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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2017-4849
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.
Environment
4. Date registrant was first informed of the incident.
5. Location of incident.
Country: CANADA
Prov / State: SASKATCHEWAN
6. Date incident was first observed.
01-JAN-14
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:
7. b) Type of formulation.
Application Information
8. Product was applied?
Unknown
9. Application Rate.
Unknown
10. Site pesticide was applied to (select all that apply).
Site: Unknown / Inconnu
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 IV: Environment (includes plants insects and wildlife)
1. Type of organism affected
Mammal-Small/Mammifère-De petite taille
2. Common name(s)
wolf
3. Scientific name(s)
Unknown
4. Number of organisms affected
2
5. Description of site where incident was observed
Fresh water
Terrestrial
Other
Salt Water
6. Check all symptoms that apply
Death
7. Describe symptoms and outcome (died, recovered, etc.).
The following is an update on secondary and non-target poisonings related to 2% LSC use. The data is taken from the Product Evaluation Forms from 2012 through 2015.
8. a) Was the incident a result of (select all that apply)
Unknown
8. b) i) How many times has the product been applied this year?
Unknown
8. b) ii) What was the date of the last application?
Unknown
9. Did it rain
9. a) During application?
Unknown
9. b) Up to 3 days after application?
Unknown
10. a) Was there a buffer zone?
Unknown
10. b) What type?
10. c) What was the size of the buffer zone?
11. a) Were environmental samples collected and analysed?
Unknown
To be determined by Registrant
12. Severity classification (if there is more than one possible classification, select the most severe)
13. Please provide supplemental information here
Subform IV: Environment (includes plants insects and wildlife)
1. Type of organism affected
Mammal-Small/Mammifère-De petite taille
2. Common name(s)
fox
3. Scientific name(s)
Unknown
4. Number of organisms affected
1
5. Description of site where incident was observed
Fresh water
Terrestrial
Other
Salt Water
6. Check all symptoms that apply
Death
7. Describe symptoms and outcome (died, recovered, etc.).
The following is an update on secondary and non-target poisonings related to 2% LSC use. The data is taken from the Product Evaluation Forms from 2012 through 2015.
8. a) Was the incident a result of (select all that apply)
Drift
Unknown
8. b) i) How many times has the product been applied this year?
Unknown
8. b) ii) What was the date of the last application?
Unknown
9. Did it rain
9. a) During application?
Unknown
9. b) Up to 3 days after application?
Unknown
10. a) Was there a buffer zone?
Unknown
10. b) What type?
10. c) What was the size of the buffer zone?
11. a) Were environmental samples collected and analysed?
Unknown
To be determined by Registrant
12. Severity classification (if there is more than one possible classification, select the most severe)
13. Please provide supplemental information here