Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2018-1816

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

Environment

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.

Unknown

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. 24977      PMRA Submission No.       EPA Registration No.

Product Name: FORAY 48B BIOLOGICAL INSECTICIDE AQUEOUS SUSPENSION

• Active Ingredient(s)
  • BACILLUS THURINGIENSIS SUBSPECIES KURSTAKI (ALL STRAINS)
    • Guarantee/concentration 10600

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7. b) Type of formulation.

Liquid

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

10. Site pesticide was applied to (select all that apply).

Site: Pub. Area - Outdoor/Zone publique - ext

Préciser le type: Outside apartment and across the road

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

The following was reported: "I was not notified of a major spray event, previous to the actual event and was blasted in my apt with all my doors and windows open. I quickly realized something was not right and had a foul odor, and shut everything down, but then two hours later another area across the road was sprayed."

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: Female

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• General
  • Symptom - Other
  • Specify - Bad taste in mouth

• Respiratory System
  • Symptom - Difficulty Breathing

• Eye
  • Symptom - Burning eye

• Respiratory System
  • Symptom - Nose bleed

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?

Unknown

6. b) For how long?

Unknown

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)

10. Route(s) of exposure.

Unknown

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.)

The following was reported: "I had a bad taste in my mouth, difficulty breathing, and blood in my nostrils and burning eyes. I then went out to get the mail and found my feet sticking to the surface of the floors and then found a pink sheet of paper that was notifying me of the second spraying on may 25th, but that was the first and only notice."

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.

Subform IV: Environment (includes plants insects and wildlife)

1. Type of organism affected

Herbaceous Plants / Plante herbacée

2. Common name(s)

Unknown

3. Scientific name(s)

Unknown

4. Number of organisms affected

Unknown

5. Description of site where incident was observed

Fresh water

Terrestrial

Residential

Salt Water

6. Check all symptoms that apply

Abnormal plant stance

7. Describe symptoms and outcome (died, recovered, etc.).

The following was reported: "then noticed my deck annuals looked droopy, so i checked them, but they were fine and just wilting."

8. a) Was the incident a result of (select all that apply)

Drift

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

Trees or shrubs / Arbre ou arbuste

2. Common name(s)

Dogwood

3. Scientific name(s)

Cornus

4. Number of organisms affected

2

5. Description of site where incident was observed

Fresh water

Terrestrial

Salt Water

6. Check all symptoms that apply

Abnormal plant stance

7. Describe symptoms and outcome (died, recovered, etc.).

The following was reported: "then I noticed the two dogwood trees in front, the leaves were wilted, as well as the alder across the road, and the large cottonwood further down were all droopy."

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

Trees or shrubs / Arbre ou arbuste

2. Common name(s)

Alder

3. Scientific name(s)

Alnus

4. Number of organisms affected

1

5. Description of site where incident was observed

Fresh water

Terrestrial

Roadside

Salt Water

6. Check all symptoms that apply

Abnormal plant stance

7. Describe symptoms and outcome (died, recovered, etc.).

The following was reported: "then I noticed the two dogwood trees in front, the leaves were wilted, as well as the alder across the road, and the large cottonwood further down were all droopy."

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

Trees or shrubs / Arbre ou arbuste

2. Common name(s)

Cottonwood

3. Scientific name(s)

Populus

4. Number of organisms affected

1

5. Description of site where incident was observed

Fresh water

Terrestrial

Salt Water

6. Check all symptoms that apply

Abnormal plant stance

7. Describe symptoms and outcome (died, recovered, etc.).

The following was reported: "then I noticed the two dogwood trees in front, the leaves were wilted, as well as the alder across the road, and the large cottonwood further down were all droopy."

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?

Aquatic

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