Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2023-4010

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

Environment

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

30-JUN-23

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. 29535      PMRA Submission No.       EPA Registration No.

Product Name: FIESTA LAWN WEED KILLER

• Active Ingredient(s)
  • IRON (PRESENT AS FEHEDTA)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No.

Product Name: TURF BUILDER (UNSPECIFIED FORMULATION)

• Active Ingredient(s)
  • CORN GLUTEN MEAL

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7. b) Type of formulation.

Liquid

Granular

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

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

Site: Res. - Out Home / Rés - à l'ext.maison

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

Called weed applicator company that has been spraying two yards opposite my home: severe adverse reaction. [Company], local. They are aggressively spraying on this street and neighboring. Various products, also [Company]. Sometimes its Fiesta, other times they say just a fertilizer. It was windy. Other neighbor is using Turf Builder, I think.

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 - Nausea
  • Symptom - Vomiting
  • Symptom - Diarrhea

• Cardiovascular System
  • Symptom - Chest pain

• Respiratory System
  • Symptom - Burning throat

• Nervous and Muscular Systems
  • Symptom - Dizziness

• Eye
  • Symptom - Itchy eye

• Respiratory System
  • Symptom - Burning lungs

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

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.

Respiratory

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.)

On the 30th, three of us were outside, and clearly were impacted by the fumes, airborne. Pesticide drift. I experienced for five plus days, nausea, vomiting, very serious diarrhea, pain in the chest and throat like burning, burning lungs, itchy eyes, dizziness.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.

Subform III: Domestic Animal Incident Report

1. Source of Report

Witness

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

• Gastrointestinal System
  • Symptom - Vomiting

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?

Other / Autre

specify Unknown

17. Provide any additional details about the incident

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

Neighbor around the corner has a young dog that has been vomiting. She feels it is the chemicals on lawns.

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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

Mammal-Small/Mammifère-De petite taille

2. Common name(s)

Raccoon

3. Scientific name(s)

Procyon lotor

4. Number of organisms affected

1

5. Description of site where incident was observed

Fresh water

Terrestrial

Residential

Salt Water

6. Check all symptoms that apply

Death

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

Another dead racoon picked up by the city a few days ago: poisoned.

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

Unknown

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?

30-JUN-23

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

Mammal-Small/Mammifère-De petite taille

2. Common name(s)

Chipmunk

3. Scientific name(s)

Tamias

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

Death

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

Dead chipmunks.

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

Unknown

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?

30-JUN-23

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?

No

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

Bird - Songbird / Oiseau - Chanteur

2. Common name(s)

Blue jay

3. Scientific name(s)

Cyanocitta cristata

4. Number of organisms affected

1

5. Description of site where incident was observed

Fresh water

Terrestrial

Residential

Salt Water

6. Check all symptoms that apply

Abnormal behavioural effects

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

A Blue Jay drinks sideways from a small crevice in a sidewalk.

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

Unknown

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?

30-JUN-23

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

Mammal-Small/Mammifère-De petite taille

2. Common name(s)

Mouse

3. Scientific name(s)

Mus musculus

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

Death

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

Dead mice.

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

Unknown

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?

30-JUN-23

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