Voluntary Incident Report

Form load failed - JavaScript required

The form requires JavaScript to be enabled to function properly. Please enable JavaScript and reload the page.

Privacy notice statement

Security notice: Up to Protected B only

This site is not approved by HC/PHAC for storage above Protected B information. Only up to Protected B information may be stored on this site.

Instructions

Mandatory Pesticide Incident Reporting (Registrants and Applicants)

In accordance with the Pest Control Products Incident Reporting Regulations, pesticide registrants and applicants are required to report to the Pest Management Regulatory Agency (PMRA) all incidents associated with their products.

If you are submitting a Mandatory Pesticide Incident Report, please use Mandatory Pesticide Incident Reporting form for Registrants and Applicants.

Complaint and Violation Report Form

If you are submitting a suspected violation related to pest control products, please use Complaint and Violation Report Form.

Note:

Complete a separate form for each incident.
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 include more information in an attachment.

Instruction 1

Reporter

The person identified on the form will be the one who is submitting an incident report. The reporter may be the person who experienced the incident or an Animal Owner or a Medical / Veterinary Professional or a witness or others. If you select "Other", you must specify what type of reporter you are. Please provide your information, such as, first name, last name, address, telephone number, e-mail address etc.

Return to instruction 1 referrer

Instruction 2

Product

Identify the product name or active ingredients or pesticide registration number.

Return to instruction 2 referrer

Instruction 3

Incident

The reporter must identify the type of incident being reported, for example, Domestic Animal or Human Health or Environment, incident location and date the incident occurred.

Describe the symptoms and incident in detail. For example,

how was the person / animal /environment was exposed to the pesticide;
amount of pesticide the person / animal /environment was exposed to;
symptoms observed, length of time the symptom(s) lasted, severity of the symptom(s), such as life-threatening, hospitalization, death etc.;
medical treatment received, including medication prescribed;
Outcome of the incident.

If there is not enough space provided for you to answer the question, you may include more information in an attachment. Do not include information in the report form that could lead to the identification of an individual.

Provide, if the incident has been reported to the manufacturer of the pesticide product.

Return to instruction 3 referrer

Instruction 4

Attachments

Attach any files you wish to include with the online form.

Return to instruction 4 referrer

1. Reporter^{Instruction 1}

Who is reporting this incident?

Other type of reporter (required)

First name

Last name

Address

City

Country

Other country (required)

Province

State

Region

Postal code / Zip

Telephone (including area code)

Telephone (including country code)

Email address (required)

Confirm your email address (required)

2. Product^{Instruction 2}

Product information (required)

Registration number (digits only) (required)

Product name (required)

Active ingredients (maximum of 500 characters) (required)
{{500-product.activeIngredients.length}}

3. Incident^{Instruction 3}

Incident location

City / Municipality

Province

Type of incident reported (required)

Incident details

Date incident occurred (YYYY-MM-DD)

Has this incident been reported to the manufacturer?

Date incident reported to manufacturer (YYYY-MM-DD)

Age

Gender

Type of animal affected (choose one per form)

Other type of animal affected (required)

Number of animals

Number of animals or plants affected (estimate)

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

What was exposed?

Describe all symptoms in detail (maximum of 2,000 characters) (required)
{{2000-incident.symptomsInDetail.length}}

Describe the incident in detail (maximum of 2,000 characters) (required)
{{2000-incident.incidentInDetail.length}}

4. Attachments^{Instruction 4}

Note: There is a known issue with Internet Explorer that may impact your ability to upload attachments. If you experience any difficulties in uploading attachments, please try one of the following:

Use another browser,
Close and restart Internet Explorer, or
Restart your computer.

Add any additional attachments you wish to include in the online form.

I have read, understood and agree with the Privacy notice statement (required)Privacy notice statement

I have read, understood and agree with the Security notice (required)Security notice