Déclaration d'incident

Sous-formulaire I: Renseignements généraux

1.Type de rapport.

Nouvelle déclaration d'incident

No de la demande: 2014-2012

2. Renseignements concernant le titulaire.

Numéro de référence du titulaire d'homologation: x

Nom du titulaire (nom légal complet, aucune abbréviation): x

Adresse: x

Ville: x

État: x

Pays: x

Code postal /Zip: X

3.Choisir le (les) sous-formulaire(s) correspondant à l'incident.

Incident chez l'humain

4. Date à laquelle le titulaire d'homologation a été informé pour la première fois de l'incident.

5. Lieu de l'incident.

Pays: CANADA

État: SASKATCHEWAN

6. Date de la première observation de l'incident.

Description du produit

7. a) Donner le nom de la matière active et, si disponibles, le numéro d'homologation et le nom du produit (incluant tous les mélanges). Si le produit n'est pas homologué, donner le numéro de la demande d'homologation.

Matière(s) active(s)

---

ARLA No d'homologation       ARLA No de la demande d'homologation       EPA No d'homologation.

Nom du produit: unknown

• Matière active
  • 2,4-D (PRESENT AS ACID)
  • GLYPHOSATE

---

7. b) Type de formulation.

Renseignments sur l'application

8. Est-ce que le produit a été appliqué?

Oui

9. Dose d'application.

Inconnu

10. Site d'application (choisir tout ce qui s'applique).

Site: Agricultural-Outdoor/Agricole-extérieur

11. Donner tout renseignement additionnel concernant l'application (comment le produit a été appliqué, la quantité utilisée, la superficie de la zone traitée, etc.)

Manager of workers that were exposed to spray drift. Suspect it was a tank mix with 2,4-d, glyphosate and maybe a growth regulator such as heat. The pesticide exposure was from spray drift into our orchard and the farmer who was spraying would not give me the chemicals he was using when I called him to discuss this matter. The direction of the wind SSE with wind gusts up to 67 km/h. Our orchard is straight north of the field being sprayed. John Deer high clearance sprayer.

À être déterminé par le titulaire

12. Selon vous, le produit a-t-il été utilisé en conformité avec le mode d'emploi de L'étiquette?

Inconnu

Sous-formulaire II : Incident chez l'humain (Obligation d'utiliser un formulaire séparé pour chaque personne affectée)

1. Source de la déclaration.

Autre

2. Renseignement démographique sur la personne affectée

Sexe: Inconnu

Âge: Unknown / Inconnu

3. Énumérez tous les symptômes, au moyen des choix suivants.

Système

• Systèmes nerveux et musculaire
  • Symptôme - Mal de tête

• Système gastro-intestinal
  • Symptôme - Nausée

• Oeil
  • Symptôme - Oeil rouge

4. Quelle a été la durée des symptômes?

Unknown / Inconnu

5. La personne affectée a-t-elle reçu des soins médicaux? Donner les détails à la question 13.

Inconnu

6. a) Est-ce que la personne a été hospitalisée?

Inconnu

6. b) Pendant combien de temps?

Inconnu

7. Scénario d'exposition

Professionnel

8. Comment l'exposition s'est-elle produite? (cocher tout ce qui s'applique)

Dérive du pesticide à partir de la zone traitée

9.Si l'exposition s'est produite lors du traitement ou au moment du retour dans la zone traitée, de l'équipement de protection individuelle était-il porté? (cocher tout ce qui s'applique)

Inconnu

10. Voie(s) d'exposition.

Inconnu

11.Durée de l'exposition?

Unknown / Inconnu

12.Temps écoulé entre l'exposition et l'apparition des symptômes.

Unknown / Inconnu

13.Donner tout détail additionnel au sujet de l'incident (p.ex. description des symptômes tels que la fréquence et la gravité, type de soins médicaux, résultats des tests médicaux, quantité de pesticide à laquelle la personne a été exposée, etc.)

