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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-2812
2. Registrant Information.
Registrant Reference Number: x
Registrant Name (Full Legal Name no abbreviations): x
Address: x
City: x
Prov / State: x
Country: xxx
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-OCT-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: 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: 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).
neighbour may be pouring something on her trees along side her house. She believes he is trying to kill the trees. - she says another neighbour witnessed him pouring something on them. This was Saturday, October 12th. Described as a 12" high red can with a silver lid. She says he was observed, at the same time, cutting the trees. - she says she has smelled a chemical smell back. - caller says they are on municipal water. Neighbour denies application of anything to hedge. Admits a couple of months ago did apply roundup to driveway for weed conntrol and some damage occurred to adjacent neighbour grass out near road which he replaced.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 - Malaise
- Specify - has been sick
12. How long did the symptoms last?
>24 hrs <=3 days / >24 h <=3 jours
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
Fully Recovered / Complètement rétabli
16. How was the animal exposed?
Other / Autre
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
She also says their dog has been sick for the last few days. -did not take dog to vet, better after a couple of days.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Not Applicable
19. Provide supplemental information here
Subform III: Domestic Animal Incident Report
1. Source of Report
Other
2. Type of animal affected
Fish / Poisson
specify Pondfish
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 - Death
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
Died
16. How was the animal exposed?
Other / Autre
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
- she says her pondfish are dying now too
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
Trees or shrubs / Arbre ou arbuste
2. Common name(s)
Unknown
3. Scientific name(s)
Unknown
4. Number of organisms affected
Unknown
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.).
- trees are now dying. -damage along driveway, hedge.
8. a) Was the incident a result of (select all that apply)
Unknown
8. b) i) How many times has the product been applied this year?
8. b) ii) What was the date of the last application?
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?
Aquatic
10. c) What was the size of the buffer zone?
11. a) Were environmental samples collected and analysed?
No
