Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-5533
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: BRITISH COLUMBIA
6. Date incident was first observed.
05-OCT-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)
PMRA Registration No.
PMRA Submission No.
EPA Registration No.
Product Name: unknown
7. b) Type of formulation.
Application Information
8. Product was applied?
No
9. Application Rate.
10. Site pesticide was applied to (select all that apply).
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
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: Male
Age: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- General
- Symptom - Flu-like symptoms
- Specify - felt 'something wasn't right'
- Symptom - Death
4. How long did the symptoms last?
Persisted until death
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
Non-occupational
8. How did exposure occur? (Select all that apply)
Poisoning from ingestion of the pesticide
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.
Oral
11. What was the length of exposure?
<=15 min / <=15 min
12. Time between exposure and onset of symptoms.
>8 hrs <=24 hrs / > 8 h < = 24 h
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.)
A bulk supplier 'gave' an individual a little bit of Paraquat in a 'juice container'. The man's wife marked it clearly with 'poison/skull and cross-bones' and said that it has to be locked away. (Name) did not do that. On Monday night he slept walked looking for something to drink. He went downstairs to the shop and seeing the juice container took a gulp - the taste awoke him, he spat out what he could and poured the rest down the drain and through the container in the recycling bin. Thinking his wife had left juice out and it had gone bad, didn't thinking anything more of it. Tuesday morning he was vomiting but thought it was a flu. Wednesday he said to his wife that something wasn't right. She was gathering the recycle and noticed the poison juice container. They then realized he'd been poisoned. He died 4 days after ingesting the product.
To be determined by Registrant
14. Severity classification.
15. Provide supplemental information here.