The 6 workers experienced head aches and nausea which was treated was treated by providing tylenol that evening. 2 of the workers experienced redness in there eyes that lasted 2 days. The 6 people were exposed as a result of the spray drift coming into the orchard they were working in. Our workers are from Nicaragua so they were not aware that they could leave the orchard or take action. (Shame on me as a Canadian farm manager as I should have told them). They continued to work throughout the day in these conditions and only told me about how they were feeling that evening. The farmer (first and last name), had one of his employees spraying his field which is directly south of our 160 acre orchard. Our workers were in the block directly across the road from where the farmer was spraying. When they told me about the incident they said the smell was very bad, caused headaches and a nauseous feeling. They reported actually feeling a mist on their faces when working. They said the wind was very strong. I did call the farmer who owns the field and asked why he would be spraying on such a windy day. I also asked him if he could give me a list of the chemicals used in his tank mix. He did not after several calls to him and told me that any further communication would be through registered mail (whatever that means). I told him that I thought he had a responsibility to provide the chemicals used and that I was definitely going to do a lab analysis to determine the chemicals present. In addition to the fact that he continued to spray even in the presence of my workers his actions caused significant damage in our orchards because our trees were at 100% blossom.

À être déterminé par le titulaire

14. Classification selon la gravité.

15. Donner des renseignements additionnels ici.

Sous-formulaire II : Incident chez l'humain (Obligation d'utiliser un formulaire séparé pour chaque personne affectée)

1. Source de la déclaration.

Autre

2. Renseignement démographique sur la personne affectée

Sexe: Inconnu

Âge: Unknown / Inconnu

3. Énumérez tous les symptômes, au moyen des choix suivants.

Système

• Systèmes nerveux et musculaire
  • Symptôme - Mal de tête

• Système gastro-intestinal
  • Symptôme - Nausée

• Oeil
  • Symptôme - Oeil rouge

4. Quelle a été la durée des symptômes?

Unknown / Inconnu

5. La personne affectée a-t-elle reçu des soins médicaux? Donner les détails à la question 13.

Inconnu

6. a) Est-ce que la personne a été hospitalisée?

Inconnu

6. b) Pendant combien de temps?

Inconnu

7. Scénario d'exposition

Professionnel

8. Comment l'exposition s'est-elle produite? (cocher tout ce qui s'applique)

Dérive du pesticide à partir de la zone traitée

9.Si l'exposition s'est produite lors du traitement ou au moment du retour dans la zone traitée, de l'équipement de protection individuelle était-il porté? (cocher tout ce qui s'applique)

Inconnu

10. Voie(s) d'exposition.

Inconnu

11.Durée de l'exposition?

Unknown / Inconnu

12.Temps écoulé entre l'exposition et l'apparition des symptômes.

Unknown / Inconnu

13.Donner tout détail additionnel au sujet de l'incident (p.ex. description des symptômes tels que la fréquence et la gravité, type de soins médicaux, résultats des tests médicaux, quantité de pesticide à laquelle la personne a été exposée, etc.)

The 6 workers experienced head aches and nausea which was treated was treated by providing tylenol that evening. 2 of the workers experienced redness in there eyes that lasted 2 days. The 6 people were exposed as a result of the spray drift coming into the orchard they were working in. Our workers are from Nicaragua so they were not aware that they could leave the orchard or take action. (Shame on me as a Canadian farm manager as I should have told them). They continued to work throughout the day in these conditions and only told me about how they were feeling that evening. The farmer (first and last name), had one of his employees spraying his field which is directly south of our 160 acre orchard. Our workers were in the block directly across the road from where the farmer was spraying. When they told me about the incident they said the smell was very bad, caused headaches and a nauseous feeling. They reported actually feeling a mist on their faces when working. They said the wind was very strong. I did call the farmer who owns the field and asked why he would be spraying on such a windy day. I also asked him if he could give me a list of the chemicals used in his tank mix. He did not after several calls to him and told me that any further communication would be through registered mail (whatever that means). I told him that I thought he had a responsibility to provide the chemicals used and that I was definitely going to do a lab analysis to determine the chemicals present. In addition to the fact that he continued to spray even in the presence of my workers his actions caused significant damage in our orchards because our trees were at 100% blossom.

