Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2021-3224

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

Domestic Animal

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

06-JUL-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. 33825      PMRA Submission No.       EPA Registration No.

Product Name: TILMOR 240 EC FUNGICIDE

• Active Ingredient(s)
  • PROTHIOCONAZOLE
    • Guarantee/concentration 80 g/L
  • TEBUCONAZOLE
    • Guarantee/concentration 160 g/L

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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).

I own 1 acre of land in X. We are surrounded by farmland and are accustomed to getting some drift from pesticides, etc. However the aerial application spraying (crop dusting) in our area has reached a criminally negligent level. The planes often fly directly over our home, sometimes at quite low altitudes, say 50ft. On Tuesday, July 6th at 8pm, my family and I were enjoying supper in the back yard when a plane suddenly flew over the east side of our property, while still spraying. It was humid, with a slight breeze from the east. We were all doused with the spray; myself, my wife, an adult friend, a 6yr old, 5 yr, old and 3 month old. Our dog, 2 cats and (formerly) organic garden were also 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

• Eye
  • Symptom - Irritated eye

• Respiratory System
  • Symptom - Other
  • Specify - Constricted throat
  • Symptom - Coughing

• Nervous and Muscular Systems
  • Symptom - Headache

• Gastrointestinal System
  • Symptom - Nausea

• Respiratory System
  • Symptom - Irritated throat

4. How long did the symptoms last?

>8 hrs <=24 hrs / > 8 h < = 24 h

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)

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.

Unknown

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

<=30 min / <=30 min

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.)

Immediate eye irritation. Irritated, constricted throat with slight cough, which petered out over 24 hours. Mild to moderate headache and nausea.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Unknown

4. Number of animals affected

1

5. Sex

Unknown

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Unknown

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

• General
  • Symptom - Abnormal behaviour

12. How long did the symptoms last?

Unknown / Inconnu

13. Was medical treatment provided? Provide details in question 17.

Unknown

14. a) Was the animal hospitalized?

Unknown

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Unknown/Inconnu

16. How was the animal exposed?

Spray drift / Dérive de pulvérisation

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

The dog has been acting strangely as well and the vet would like to do some blood work to check for kidney failure.

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To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Not Applicable

19. Provide supplemental information here