Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2017-3336

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.

18-JUN-17

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: Roundup

• Active Ingredient(s)
  • GLYPHOSATE (PRESENT AS ISOPROPYLAMINE SALT OR ETHANOLAMINE SALT)

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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: Agricultural-Outdoor/Agricole-extérieur

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

Sprayed on field, 3/4 of a barrel field across from us on (address) it was (First name Last name) land.There was more than 8km hour of wind. Spray came our way. (First name Last name) driving too fast more than 10km hour. Sprayed came on threw the air by the wind for about an hour. Smelled the spray in the house and outside for about 3 days.

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.

Data Subject

2. Demographic information of data subject

Sex: Male

Age: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

• Cardiovascular System
  • Symptom - Chest tightness
  • Specify - heaviness in chest

• Eye
  • Symptom - Burning eye

• Gastrointestinal System
  • Symptom - Burning mouth

• General
  • Symptom - Chemical taste in mouth
  • Specify - bitter taste in mouth

• Gastrointestinal System
  • Symptom - Sore throat

• General
  • Symptom - Malaise

• Nervous and Muscular Systems
  • Symptom - Headache

• Respiratory System
  • Symptom - Choking
  • Symptom - Coughing

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?

No

6. b) For how long?

7. Exposure scenario

Non-occupational

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)

None

10. Route(s) of exposure.

Eye

Respiratory

11. What was the length of exposure?

>15 min <=2 hrs / >15 min <=2 h

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.)

Coughing, headache, bitter taste in mouth, burning mouth, noise, eyes, throat. Throat very sore. Feeling sick, chocking, heaviness in chest, felt like same was in our chest. What rights do we have so that sprayed (first name)was using not to come on our land in the air, so we can look after our animals and garden or just relaxing outside or doing anything in the house so it doesnt bother us at night or day. So we dont have to go for a few days because its causes us problems. And we cant go because we need to be there for our animals and garden and look after our grandchild when (name) works. We like beings outside and going for walking in the evening or looking at the sky. 7 days later we still could not go for walk because the Roundup would still burn our throat and make it very sore, and would give us a headache. It wrecked fathers day for relaxing outside. Wht right do they have for stopping us for having our windows open or doing anything outside because of the Roundup in the field. (Name) could have put it anywhere else in that field or other fields so it would not bother people. It took 7 days to show signs of the vegetation dying.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.

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.

System

• Respiratory System
  • Symptom - Coughing

• Nervous and Muscular Systems
  • Symptom - Headache

• Gastrointestinal System
  • Symptom - Burning mouth

• Eye
  • Symptom - Burning eye

• Gastrointestinal System
  • Symptom - Sore throat

• General
  • Symptom - Malaise

• Respiratory System
  • Symptom - Choking

• Cardiovascular System
  • Symptom - Chest tightness
  • Specify - heaviness in chest

• General
  • Symptom - Chemical taste in mouth
  • Specify - bitter taste in mouth

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?

No

6. b) For how long?

7. Exposure scenario

Unknown

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)

None

10. Route(s) of exposure.

Eye

Respiratory

11. What was the length of exposure?

>15 min <=2 hrs / >15 min <=2 h

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.)

Coughing, headache, bitter taste in mouth, burning mouth, noise, eyes, throat. Throat very sore. Feeling sick, chocking, heaviness in chest, felt like same was in our chest. What rights do we have so that sprayed (first name)was using not to come on our land in the air, so we can look after our animals and garden or just relaxing outside or doing anything in the house so it doesnt bother us at night or day. So we dont have to go for a few days because its causes us problems. And we cant go because we need to be there for our animals and garden and look after our grandchild when (name) works. We like beings outside and going for walking in the evening or looking at the sky. 7 days later we still could not go for walk because the Roundup would still burn our throat and make it very sore, and would give us a headache. It wrecked fathers day for relaxing outside. Wht right do they have for stopping us for having our windows open or doing anything outside because of the Roundup in the field. (Name) could have put it anywhere else in that field or other fields so it would not bother people. It took 7 days to show signs of the vegetation dying.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.