Pesticide Incident Reporting Form for the Public - Human Health Incident

Privacy Notice Statement

Health Canada

Collection and use of personal information in this application is in accordance with the federal Privacy Act.

The personal information you provide is collected under the authority of section 3(1)(a) of the Pest Control Products Incident Reporting Regulations for the purpose of internal reporting. The personal information and its use are described in Info Source under the Personal Information Bank (PIB) Pesticide Incident Reporting – HC PPU 315.

The Privacy Act gives you the rights of access to, correction of and protection of your personal information. For further information about this Privacy statement please contact Health Canada’s Access to Information and Privacy Coordinator by email at atip-aiprp@hc-sc.gc.ca.

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.

Help

Complete a separate form for each person affected.


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

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Help 5

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

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Help 7

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.

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Help 8

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 readyto- 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.

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Help 10

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

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Help 11

IMPORTANT: do not include personal information such as names or addresses. (see Privacy Notice Statement)

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Form


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


2. Who is reporting this incident?





Instruction 4
Instruction 5
6. Age/Gender: (see Privacy Notice Statement)
Instruction 7
Instruction 8
9. What was exposed?




10. Has this incident been reported to the manufacturer? Instruction 10


Instruction 11
Privacy Notice Statement

PMRA/ARLA 7009 (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.