Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2020-1543
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.
29-MAY-20
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: ortho weed b gon weed killer lawns concentrate2
- Active Ingredient(s)
- 2,4-D (PRESENT AS AMINE SALTS : DIMETHYLAMINE SALT, DIETHANOLAMINE SALT, OR OTHER AMINE SALTS)
- DICAMBA (PRESENT AS ACID, AMINE SALT, ESTER, POTASSIUM SALT, OR SODIUM SALT)
- MECOPROP-P (PRESENT AS DIMETHYLAMINE SALT)
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: 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).
The following was reported: Ortho weed b gon with 2,4. -D. After detecting strong odour , notice 2 hired men, next home south of me , spraying chemicals on lawn / property,,there was a slight wind.,I went out asking what product was being used ? Worker handed me a near full bottle to take a photo of the container( attachments included ) the man called product ? round up?. adding it is obtained from source in USA . I asked risks of the chemicals and was Told dogs can get sick from this? I suggested the men get PPE , to reduce risk of illness or worse, I went to my home, closed all windows.
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: >64 yrs / > 64 ans
3. List all symptoms, using the selections below.
System
- Nervous and Muscular Systems
- Respiratory System
- Symptom - Respiratory congestion
- Specify - clear phlegm
- 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?
Unknown
6. b) For how long?
7. Exposure scenario
Non-occupational
8. How did exposure occur? (Select all that apply)
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
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 went into my home, starting to experience nausea, then a headache, then a productive clear foamy cough. I hydrated, took elderberry syrup to promote good lung health.
To be determined by Registrant
14. Severity classification.
15. Provide supplemental information here.