Health Canada
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Incident Report
Subform I: General Information
1. Report Type.
Update the report
Incident Report Number: 2015-3352
2. Registrant Information.
Registrant Reference Number: x
Registrant Name (Full Legal Name no abbreviations): x
Address: x
City: x
Prov / State: xx
Country: 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: QUEBEC
6. Date incident was first observed.
Unknown
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. PMRA Submission No. EPA Registration No.
Product Name: product name unknown
- Active Ingredient(s)
- CHLORPYRIFOS
7. b) Type of formulation.
Application Information
8. Product was applied?
Yes
9. Application Rate.
46.3Units: %
Unknown
10. Site pesticide was applied to (select all that apply).
Site: Unknown / Inconnu
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
La seule matiere active est chlorpyrifos a un taux de 46.3%. Homeowner (gender unknown) had been applying product to his lawn for about 20 minutes.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
- Respiratory System
- Symptom - Respiratory distress
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?
Yes
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)
Unknown
10. Route(s) of exposure.
Unknown
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.)
L'ingredient actif a ete identifier concernant la vente de produits non-homologues qui a resulte qu'une personne a ete admise a l'hopital en detresse respiratoire suite a l'utilisation de ces produits non-homologues. Aucune nouvelle sur son etat de sante apres l'admission a l'hopital.
