Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2021-4059

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.

Domestic Animal

Environment

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: MANITOBA

6. Date incident was first observed.

29-JUN-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: ROUND UP

• Active Ingredient(s)
  • GLYPHOSATE

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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).

On June 29/2021 at approximately 13:15hrs. The farmer that rents land west of my shelter belt and yard started spraying round up on a canola field on a very windy day. Wind was 25-30 km/hr. After making one pass around the field I began to smell chemical round up right away. This has been happening every year.

To be determined by Registrant

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

Unknown

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

• Skin
  • Symptom - Rash

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

My dog had skin rash issues.

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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

Subform IV: Environment (includes plants insects and wildlife)

1. Type of organism affected

Trees or shrubs / Arbre ou arbuste

2. Common name(s)

Unknown

3. Scientific name(s)

Unknown

4. Number of organisms affected

250

5. Description of site where incident was observed

Fresh water

Terrestrial

Residential

Salt Water

6. Check all symptoms that apply

Abnormal leaf discoloration

Death

Visible injury ( eg. chlorosis, necrosis, bleaching)

7. Describe symptoms and outcome (died, recovered, etc.).

My trees are dying , leaves are falling off and they are thin. I also noticed a week later that the grass and outer tree leaves were turning brown.

8. a) Was the incident a result of (select all that apply)

Drift

8. b) i) How many times has the product been applied this year?

Unknown

8. b) ii) What was the date of the last application?

Unknown

9. Did it rain

9. a) During application?

Unknown

9. b) Up to 3 days after application?

Unknown

10. a) Was there a buffer zone?

Unknown

10. b) What type?

10. c) What was the size of the buffer zone?

11. a) Were environmental samples collected and analysed?

Unknown

To be determined by Registrant

12. Severity classification (if there is more than one possible classification, select the most severe)

13. Please provide supplemental information here

Subform IV: Environment (includes plants insects and wildlife)

1. Type of organism affected

Herbaceous Plants / Plante herbacée

2. Common name(s)

Grass

3. Scientific name(s)

Unknown

4. Number of organisms affected

Unknown

5. Description of site where incident was observed

Fresh water

Terrestrial

Residential

Salt Water

6. Check all symptoms that apply

Visible injury ( eg. chlorosis, necrosis, bleaching)

7. Describe symptoms and outcome (died, recovered, etc.).

I noticed a week later that the grass was turning brown.

8. a) Was the incident a result of (select all that apply)

Drift

8. b) i) How many times has the product been applied this year?

Unknown

8. b) ii) What was the date of the last application?

Unknown

9. Did it rain

9. a) During application?

Unknown

9. b) Up to 3 days after application?

Unknown

10. a) Was there a buffer zone?

Unknown

10. b) What type?

10. c) What was the size of the buffer zone?

11. a) Were environmental samples collected and analysed?

Unknown

To be determined by Registrant

12. Severity classification (if there is more than one possible classification, select the most severe)

13. Please provide supplemental information here