À être déterminé par le titulaire

14. Classification selon la gravité.

15. Donner des renseignements additionnels ici.

Sous-formulaire II : Incident chez l'humain (Obligation d'utiliser un formulaire séparé pour chaque personne affectée)

1. Source de la déclaration.

Autre

2. Renseignement démographique sur la personne affectée

Sexe: Inconnu

Âge: Unknown / Inconnu

3. Énumérez tous les symptômes, au moyen des choix suivants.

Système

• Systèmes nerveux et musculaire
  • Symptôme - Mal de tête

• Système gastro-intestinal
  • Symptôme - Nausée

4. Quelle a été la durée des symptômes?

Unknown / Inconnu

5. La personne affectée a-t-elle reçu des soins médicaux? Donner les détails à la question 13.

Inconnu

6. a) Est-ce que la personne a été hospitalisée?

Inconnu

6. b) Pendant combien de temps?

Inconnu

7. Scénario d'exposition

Professionnel

8. Comment l'exposition s'est-elle produite? (cocher tout ce qui s'applique)

Dérive du pesticide à partir de la zone traitée

9.Si l'exposition s'est produite lors du traitement ou au moment du retour dans la zone traitée, de l'équipement de protection individuelle était-il porté? (cocher tout ce qui s'applique)

Inconnu

10. Voie(s) d'exposition.

Inconnu

11.Durée de l'exposition?

Unknown / Inconnu

12.Temps écoulé entre l'exposition et l'apparition des symptômes.

Unknown / Inconnu

13.Donner tout détail additionnel au sujet de l'incident (p.ex. description des symptômes tels que la fréquence et la gravité, type de soins médicaux, résultats des tests médicaux, quantité de pesticide à laquelle la personne a été exposée, etc.)

The 6 workers experienced head aches and nausea which was treated was treated by providing tylenol that evening. 2 of the workers experienced redness in there eyes that lasted 2 days. The 6 people were exposed as a result of the spray drift coming into the orchard they were working in. Our workers are from Nicaragua so they were not aware that they could leave the orchard or take action. (Shame on me as a Canadian farm manager as I should have told them). They continued to work throughout the day in these conditions and only told me about how they were feeling that evening. The farmer (first and last name), had one of his employees spraying his field which is directly south of our 160 acre orchard. Our workers were in the block directly across the road from where the farmer was spraying. When they told me about the incident they said the smell was very bad, caused headaches and a nauseous feeling. They reported actually feeling a mist on their faces when working. They said the wind was very strong. I did call the farmer who owns the field and asked why he would be spraying on such a windy day. I also asked him if he could give me a list of the chemicals used in his tank mix. He did not after several calls to him and told me that any further communication would be through registered mail (whatever that means). I told him that I thought he had a responsibility to provide the chemicals used and that I was definitely going to do a lab analysis to determine the chemicals present. In addition to the fact that he continued to spray even in the presence of my workers his actions caused significant damage in our orchards because our trees were at 100% blossom.

À être déterminé par le titulaire

14. Classification selon la gravité.

15. Donner des renseignements additionnels ici.

Sous-formulaire II : Incident chez l'humain (Obligation d'utiliser un formulaire séparé pour chaque personne affectée)

1. Source de la déclaration.

Autre

2. Renseignement démographique sur la personne affectée

Sexe: Inconnu

Âge: Unknown / Inconnu

3. Énumérez tous les symptômes, au moyen des choix suivants.

Système

• Systèmes nerveux et musculaire
  • Symptôme - Mal de tête

• Système gastro-intestinal
  • Symptôme - Nausée

4. Quelle a été la durée des symptômes?

Unknown / Inconnu

5. La personne affectée a-t-elle reçu des soins médicaux? Donner les détails à la question 13.

Inconnu

6. a) Est-ce que la personne a été hospitalisée?

Inconnu

6. b) Pendant combien de temps?

