Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2019-3335

2. Registrant Information.

Registrant Reference Number: NEU 29535 18June2019

Registrant Name (Full Legal Name no abbreviations): W. Neudorff GmbH KG

Address: #11-6782 Veyaness Road

City: Saanichton

Prov / State: B.C.

Country: Canada

Postal Code: V8M 2C2

3. Select the appropriate subform(s) for the incident.

Human

4. Date registrant was first informed of the incident.

18-JUN-19

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

18-JUN-19

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. 29535      PMRA Submission No.       EPA Registration No.

Product Name: Fiesta Lawn Weed Killer

• Active Ingredient(s)
  • IRON (PRESENT AS FEHEDTA)

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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: Res. - Out Home / Rés - à l'ext.maison

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

Non-target exposure through spray drift to residential lawn.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

No

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

• Eye
  • Symptom - Irritated eye

4. How long did the symptoms last?

<=30 min / <=30 min

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

No

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)

10. Route(s) of exposure.

Eye

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

<=30 min / <=30 min

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.)

Spray drift from application to neighbouring residential lawn. Person exposed was outside in their yard and could smell the pesticide, and had slightly irritated eyes.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.