Packaging Failure 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.

Packaging Failure Incident

Complete a separate form for each packaging failure incident if the incident is related to a different pesticide.

1. Provide location where the incident occurred:

• City / Locality:
• Province:

2. Did you observe this incident first hand?

• Yes
• No

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

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. What is the type of packaging that failed?

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Examples:

• Glass bottle
• Plastic jug
• Hose-end sprayer
• Pressurized product
• Water soluble

6. When did the packaging failure occur? During the:

• Use of Product
• Storage
• Transportation
• Other (describe):

7. Were environmental samples collected and analysed?

• 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 pesticide label.

8. Describe how the packaging failed, as well as any additional information concerning the incident.

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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.