Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2022-1192

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: BRITISH COLUMBIA

6. Date incident was first observed.

Unknown

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: ROUNDUP (UNSPECIFIED FORMULATION)

• Active Ingredient(s)
  • GLYPHOSATE

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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

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

Exposure to freshly sprayed, diluted Roundup on site during routine ground spraying. Exposure would have been almost daily for some weeks during the summer, and less frequently for most of the year, none in the winter.

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

• General
  • Symptom - Fatigue
  • Symptom - Weakness

• Nervous and Muscular Systems
  • Symptom - Other
  • Specify - Brain fog

• General
  • Symptom - Other
  • Specify - Swollen lymph nodes

• Respiratory System
  • Symptom - Sore throat

• General
  • Symptom - Fever

• Nervous and Muscular Systems
  • Symptom - Headache

• Respiratory System
  • Symptom - Difficulty Breathing

• Cardiovascular System
  • Symptom - Chest pain

• Skin
  • Symptom - Itchy skin

• Gastrointestinal System
  • Symptom - Bloating
  • Symptom - Stomach pain

4. How long did the symptoms last?

>6 mos / > 6 mois

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

Occupational

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

Contact with treated area

What was the activity? Skin exposure to freshly sprayed, diluted Roundup on site during routine ground spraying

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

None

10. Route(s) of exposure.

Skin

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.)

Ongoing fatigue and weakness, brain fog, swollen lymph nodes, and sore throat. Occasional fevers, headaches, breathing, difficulty and chest pain. Skin itching Persistent bloating and abdominal pain. Symptoms are ongoing and started to appear in 2019.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.