Pesticide Incident Reporting Form for the Public - Domestic Animal Incident

Table of Contents

To submit form, send to: pmra_infoserv@hc-sc.gc.ca

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, domestic animals or the environment from the use of pesticides under “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.

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.

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.


Help

Use a separate form for each animal affected. If an incident involves multiple animals of the same type with the same symptoms, a single form can be used (see Question 6)


Help 4

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

Return to help 4 referrer

Help 5

Application rate examples:

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

Site examples:

  • living room carpet
  • dog
  • front lawn
  • strawberries

Method of application examples:

  • spot-on treatment
  • flea shampoo
  • hose-end sprayer
  • bait station
  • aerosol

Return to help 5 referrer

Help 6

Examples of breeds:

  • golden retriever
  • siamese
  • mixed
  • parrot

Return to help 6 referrer

Help 7

Examples:

  • Lethargy that lasted for 3 days. Dog was taken to a veterinarian and medication Y was prescribed.
  • Vomiting approximately every hour for 5 hours. Called the poison control centre; no treatment was recommended.
  • Tremors for 3 hours

Return to help 7 referrer

Help 8

Examples

  • Dog was treated with pesticide (e.g. flea collar, spot-on treatment)
  • Cat was not treated, but licked dog that had been treated for fleas.
  • Dog ate 3 ant traps.
  • Children accidentally sprayed cat in the face with bear spray.

Return to help 8 referrer

Help 11

The name, address and telephone number of the manufacturer can be found on the pesticide label.

Return to help 11 referrer

Help 12

IMPORTANT: do not include personal information such as names or addresses.

(See Confidentiality Statement)

Return to help 12 referrer


Form


1. Provide location where the incident occurred.


2. Who is reporting this incident?




Help 4
Help 5
6. What type of animal was affected? (Choose only one per form) Help 6










Help 7
9. What was exposed?





10. What was the outcome of the incident?




11. Has this incident been reported to the manufacturer? Help 11


Help 12

PMRA/ARLA 7007 (May 2008)


Definitions - Pesticide Incident Reporting for the Public

Active ingredient

The ingredient in a pesticide that is responsible for the intended effects of the product.

Adverse effect

A detrimental effect that relates to the health or environmental risks of a pesticide.

Application

The act of applying the pesticide on its intended site.

Bait station

A method of pesticide application. Bait treated with a pesticide that is placed in a container. Access is restricted to target pests (e.g. rodents).

Crop

A cultivated plant.

Domestic animal

An animal that is under the control of humans and is dependent on them for its survival. It includes pets and livestock.

Exposure

Contact with a source of a pesticide in such a manner that effective transmission of the pesticide occurs.

Incident

An event that occurs where an adverse effect is observed, and relates to humans, domestic animals or the environment.

Label

A “label” includes any legend, word or symbol that conveys information and is attached to, included in, or accompanying a pesticide. All pesticides offered for sale in Canada must bear the approved label.

Method of application

The way in which the pesticide is applied to the site.

Organism

An individual animal, plant, or single-celled life form.

Personal information

Any information that can be used alone, or in conjunction with other information, to identify a person.

Pesticide

A pest control product. Any product, device, organism or substance that is manufactured, represented, sold or used as a means for directly or indirectly controlling, preventing, destroying, mitigating, attracting or repelling a pest.

Registration number

A four or five digit number assigned to each registered pesticide by the PMRA. All pesticides must be registered and be issued a registration number before being permitted for sale, import or use in Canada. May be listed on the pesticide label as “REG. NO. ####”, “Registration No. ####”, or “Registration Number ####”.

Route of exposure

The manner in which a person, animal or the environment comes into contact with a pesticide. It is the pathway taken by the pesticide.

Site

The location, area, structure, object or organism that a pesticide may be applied to.