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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-2381
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.
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.
16-SEP-12Product 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: Roundup
- Active Ingredient(s)
- GLYPHOSATE (PRESENT AS ISOPROPYLAMINE SALT OR ETHANOLAMINE SALT)
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
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
Caller is reporting that he believes the property immediately south of his was sprayed under conditions it should not have been sprayed in. The day which it was sprayed was windy and raining. The suspect farmer spraying the field is renting the property. Based on his description, the spraying was most likely Roundup.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: Male
Age: Unknown / Inconnu
3. List all symptoms, using the selections below.
System
- Eye
- Symptom - Watery eye
- Respiratory System
- Symptom - Sore 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)
Unknown
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 pesticide he feels blew on to his property and he and his wife had watery eyes and sore throats caused by the incident. The caller and his wife needed to go indoors and he stated that that didn't even help with the smell. They needed to rewash their clothes which were hanging outside after the incident to remove the smell. The smell was reported as remaining for "weeks". The caller also stated that the area is a highly sensitive wetlands area and he is not certain if spraying is even allowed there. The suspect farmer spraying the field is renting the property. No visible damage/vegetation killed off-site.
To be determined by Registrant
14. Severity classification.
15. Provide supplemental information here.
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
- Eye
- Symptom - Watery eye
- Respiratory System
- Symptom - Sore 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?
No
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)
Unknown
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 pesticide he feels blew on to his property and he and his wife had watery eyes and sore throats caused by the incident. The caller and his wife needed to go indoors and he stated that that didn't even help with the smell. They needed to rewash their clothes which were hanging outside after the incident to remove the smell. The smell was reported as remaining for "weeks". The caller also stated that the area is a highly sensitive wetlands area and he is not certain if spraying is even allowed there. The suspect farmer spraying the field is renting the property. No visible damage/vegetation killed off-site.
