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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2020-3167

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.


4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.


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.


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

Product Name: Unknown

  • Active Ingredient(s)

7. b) Type of formulation.

Application Information

8. Product was applied?


9. Application Rate.


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

Site: Res. - Out Home / Rés - à l'

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

The following was reported: c'est la troisième année que je demeure à cette adresse et la compagnie (NOM)...vient à chaque année...épandre les produits...en avant ...sur le côté à l'avant...sans mettre de pancarte d'avertissement...sans tenir compte de la tempé pour leur ai envoyé une mise en demeure...avec certificat médical....ils sont venus quand même ....en appliquer...sans mettre de pancarte à l'issue arrière...juste une petite pancarte en avant....c'est vraiment inacceptable

To be determined by Registrant

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


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.


  • Eye
    • Symptom - Burning eye
  • Gastrointestinal System
    • Symptom - Burning throat
    • Symptom - Burning mouth
    • Specify - Lips
  • Skin
    • Symptom - Burning skin
    • Specify - forearms and hands
    • Symptom - Itchy skin
    • Specify - ears and arms
  • General
    • Symptom - Swelling
    • Specify - swollen hands
  • Respiratory System
    • Symptom - Burning lungs
  • Nervous and Muscular Systems
    • Symptom - Headache
  • Gastrointestinal System
    • Symptom - Nausea
    • Specify - mal au coeur

4. How long did the symptoms last?

Unknown / Inconnu

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


6. a) Was the person hospitalized?


6. b) For how long?

7. Exposure scenario


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)


10. Route(s) of exposure.




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: mes yeux gorge...mes lè peau...avantbras et mains...surtout...oreilles bras,,,démangeaisons...mains enflées...mal au coeur...mal de tête...

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.