Inconnu

7. Scénario d'exposition

Professionnel

8. Comment l'exposition s'est-elle produite? (cocher tout ce qui s'applique)

Dérive du pesticide à partir de la zone traitée

9.Si l'exposition s'est produite lors du traitement ou au moment du retour dans la zone traitée, de l'équipement de protection individuelle était-il porté? (cocher tout ce qui s'applique)

Inconnu

10. Voie(s) d'exposition.

Inconnu

11.Durée de l'exposition?

Unknown / Inconnu

12.Temps écoulé entre l'exposition et l'apparition des symptômes.

Unknown / Inconnu

13.Donner tout détail additionnel au sujet de l'incident (p.ex. description des symptômes tels que la fréquence et la gravité, type de soins médicaux, résultats des tests médicaux, quantité de pesticide à laquelle la personne a été exposée, etc.)

The 6 workers experienced head aches and nausea which was treated was treated by providing tylenol that evening. 2 of the workers experienced redness in there eyes that lasted 2 days. The 6 people were exposed as a result of the spray drift coming into the orchard they were working in. Our workers are from Nicaragua so they were not aware that they could leave the orchard or take action. (Shame on me as a Canadian farm manager as I should have told them). They continued to work throughout the day in these conditions and only told me about how they were feeling that evening. The farmer (first and last name), had one of his employees spraying his field which is directly south of our 160 acre orchard. Our workers were in the block directly across the road from where the farmer was spraying. When they told me about the incident they said the smell was very bad, caused headaches and a nauseous feeling. They reported actually feeling a mist on their faces when working. They said the wind was very strong. I did call the farmer who owns the field and asked why he would be spraying on such a windy day. I also asked him if he could give me a list of the chemicals used in his tank mix. He did not after several calls to him and told me that any further communication would be through registered mail (whatever that means). I told him that I thought he had a responsibility to provide the chemicals used and that I was definitely going to do a lab analysis to determine the chemicals present. In addition to the fact that he continued to spray even in the presence of my workers his actions caused significant damage in our orchards because our trees were at 100% blossom.

À être déterminé par le titulaire

14. Classification selon la gravité.

15. Donner des renseignements additionnels ici.

Sous-formulaire II : Incident chez l'humain (Obligation d'utiliser un formulaire séparé pour chaque personne affectée)

1. Source de la déclaration.

Autre

2. Renseignement démographique sur la personne affectée

Sexe: Inconnu

Âge: Unknown / Inconnu

3. Énumérez tous les symptômes, au moyen des choix suivants.

Système

• Système gastro-intestinal
  • Symptôme - Nausée

• Systèmes nerveux et musculaire
  • Symptôme - Mal de tête

4. Quelle a été la durée des symptômes?

Unknown / Inconnu

5. La personne affectée a-t-elle reçu des soins médicaux? Donner les détails à la question 13.

Inconnu

6. a) Est-ce que la personne a été hospitalisée?

Inconnu

6. b) Pendant combien de temps?

Inconnu

7. Scénario d'exposition

Professionnel

8. Comment l'exposition s'est-elle produite? (cocher tout ce qui s'applique)

Dérive du pesticide à partir de la zone traitée

9.Si l'exposition s'est produite lors du traitement ou au moment du retour dans la zone traitée, de l'équipement de protection individuelle était-il porté? (cocher tout ce qui s'applique)

Inconnu

10. Voie(s) d'exposition.

Inconnu

11.Durée de l'exposition?

Unknown / Inconnu

12.Temps écoulé entre l'exposition et l'apparition des symptômes.

Unknown / Inconnu

13.Donner tout détail additionnel au sujet de l'incident (p.ex. description des symptômes tels que la fréquence et la gravité, type de soins médicaux, résultats des tests médicaux, quantité de pesticide à laquelle la personne a été exposée, etc.)

