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Sécurité des produits de consommation

Déclaration d'incident

Sous-formulaire I: Renseignements généraux

1.Type de rapport.

Nouvelle déclaration d'incident

No de la demande: 2017-0456

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.



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 29752      ARLA No de la demande d'homologation       EPA No d'homologation.


  • Matière active

7. b) Type de formulation.

Renseignments sur l'application

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


9. Dose d'application.


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

Site: Pub. Area - Outdoor/Zone publique - ext

Specify Type: Roadside

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

This past year, for the first time in 26 years, the municipal government voted to apply herbicides along its roadsides to control weeds. They used the herbicide Clearview with the surfactant Gateway. The municipal government granted me a 20 km buffer zone. The Clearview herbicide application near the buffer zone was a one day application only and it took place on Wednesday, June 15th. The application was East and Southeast of our home, with the majority being in the southeast direction. The Clearview application was a width of ten feet of spraying on both sides of the road and the full length of the road, except where there was water or a No Spray sign.The road supervisor notified me when they applied Clearview near the buffer zone; and I immediately went under house arrest. This means that I will no longer go outdoors until the weather turns cold and the pesticide can no longer vapourize. I will only go outdoors when the outside air quality has returned to being good and it is free from pesticide vapour. The wind direction and the wind speed are continually monitored, from the time of application till the weather turns cold in the fall. Also, the doors and windows are kept closed at all times - except for the times someone is entering or exiting the home. An intercom system is set up at the door, and no one opens the door until I am away from the door and in another room. The air purifiers are turned on and will run continuously 24/7 until the weather turns cold. Implementing the strict protocol mentioned above.

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?


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

1. Source de la déclaration.

Personne affectée

2. Renseignement démographique sur la personne affectée

Sexe: Femme

Âge: >19 <=64 yrs / >19 <=64 ans

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


  • Système gastro-intestinal
    • Symptôme - Nausée
    • Symptôme - Vomit
  • Systèmes nerveux et musculaire
    • Symptôme - Faiblesse musculaire
    • Specify - all muscles in the entire leg on both legs and all muscles in the entire in both arms
    • Symptôme - Spasme musculaire
    • Symptôme - Douleur musculaire
  • General
    • Symptôme - Douleur aux articulations
  • Systèmes nerveux et musculaire
    • Symptôme - Mal de tête
    • Symptôme - Étourdissement
  • General
    • Symptôme - Sensation de faiblesse
  • Systèmes nerveux et musculaire
    • Symptôme - Difficulté de marcher
    • Symptôme - Difficulté de concentration
    • Specify - Reduced cognitive function
    • Symptôme - Difficulté d'élocution
    • Specify - Reduced speech ability
  • Système gastro-intestinal
    • Symptôme - Incontinence fécale
    • Specify - Bowel control problems
  • Systèmes nerveux et musculaire
    • Symptôme - Autre
    • Specify - Loss of range of motion in both my legs and arms
  • Sang
    • Symptôme - Hypoglycémie
    • Specify - Low blood sugar
  • General
    • Symptôme - Autre
    • Specify - Difficulty standing

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.


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


6. b) Pendant combien de temps?

7. Scénario d'exposition

Non 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)


10. Voie(s) d'exposition.


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.)

From Wednesday to Friday, the wind directions fluctuated a lot, but there were times that the wind was coming from either the East or the South East. Some of my toxic reactions came on me suddenly and others began very subtly and very gradually. Over the few days from Wednesday to about Sunday, very slowly I gradually lost some muscle strength in all my extremities (all muscles in the entire leg on both legs and all muscles in the entire arm in both arms). By Saturday morning, I was beginning to lose range of motion in both my legs and arms, and I was experiencing muscle spasms and increased muscle pain. Standing and walking became increasingly difficult - primarily due to the muscles becoming too weak to carry my weight. Early afternoon on Friday, I suddenly became very dizzy, lightheaded and nauseous, and I vomited shortly after the onset. Although the vomiting ended, the nausea and lightheadedness persisted for the remainder of the day; and I continued to experience the nausea and dizziness periodically over the following week. Headaches and low blood sugar levels were other symptoms that I periodically experienced. Thankfully, by Sunday evening my body started showing indications of pulling out of the toxic reaction and recovering. It took me about 8 days to pull out of the reaction. Since the afternoon of Friday, June 17th, the wind has only very rarely been from the E or SE, and that has only been for very brief periods of time at a low speed. Therefore so far, I haven't noticed any negative effects from these brief periods. Consequently, my body has had an opportunity for the recovery process. The gastrointestinal reaction, although very unpleasant, was expected as I had learned that both the main ingredients in Clearview can effect the gastrointestinal system. However, reacting neurologically took me quite by surprise. I was not anticipating the neuro-muscular reactions. Since we are now at the end of August, I thought I would give you a bit of an update and let you know how the Clearview herbicide has affected me over the last two months. Thankfully, this summer the wind has primarily been westerly and my toxic reactions have been few. The first reaction to Clearview, as it began to degrade and release toxic gases, was in early July. That reaction was almost identical to my reaction to the initial application of Clearview. However, this time, the gastrointestinal symptoms were the most prominent. Also, I was in and out of the reaction in only 4 days. All my reactions since then have been primarily gastrointestinal, with almost no neuro-muscular reaction. Also the reactions are becoming less severe and shorter in duration. Now, at the end of August, a reaction might last half a day or a few hours. So they have substantially diminished over the course of the summer.This association has become deeply imbedded in my mind, as my toxic reactions have been confirmed each time with verification of exposure to Clearview by checking the wind direction and wind speed over the previous 24 hours. Thankfully, both the duration and severity is getting less and less. What I anticipated would happen in the fall, is exactly what did happen. It was more of the same - dizziness, nausea, vomiting and bowel urgency - with a continuing diminishing of the duration and the severity. The cold weather did stop the toxic vapour from being released, and then the air quality did improve. At that point, any danger to my health was over.

À être déterminé par le titulaire

14. Classification selon la gravité.

15. Donner des renseignements additionnels ici.