Environmental Incident

To submit form, send to

Mailing address:
Health Canada
Pest Management Regulatory Agency
2720 Riverside Drive
Ottawa, Ontario
A.L. 6606D2
K1A 0K9
Attention: Pesticide Incident Reporting Program

Phone: 1-800-267-6315 within Canada
1-613-736-3799 outside of Canada (Long distance charges apply)

Instructions

• It is important to provide as much information as possible. The more information collected, the better understanding the Pest Management Regulatory Agency (PMRA) will have of the incident.
• Do not include information in the report form that could lead to the identification of an individual. Examples include doctor's names, hospital names, etc. This information will not be added to our records.
• If there is not enough space provided for you to answer the question, you may attach a separate sheet with the text on it.

How will the information you are about to report be used by the PMRA?

Pesticides are tested and evaluated for environmental and health risks before they are registered by the PMRA. However, some adverse effects may not become evident until the product is used under "real-life" circumstances. The information you are about to report will provide the PMRA with valuable data regarding potential risks to humans from the use of pesticides in "real-life" circumstances.

Information provided by the public and by professionals is added to the PMRA database on pesticides. The database will be regularly searched for any type of pattern related to a specific pesticide. If the result of a search indicates that there is a trend, such as multiple incidents for a particular pesticide, the PMRA will evaluate the information in conjunction with scientific literature. If evaluation of this information identifies a safety issue, appropriate action will be taken. Such action could range from minor label changes to discontinuation of the product.

In order for the information you provide to be useful, it is necessary to be as specific as possible, particularly with regards to the type of pesticide and the effect(s) experienced.

Environmental Incident

Use a separate form for each type of organism affected (see Question 6)

1. Did you observe this incident first hand?

• Yes
• No

Help
If someone else told you about it, check 'No'

2. Provide location where the incident occurred.

• Municipality/township/county:
• Province:

3. Date incident occurred (dd/mm/yyyy):

4. If known, provide the product registration number and product name of the pesticide, both of which are on the product label. If not known, list the active ingredients.

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Registration number examples:

• Registration No. 23756 Pest Control Products Act
• REG. NO. 55555 P.C.P ACT

Product name example:

• Weed Be Gone

Active ingredient example:

• glyphosate

5. If known, describe the application of the pesticide. Information could include:

• application rate;
• site or crop pesticide was applied to; and
• method of application.

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Application rate examples:

• 10L of pesticide
• 12 g ai/ha

Site examples:

• corn
• strawberries
• wood lot
• apple orchard

Method of application examples:

• aerial
• groundboom
• air blast sprayer

6. What type of organism was affected? (Please complete a separate form for each type.)

• Bird
• Fish
• Mammal
• Reptile
• Plant
• Tree
• Other (describe):

Name of animals or plants affected (if known):
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Examples of names:

• Lilac bush
• Canada Goose
• Trout

7. Total number of animals or plants affected (estimate if not counted).

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For plants, indicate if the entire plant was affected or a portion of it. Estimate the percentage of plant(s) affected.

8. What symptoms or effects were observed?

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Examples of symptoms or effects:

• death
• twitching
• discolouration of leaves
• wilting

9. What happened to the animal(s) or plant(s) after the initial observation (i.e., what was the final outcome of the incident)?

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Examples of outcomes:

• full recovery
• affected reproduction
• permanent plant damage
• death

10. Where was/were the animal(s) or plant(s) found?

• Land
• Fresh water
• Salt water

11. Were environmental samples collected and analysed?

• Yes
• No
• Unknown

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Environmental samples can include animals, water, sediment, etc.
It is beneficial to submit all analytical results.

12. Has this incident been reported to the manufacturer?

• Yes
• No
• Unknown

If so, when was it reported (dd/mm/yyyy)?
What was the name of the manufacturer? Help
The name, address and telephone number of the manufacturer can be found on the pesticide label.

13. Additional information can be provided in the space below, including any analytical results.

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Important: do not include personal information such as names or addresses. (see Confidentiality Statement)
Analytical results = chemical or residue analysis of animals that died; water; soil; plant material; etc.
Include any information that would be considered important in the review of this incident.

Confidentiality Statement: Any information related to the identity of persons will be protected as per the Privacy Act. Any unsolicited personal information will be destroyed.