Human Health 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.

Human Health Incident

Complete a separate form for each person affected

1. Provide location where the incident occurred (see Confidentiality Statement).

• City / Locality:
• Province:

2. Who is reporting this incident?

• The person who experienced the incident
• Medical professional
• Witness
• Other (describe)

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.

Help
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. Include the amount of pesticide applied (application rate), the site that the pesticide was applied to and the method of application.

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Application rate examples:

• 10 ml of pesticide
• 1 10 oz can
• 1 cc of pesticide
• 12 g ai/ha

Site examples:

• living room carpet
• dog
• front lawn
• strawberries
• wheat field

Method of application examples:

• hose-end sprayer
• bait station
• aerosol
• groundboom
• aerial

6. Age: (see Confidentiality Statement)
Gender:

7. Describe all symptoms. Include the length of time the symptom(s) lasted, the severity of the symptom(s), and how often the symptom(s) occurred. Also describe any medical treatment received, including medication prescribed, test results and length of hospitalization (if applicable).

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Examples:

• Severe headache that lasted for 2 days.
• Rash on forearms and hands that lasted 1 week. Saw doctor 2 days after incident and was given a prescription for medication X.
• Vomited 3 times, approximately every 2 hours.
• Burning eyes. Called the poison control centre and was instructed to flush eyes with water for 10 minutes. Eyes remained red and irritated for approximately 3 days.

8. How was the person exposed to the pesticide? Include, if available, the amount of the pesticide the person was exposed to, and how long or how often the person was exposed to it.

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Examples:

• A child accidentally set off an insect fogger stored on bathroom shelf and was exposed to the mist for about 1 min.
• Picked up a ready-to-use spray bottle to spray his lawn and inadvertently sprayed himself in the eyes.
• The person mowed his lawn 30 minutes after it was sprayed with pesticide. His running shoes were soaking wet.

9. What was exposed?

• Skin
• Eye
• Oral
• Respiratory (breathing)
• Unknown

10. 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?
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The name, address and telephone number of the manufacturer is listed on the label.

11. Additional information can be provided in the space below, or on a separate sheet.

Help
Important: do not include personal information such as names or addresses. (see Confidentiality Statement)

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.