Health Canada
www.hc-sc.gc.ca
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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-4649
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.
17-JUL-14Product 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: Fiesta
- Active Ingredient(s)
- IRON (PRESENT AS FEHEDTA)
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).
Weedman's spraying was making his wife sick. She explained that the use of the product Fiesta on neighbouring lawns was making her sick - trouble breathing, headache, stomach, bowel; she's been sick for 5 weeks. She said that their neighbour to the left (when facing the house from the street) had agreed to cease spraying, however the neighbour to the right refused and intends to spray again in the fall. She is seeing her doctor next week (for the first time), since she has no medical 'proof' of impacts currently. The last spraying reportedly occurred one week ago yesterday. Her symptoms used to last 3 days to a week, but are now lasting longer - for weeks. They have lived at the residence since the 1960's. She claimed that Health Canada had told her that Fiesta was toxic, while the Weed Man manager told her is wasn't.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
- Respiratory System
- Symptom - Difficulty Breathing
- Nervous and Muscular Systems
- Symptom - Headache
- Gastrointestinal System
- Symptom - Other
- Specify - sick - stomach, bowel
4. How long did the symptoms last?
>1 mo and <= 2mos / >1 mois et < = 2mois
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)
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.)
The use of the product Fiesta on neighbouring lawns was making her sick - trouble breathing, headache, stomach, bowel; she's been sick for 5 weeks. Her symptoms used to last 3 days to a week, but are now lasting longer - for weeks.
