Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-2602

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: ALBERTA

6. Date incident was first observed.

23-JUN-14

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)

---

PMRA Registration No. 27972      PMRA Submission No.       EPA Registration No.

Product Name: NUFARM TRILLION TURF HERBICIDE

• Active Ingredient(s)
  • 2,4-D (PRESENT AS AMINE SALTS : DIMETHYLAMINE SALT, DIETHANOLAMINE SALT, OR OTHER AMINE SALTS)
  • DICAMBA (PRESENT AS ACID, AMINE SALT, ESTER, POTASSIUM SALT, OR SODIUM SALT)
  • MECOPROP-P (PRESENT AS DIMETHYLAMINE 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: 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).

Applied with a spray hose on condo property's lawn, on everything (not spot treatment). According to the condo's lawn care contractor, I believe the pesticide was mixed with a fertilizer called Green with Envy 16-8-3 (MSDS #GWE-14-LPI), and a urea fertilizer mixed with water and potash, applied at 0.34 kg/100 square meters.

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.

Data Subject

2. Demographic information of data subject

Sex: Female

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Cardiovascular System
  • Symptom - Chest pain

• Respiratory System
  • Symptom - Other
  • Specify - my lungs hurt

• Gastrointestinal System
  • Symptom - Nausea

• Nervous and Muscular Systems
  • Symptom - Headache

4. How long did the symptoms last?

>1 wk <=1 mo / > 1 sem < = 1 mois

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

Unknown

8. How did exposure occur? (Select all that apply)

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

10. Route(s) of exposure.

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

<=30 min / <=30 min

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.)

If my windows were open longer than a minute, I got a severe headache, which took a few hours to go away once closing the windows. If my windows were open longer than a few minutes, my lungs hurt and I had chest pains, symptoms which took a few hours to go away once closing the windows. If my windows were open longer than a few minutes, I felt nauseous, and this took a few hours to go away once closing the windows. I could smell the lawn treatment for an entire month after application, and had these symptoms for the entire month, if I opened the windows or went out on my patio at all.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.

There was no warning posted about the lawn being treated, and it was very hot that day, so my windows were all open when the spraying happened, for about 10 minutes until I noticed the lawn was being sprayed. The spraying was within 3 meters of the window I was sitting by. It took an entire day with 3 air purifiers running on high to clear the air inside my condo. Whenever I had to crack the windows open (e.g. if it was too hot in the house or I had to water the plants on my patio), it would take hours to clear the air again. I was exposed to the pesticide every day until it dissipated completely a month later, for as long as I had to be exposed to the outside air via my windows or patio, and whenever I walked outside the building's front door past the building's front lawn.