The 6 workers experienced head aches and nausea which was treated was treated by providing tylenol that evening. 2 of the workers experienced redness in there eyes that lasted 2 days. The 6 people were exposed as a result of the spray drift coming into the orchard they were working in. Our workers are from Nicaragua so they were not aware that they could leave the orchard or take action. (Shame on me as a Canadian farm manager as I should have told them). They continued to work throughout the day in these conditions and only told me about how they were feeling that evening. The farmer (first and last name), had one of his employees spraying his field which is directly south of our 160 acre orchard. Our workers were in the block directly across the road from where the farmer was spraying. When they told me about the incident they said the smell was very bad, caused headaches and a nauseous feeling. They reported actually feeling a mist on their faces when working. They said the wind was very strong. I did call the farmer who owns the field and asked why he would be spraying on such a windy day. I also asked him if he could give me a list of the chemicals used in his tank mix. He did not after several calls to him and told me that any further communication would be through registered mail (whatever that means). I told him that I thought he had a responsibility to provide the chemicals used and that I was definitely going to do a lab analysis to determine the chemicals present. In addition to the fact that he continued to spray even in the presence of my workers his actions caused significant damage in our orchards because our trees were at 100% blossom.

À être déterminé par le titulaire

14. Classification selon la gravité.

15. Donner des renseignements additionnels ici.

Sous-formulaire II : Incident chez l'humain (Obligation d'utiliser un formulaire séparé pour chaque personne affectée)

1. Source de la déclaration.

Autre

2. Renseignement démographique sur la personne affectée

Sexe: Inconnu

Âge: Unknown / Inconnu

3. Énumérez tous les symptômes, au moyen des choix suivants.

Système

• Système gastro-intestinal
  • Symptôme - Nausée

• Systèmes nerveux et musculaire
  • Symptôme - Mal de tête

4. Quelle a été la durée des symptômes?

Unknown / Inconnu

5. La personne affectée a-t-elle reçu des soins médicaux? Donner les détails à la question 13.

Inconnu

6. a) Est-ce que la personne a été hospitalisée?

Inconnu

6. b) Pendant combien de temps?

Inconnu

7. Scénario d'exposition

Professionnel

8. Comment l'exposition s'est-elle produite? (cocher tout ce qui s'applique)

Dérive du pesticide à partir de la zone traitée

9.Si l'exposition s'est produite lors du traitement ou au moment du retour dans la zone traitée, de l'équipement de protection individuelle était-il porté? (cocher tout ce qui s'applique)

Inconnu

10. Voie(s) d'exposition.

Inconnu

11.Durée de l'exposition?

Unknown / Inconnu

12.Temps écoulé entre l'exposition et l'apparition des symptômes.

Unknown / Inconnu

13.Donner tout détail additionnel au sujet de l'incident (p.ex. description des symptômes tels que la fréquence et la gravité, type de soins médicaux, résultats des tests médicaux, quantité de pesticide à laquelle la personne a été exposée, etc.)

The 6 workers experienced head aches and nausea which was treated was treated by providing tylenol that evening. 2 of the workers experienced redness in there eyes that lasted 2 days. The 6 people were exposed as a result of the spray drift coming into the orchard they were working in. Our workers are from Nicaragua so they were not aware that they could leave the orchard or take action. (Shame on me as a Canadian farm manager as I should have told them). They continued to work throughout the day in these conditions and only told me about how they were feeling that evening. The farmer (first and last name), had one of his employees spraying his field which is directly south of our 160 acre orchard. Our workers were in the block directly across the road from where the farmer was spraying. When they told me about the incident they said the smell was very bad, caused headaches and a nauseous feeling. They reported actually feeling a mist on their faces when working. They said the wind was very strong. I did call the farmer who owns the field and asked why he would be spraying on such a windy day. I also asked him if he could give me a list of the chemicals used in his tank mix. He did not after several calls to him and told me that any further communication would be through registered mail (whatever that means). I told him that I thought he had a responsibility to provide the chemicals used and that I was definitely going to do a lab analysis to determine the chemicals present. In addition to the fact that he continued to spray even in the presence of my workers his actions caused significant damage in our orchards because our trees were at 100% blossom.

À être déterminé par le titulaire

14. Classification selon la gravité.

15. Donner des renseignements additionnels ici.