Health Canada
Symbol of the Government of Canada
Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2017-2060

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.


Domestic Animal

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. 29535      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: Res. - Out Home / Rés - à l'

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

Fiesta Lawn Weed Killer, Ammonium Sulfate. Unknown, application done during high winds. (Company) Technician Sprayed during high winds on a neighbors property, I was covered in red residue while sitting on my back deck. I inhaled the substance and immediately called the company for the MSDS sheets, but they would not send them, or disclose the information. Constant exposure on the ground, yard due to the drift of spray when they are applying. Ammonium Sulfate Lawn products.

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.


  • Cardiovascular System
    • Symptom - Chest pain
  • Respiratory System
    • Symptom - Other
    • Specify - Lung lesions
  • Cardiovascular System
    • Symptom - Other
    • Specify - heart problems
  • Respiratory System
    • Symptom - Difficulty Breathing
  • Gastrointestinal System
    • Symptom - Nausea
  • Nervous and Muscular Systems
    • Symptom - Dizziness
  • Eye
    • Symptom - Burning eye
  • Skin
    • Symptom - Burning skin
  • General
    • Symptom - Malaise
    • Specify - feeling ill
  • Respiratory System
    • Symptom - Burning lungs
  • Eye
    • Symptom - Blurred vision

4. How long did the symptoms last?

>6 mos / > 6 mois

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.)

Respiratory Issues, such as shortness of breathe, Lesions on my lungs 0.5 cm and one that is 3.0 cm. Dizzy, nausea, generally ill feeling. Blurred vision, and burning in lungs. I was prescribed Nitro 0.4 mg, Respirmatt inhaler, rescue inhaler. I had a ct scan and now have lesions on my lungs and more difficulty breathing. I went to the doctor and have had ongoing health problems since. I now have heart problems and was already ill with emphysema and fibrosis when this occurred. They come regularly to treat my neighbors lawn, so it has been constant exposure there after. I have a chronic illness, Emphysema and Fibrosis in the lungs. After being exposed I have suffered greatly with chest pain, lung issues such as lesions on my lungs, and difficulty breathing. I had a burning in my eyes and skin. I felt nausea and was dizzy immediately after the incident. I tried to get the manager to send me the Msds sheets for treatment and he refused, as well he refused to give me notice when they were coming to spray the neighbors lawn. So I am constantly being exposed.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Rotti X and Beagle X

4. Number of animals affected


5. Sex

6. Age (provide a range if necessary )


7. Weight (provide a range if necessary )


8. Route(s) of exposure





9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms


  • Nervous and Muscular Systems
    • Symptom - Muscle tremors
    • Specify - Tremors
    • Symptom - Seizure
  • Gastrointestinal System
    • Symptom - Vomiting
    • Symptom - Diarrhea
  • Liver
    • Symptom - Elevated liver enzymes
  • Gastrointestinal System
    • Symptom - Other
    • Specify - pancreatitis
  • Renal System
    • Symptom - Renal failure
  • Nervous and Muscular Systems
    • Symptom - Ataxia
  • Skin
    • Symptom - Other
    • Specify - Numerous paw infections
    • Symptom - Lesion
    • Symptom - Hair loss
    • Specify - loss of fur
  • Nervous and Muscular Systems
    • Symptom - Coma
    • Specify - coma like state
  • Respiratory System
    • Symptom - Other
    • Specify - fluid in lungs

12. How long did the symptoms last?

Unknown / Inconnu

13. Was medical treatment provided? Provide details in question 17.


14. a) Was the animal hospitalized?


14. b) How long was the animal hospitalized?

15. Outcome of the incident


16. How was the animal exposed?

Spray drift / Dérive de pulvérisation

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

Tremors, Seizures, vomiting, diarrhea, elevated liver enzymes, pancreatitis, and renal failure and ataxia. Numerous Paw infections and skin lesions, loss of fur and coma like state, one dog had fluid in the lungs. They were prescribed phenobarbital, renal powder, benedryl, thermaderm cream an Gabapentin for pain. Totalling over $5000.00 dollars in medical treatment this past year. The dogs are in constant exposure due to Neighbors Lawn Care Service with (company). One time the wind blew and it left a red residue on them. The drift brings granules and mists over to our side of property. Front and back yard is contaminated. The neighbor uses the lawn service regularly and my dogs are constantly exposed, causing sore irritated paws, ataxia, seizures every time they do a treatment. Both my dogs nearly died three times in one year, and now we will be facing another year of exposure. I have taken all methods to try and protect them, but with constant unregulated spraying, the company refused msds sheets and to give me notice ahead when spraying. So they are still going through this on a regular basis.

To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification


19. Provide supplemental information here