Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2024-2333
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
Environment
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.
23-MAY-24
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. 24977
PMRA Submission No.
EPA Registration No.
Product Name: FORAY 48B BIOLOGICAL INSECTICIDE AQUEOUS SUSPENSION
- Active Ingredient(s)
- BACILLUS THURINGIENSIS SUBSPECIES KURSTAKI (ALL STRAINS)
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: Pub. Area - Outdoor/Zone publique - ext
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
I was sprayed over my head with an insecticide.
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: Unknown
Age: Unknown / Inconnu
3. List all symptoms, using the selections below.
System
- Respiratory System
- Symptom - Irritated throat
- Nervous and Muscular Systems
4. How long did the symptoms last?
>3 days <=1 wk / >3 jours <=1 sem
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)
Other
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.)
Making me sick. Throat irritation, headache, coughing up stuff for a week.
To be determined by Registrant
14. Severity classification.
15. Provide supplemental information here.
Subform IV: Environment (includes plants insects and wildlife)
1. Type of organism affected
Terr. Invrtbrt-Other/Inv.Ter-Autre
2. Common name(s)
Butterfly
3. Scientific name(s)
Unknown
4. Number of organisms affected
Unknown
5. Description of site where incident was observed
Fresh water
Terrestrial
Other
Salt Water
6. Check all symptoms that apply
Death
7. Describe symptoms and outcome (died, recovered, etc.).
Killing butterflies.
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?
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