Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2021-3885
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.
28-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)
PMRA Registration No.
PMRA Submission No.
EPA Registration No.
Product Name: Movento
PMRA Registration No.
PMRA Submission No.
EPA Registration No.
Product Name: Manzate
7. b) Type of formulation.
Application Information
8. Product was applied?
Yes
9. Application Rate.
Unknown
10. Site pesticide was applied to (select all that apply).
Site: Unknown / Inconnu
Préciser le type: Outdoor property
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
July 28 at 0820hrs source was aerial spraying and mistakenly sprayed caller's property. Caller spoke to source (name, number) that morning and source adv spraying combination Insecticide: Movento, fungicide: Manzate. Source adv caller their applicator admitted to making a mistake, the spray can be seen as yellow specks where it fell. And source adv caller to buy raspberries and they will pay for them. Caller did not discuss cleanup with source. Caller has been washing everything, and whatever was sprayed is now sticky.
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: Unknown
Age: Unknown / Inconnu
3. List all symptoms, using the selections below.
System
- Nervous and Muscular Systems
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)
Application
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.
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.)
Caller concerned about exposure and sticky substance covering everything.
To be determined by Registrant
14. Severity classification.
15. Provide supplemental information here.