Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2019-4863

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: ONTARIO

6. Date incident was first observed.

16-AUG-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. 32189      PMRA Submission No.       EPA Registration No.

Product Name: HEADLINE AMP

• Active Ingredient(s)
  • METCONAZOLE
  • PYRACLOSTROBIN

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PMRA Registration No. 29767      PMRA Submission No.       EPA Registration No.

Product Name: CARAMBA FUNGICIDE

• Active Ingredient(s)
  • METCONAZOLE

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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: Agricultural-Outdoor/Agricole-extérieur

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

The following was reported: We live on a 50 acre farm, adjacent farm is owned by off site farm organization. At approx 8:45 am we had a helicopter pass by the back east side of our house about 100 feet away 15 feet off ground he was spraying a corn field. My wife and I ran out of our front door ,west side of house, towards our horses which were spooking from the helicopter ( running around frantically) after coming around the corner southwest of the house we were covered in a cloud of mist spray, we continued towards the horses to settle them,(they were 400 feet from the property line) we then went to the east property line to try and get the pilots attention, he saw me and continued spraying, all this time we were getting covered in heavy mist. We have a video of his last few minutes of flight and where he flies directly at us over our property at 10 feet off the ground. Our 4 horses were also contaminated, no visible symptoms, but BASF vet advisor said they could colic within 24/48 hours due to ingestion of pasture that 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: Male

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Nausea

• Nervous and Muscular Systems
  • Symptom - Dizziness
  • Symptom - Headache

• General
  • Symptom - Fatigue

• Nervous and Muscular Systems
  • Symptom - Confusion

• Respiratory System
  • Symptom - Sore throat
  • Symptom - Burning lungs

• General
  • Symptom - Flu-like symptoms

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)

Unknown

10. Route(s) of exposure.

Skin

Respiratory

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: Headache nausea fatigue dizziness/ confusion sore throat slight burning in lungs, felt flu like symptoms also.

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.

Other

2. Demographic information of data subject

Sex: Female

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Headache
  • Symptom - Dizziness
  • Symptom - Confusion

• General
  • Symptom - Fatigue
  • Symptom - Flu-like symptoms

• Respiratory System
  • Symptom - Sore throat
  • Symptom - Burning lungs

• Gastrointestinal System
  • Symptom - Nausea

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)

Unknown

10. Route(s) of exposure.

Skin

Respiratory

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: Headache nausea fatigue dizziness/ confusion sore throat slight burning in lungs, felt flu like symptoms also.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.