Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2021-3449

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: QUEBEC

6. Date incident was first observed.

15-JUN-16

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: GLYPHOSATE

• Active Ingredient(s)
  • GLYPHOSATE

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7. b) Type of formulation.

Application Information

8. Product was applied?

Unknown

9. Application Rate.

Unknown

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

Site: Unknown / Inconnu

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

Je suis devenue allergique ou intolerante en consommant chaque jour du ble entier et autres cereales et viandes nourries au glyphosate. Je voudrais eviter e d'autres enfants ou adultes de subir le meme sort. Il y a plusieurs personnes de mon age ne plus pouvoir manger le ble traite au glyphosate.

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

• Gastrointestinal System
  • Symptom - Other
  • Specify - Wheat intolerance
  • Symptom - Other
  • Specify - Dairy intolerance
  • Symptom - Other
  • Specify - Veal and beef intolerance
  • Symptom - Other
  • Specify - Legume intolerance
  • Symptom - Other
  • Specify - Colitis-like symptoms

• Nervous and Muscular Systems
  • Symptom - Headache
  • Specify - Migraine

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

Unknown

8. How did exposure occur? (Select all that apply)

Contact with treated area

What was the activity? CONSUMING TREATED FOOD PRODUCTS

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.

Oral

11. What was the length of exposure?

>1 yr / > 1 an

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.)

Depuis 2016, je ne peux plus consommer aucun produit qui a ete traite au glyphosate y compris les animaux qui consomment du ble et autres produits contenant ou ayant ete traites au glyphosate. Je suis devenue intolerante au ble sans etre coeliaque, aux produits laitiers (pas seulement le lactose) tous les fromages, veau, vache ainsi que les legumineuses qui sont traitees au glyphosate. J'ai regulierement des symptomes de colites et j'ai ete examinee 2 fois pour ces maladies de l'intestin, resultat negatif. Le glyphosate est utilise depuis 50 ans, j'en ai X donc j'en ai mange toute ma vie ce qui me causait des migraines atroces et autres inconvenients intestinaux. Depuis que je mange bio, fini les migraines et derangements intestinaux.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.