Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2021-2048

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: NEW BRUNSWICK

6. Date incident was first observed.

10-MAY-21

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.       PMRA Submission No.       EPA Registration No.

Product Name: BUMPER (PROPICONAZOLE) not specified

• Active Ingredient(s)
  • PROPICONAZOLE

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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

Préciser le type: Site sprayed was 30 meters from neighbor/witness property

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

A Tractor operating a large agrochemical sprayer arrived at the property east of the witness' residence/Garden Center and started discharging agro-chemicals next to the east boundary line of their property. The incident caused plumes of spray to drift in the witness property exposing them and their employees.

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: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Cardiovascular System
  • Symptom - Abnormally high blood pressure

• Eye
  • Symptom - Irritated eye

• General
  • Symptom - Fatigue

• Respiratory System
  • Symptom - Respiratory irritation

4. How long did the symptoms last?

Unknown / Inconnu

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.

Skin

Eye

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.)

Drift from a Tractor sprayer approximately 30 meters from the witness' residence and garden center buisness. This affected 3 employees exposed, breathing irritation, eyes, high blood pressure,fatigue symptoms reported. Contamination of Irrigation stream feeding irrigation pond discharging on wetlands. The incident caused plumes of spray to drift into the witness' property exposing them and their employees that were working. The garden center stock displayed near the property line was also exposed. Customers complained about the chemical smell and left.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.