Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2020-2033
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: ALBERTA
6. Date incident was first observed.
23-JUN-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: glyphosate
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
Préciser le type: aerial crop application
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
The following was reported: My son was out for a bike ride at approximately 7:45pm and a plane (white with red markings) started spraying the crops he was riding next to. The plane did not wait for my son to be out of the area and began to spray. My son was sprayed. He was having difficulty breathing. He was enveloped in a cloud of spray. My husband had to quickly drive to his rescue and pick him up.
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.
2. Demographic information of data subject
Sex: Male
Age: >6 <=12 yrs / > 6 < = 12 ans
3. List all symptoms, using the selections below.
System
- Respiratory System
- Symptom - Difficulty Breathing
- Symptom - Shortness of breath
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: Shortness of breath, trouble breathing. Total body covered in cloud of spray from aerial plane spraying farmers crop field.
To be determined by Registrant
14. Severity classification.
15. Provide supplemental information here.