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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2017-2865

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


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. 28198      PMRA Submission No.       EPA Registration No.

Product Name: Roundup Transorb HC Liquid Herbicide

  • 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: Agricultural-Outdoor/Agricole-extérieur

Préciser le type: Orchard

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

Pesticide crop spray May 20th and May 29th close proximity dwelling. Sprayed and became ill as I sleep with windows open. Application with tractor pulling tank behind with driver fully masked. I asked my landlord to be notified spray came into my windows all over my house , floors, counter, carpets, clothes, etcetera . He never gave any notice. I woke up to spray blowing in. I have been very sick, severe headaches, raw and blistered tongue, red sore throat. I had to leave my own home rented from him.

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.


  • Skin
    • Symptom - Burning skin
  • General
    • Symptom - Chemical taste in mouth
    • Specify - very bad taste in mouth, tongue, throat
  • Gastrointestinal System
    • Symptom - Loss of appetite
  • Respiratory System
    • Symptom - Other
    • Specify - phlem discharge from lungs
  • General
    • Symptom - Lethargy
  • Nervous and Muscular Systems
    • Symptom - Headache
  • Gastrointestinal System
    • Symptom - Other
    • Specify - inflamed throat
    • Symptom - Oral hemorrhage
    • Specify - bleeding tongue, swollen with bumps
  • Skin
    • Symptom - Blister
    • Specify - blistered tongue
  • Gastrointestinal System
    • Symptom - Sore throat
    • Specify - red, sore throat
  • General
    • Symptom - Malaise
    • Specify - very sick
  • Blood
    • Symptom - Leukocytosis
    • Specify - neutrophilia
    • Symptom - Other
    • Specify - increased blood count

4. How long did the symptoms last?

>3 days <=1 wk / >3 jours <=1 sem

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.)

I am renting amongst an orchard and asked my landlord when to be notified when the are going to spray orchards. I would go stay at a friends. Prescribed naproxen 250mg and Pharixia Oral Rinse 0.15%.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.