Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-4653

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.

22-AUG-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)

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

Product Name: unknown

• Active Ingredient(s)
  • 2,4-D (PRESENT AS ACID)

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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: Pub. Area - Outdoor/Zone publique - ext

Préciser le type: roadside

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

Caller states that the MTO and their maintenance contractor have been spraying 2-4-D along XXX XXXXXXX during the day today (2014/08/23) and yesterday (2014/08/22). Caller was upset as there were no roadside signs notifying residents of the spraying, nor was there any consultation of the residents. . Further, caller states that other road users were passing the spraying activity without knowing that pesticide was being applied to the roadway. Caller indicated this has happened in the past as well, though this time they reportedly did not leave a buffer at their property as they did in the past.

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: Female

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• General
  • Symptom - Malaise

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?

Unknown

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.)

Caller complained of feeling ill as a result of the spraying.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.