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)
PMRA Registration No. 29535
PMRA Submission No.
EPA Registration No.
Product Name: FIESTA LAWN WEED KILLER
- Active Ingredient(s)
- IRON (PRESENT AS FEHEDTA)
PMRA Registration No.
PMRA Submission No.
EPA Registration No.
Product Name: TURF BUILDER (UNSPECIFIED FORMULATION)
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
- 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
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
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.
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