Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-3543

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: MANITOBA

6. Date incident was first observed.

12-JUN-15

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. 25111      PMRA Submission No.       EPA Registration No.

Product Name: Odyssey Water Dispersible Granular Herbicide

• Active Ingredient(s)
  • IMAZAMOX
  • IMAZETHAPYR

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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

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

Spray of soybeans by farmer in field directly south of perty/house. Spray took place by the farmer between the hours of 11:00pm and 12:00am on June 12,2015. Wind speed 14.1-16.6 km/hr with gusts at 23.9-30.1 km/hr in a SSE direction. Noticed the sprayer in field next to the property and also noticed a smell of chemical coming into the house. Photos of the sprayer in the field were taken and windows were closed in the house. Expected was approx 30 min. Distance from field edge to property edge would be about 15 m. Distance from field to house would be about 150 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: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Headache

• Respiratory System
  • Symptom - Asthma

4. How long did the symptoms last?

>8 hrs <=24 hrs / > 8 h < = 24 h

5. Was medical treatment provided? Provide details in question 13.

No

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)

None

10. Route(s) of exposure.

Skin

Eye

Respiratory

11. What was the length of exposure?

>15 min <=2 hrs / >15 min <=2 h

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.)

No medical attention was required for this incident - symptoms were gone by the next morning. Additional concerns: very concerned with the safety of her animals and the pesticide exposure they received from this and other applications from near by agriculture and roadside spraying. Moderate headache - lasting that evening. Symptoms seemed to be subsided the following day. Is asthmatic and took ventalin as needed day of occurence.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.