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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2017-0456

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.


4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.


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.


PMRA Registration No. 29752      PMRA Submission No.       EPA Registration No.


  • Active Ingredient(s)

7. b) Type of formulation.

Application Information

8. Product was applied?


9. Application Rate.


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).

This past year, for the first time in 26 years, the municipal government voted to apply herbicides along its roadsides to control weeds. They used the herbicide Clearview with the surfactant Gateway. The municipal government granted me a 20 km buffer zone. The Clearview herbicide application near the buffer zone was a one day application only and it took place on Wednesday, June 15th. The application was East and Southeast of our home, with the majority being in the southeast direction. The Clearview application was a width of ten feet of spraying on both sides of the road and the full length of the road, except where there was water or a No Spray sign.The road supervisor notified me when they applied Clearview near the buffer zone; and I immediately went under house arrest. This means that I will no longer go outdoors until the weather turns cold and the pesticide can no longer vapourize. I will only go outdoors when the outside air quality has returned to being good and it is free from pesticide vapour. The wind direction and the wind speed are continually monitored, from the time of application till the weather turns cold in the fall. Also, the doors and windows are kept closed at all times - except for the times someone is entering or exiting the home. An intercom system is set up at the door, and no one opens the door until I am away from the door and in another room. The air purifiers are turned on and will run continuously 24/7 until the weather turns cold. Implementing the strict protocol mentioned above.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?


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: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.


  • Gastrointestinal System
    • Symptom - Nausea
    • Symptom - Vomiting
  • Nervous and Muscular Systems
    • Symptom - Muscle weakness
    • Specify - all muscles in the entire leg on both legs and all muscles in the entire in both arms
    • Symptom - Muscle spasm
    • Symptom - Muscle pain
  • General
    • Symptom - Joint pain
  • Nervous and Muscular Systems
    • Symptom - Headache
    • Symptom - Dizziness
  • General
    • Symptom - Lightheadedness
  • Nervous and Muscular Systems
    • Symptom - Difficulty walking
    • Symptom - Difficulty concentrating
    • Specify - Reduced cognitive function
    • Symptom - Difficulty talking
    • Specify - Reduced speech ability
  • Gastrointestinal System
    • Symptom - Fecal incontinence
    • Specify - Bowel control problems
  • Nervous and Muscular Systems
    • Symptom - Other
    • Specify - Loss of range of motion in both my legs and arms
  • Blood
    • Symptom - Hypoglycemia
    • Specify - Low blood sugar
  • General
    • Symptom - Other
    • Specify - Difficulty standing

4. How long did the symptoms last?

Unknown / Inconnu

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


6. a) Was the person hospitalized?


6. b) For how long?

7. Exposure scenario


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)


10. Route(s) of exposure.


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.)

From Wednesday to Friday, the wind directions fluctuated a lot, but there were times that the wind was coming from either the East or the South East. Some of my toxic reactions came on me suddenly and others began very subtly and very gradually. Over the few days from Wednesday to about Sunday, very slowly I gradually lost some muscle strength in all my extremities (all muscles in the entire leg on both legs and all muscles in the entire arm in both arms). By Saturday morning, I was beginning to lose range of motion in both my legs and arms, and I was experiencing muscle spasms and increased muscle pain. Standing and walking became increasingly difficult - primarily due to the muscles becoming too weak to carry my weight. Early afternoon on Friday, I suddenly became very dizzy, lightheaded and nauseous, and I vomited shortly after the onset. Although the vomiting ended, the nausea and lightheadedness persisted for the remainder of the day; and I continued to experience the nausea and dizziness periodically over the following week. Headaches and low blood sugar levels were other symptoms that I periodically experienced. Thankfully, by Sunday evening my body started showing indications of pulling out of the toxic reaction and recovering. It took me about 8 days to pull out of the reaction. Since the afternoon of Friday, June 17th, the wind has only very rarely been from the E or SE, and that has only been for very brief periods of time at a low speed. Therefore so far, I haven't noticed any negative effects from these brief periods. Consequently, my body has had an opportunity for the recovery process. The gastrointestinal reaction, although very unpleasant, was expected as I had learned that both the main ingredients in Clearview can effect the gastrointestinal system. However, reacting neurologically took me quite by surprise. I was not anticipating the neuro-muscular reactions. Since we are now at the end of August, I thought I would give you a bit of an update and let you know how the Clearview herbicide has affected me over the last two months. Thankfully, this summer the wind has primarily been westerly and my toxic reactions have been few. The first reaction to Clearview, as it began to degrade and release toxic gases, was in early July. That reaction was almost identical to my reaction to the initial application of Clearview. However, this time, the gastrointestinal symptoms were the most prominent. Also, I was in and out of the reaction in only 4 days. All my reactions since then have been primarily gastrointestinal, with almost no neuro-muscular reaction. Also the reactions are becoming less severe and shorter in duration. Now, at the end of August, a reaction might last half a day or a few hours. So they have substantially diminished over the course of the summer.This association has become deeply imbedded in my mind, as my toxic reactions have been confirmed each time with verification of exposure to Clearview by checking the wind direction and wind speed over the previous 24 hours. Thankfully, both the duration and severity is getting less and less. What I anticipated would happen in the fall, is exactly what did happen. It was more of the same - dizziness, nausea, vomiting and bowel urgency - with a continuing diminishing of the duration and the severity. The cold weather did stop the toxic vapour from being released, and then the air quality did improve. At that point, any danger to my health was over.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.