The air is unbreathable.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.