Guidance to designated national authorities on the operation of the Rotterdam Convention

Annex 7.5.3 Severely Hazardous Pesticide Formulation Report Forms – Human Health Incidents

Annex 7.5.4 Severely Hazardous Pesticide Formulation Report Forms – Environmental Incidents

Secretariat for the Rotterdam Convention on the Prior Informed Consent Procedure for Certain Hazardous Chemicals and Pesticides in International Trade

Introduction to the Severely Hazardous Pesticide Formulation Report Form - Human Health Incidents

The severely hazardous pesticide formulation report form consists of three sections:

Introduction, the text is intended to provide relevant background information on the Rotterdam Convention and how the information collected by the form and submitted by the Designated National Authority will be used.

Part A is to be completed by the Designated National Authority once he/she receives Part B from the field. It reflects the information requirements of part 1 of Annex IV of the Convention. There is some redundancy between Parts A and B of the form particularly with respect to information on product identity. It was thought that this redundancy might help countries to consolidate responses by using Part A of the form to report on more than one incident for the same formulation.

Part B is designed to provide “a clear description of the incidents related to the problem, including the adverse effects and the way in which the formulation was used” (part 1 paragraph g of Annex IV of the Convention). The form has been constructed around these points. It consists of a series of closed questions or checklist that captures the basic information needed with options for including additional information where it is available.

SEVERELY HAZARDOUS PESTICIDE FORMULATION REPORT FORM – HUMAN HEALTH INCIDENTS

Purpose of this form

The Severely Hazardous Pesticide Formulation (SHPF) Report form was developed to facilitate the identification of candidate formulations for inclusion in the Rotterdam Convention. The Convention provides a mechanism for countries to decide whether or not they wish to receive future shipments of such pesticide formulations and for ensuring compliance with these decisions by exporting countries.

What is the Rotterdam Convention?

The Rotterdam Convention on the Prior Informed Consent (PIC) Procedure for Certain Hazardous Chemicals and Pesticides in International Trade promotes a shared responsibility between importing and exporting Parties in the international trade of certain hazardous chemicals. It gives importing countries the power to decide which chemicals they want to receive and to exclude those they cannot manage safely. The Convention includes provisions for developing countries and countries with economy in transition, that are experiencing problems with severely hazardous pesticide formulations under conditions of use, to identify the formulations as candidates for inclusion in the Convention. Further information on the operation of the Rotterdam Convention may be found at www.pic.int

What is the severely hazardous pesticide formulation report form?

This form consists of two parts Part A and Part B. Part A (Transmittal Form) is to be used by the Designated National Authority (DNA) to transmit an incident report form to the Secretariat. Part B (Pesticide Incident Report Form) has been developed to collect the information required by the Convention, that is a clear description of the incidents related to the use of a severely hazardous pesticide formulation, including the adverse effects and the way in which the formulation was used. Part B of the form consists of a series of closed questions or checklist that captures the basic information needed with options for including additional information where it is available. It is fully compatible with programs collecting quantitative information on pesticide poisonings in support of epidemiological studies or national programmes concerning the reporting of adverse effects associated with pesticide use. The format has been developed so that it might be widely used by States, aid agencies, intergovernmental organizations and non-governmental organizations etc., in reporting on pesticide incidents. If there are other formats available that meet the information requirements of Parts 1 and 3, Annex IV of the Convention, they may also be used in preparing a submission and forwarded through the DNA to the Secretariat together with Part A of the SHPF form. There is some redundancy between Parts A and B of this form. It was thought that this might help countries to consolidate responses by using Part A of the form to report on more than one incident for the same formulation.

What happens to the completed form?

Once Part B- Incident report form has been completed to the extent possible based on the information available, it should be forwarded to the DNA. The DNA is to coordinate the completion of Part A- Transmittal form and forward the entire document to the Secretariat. The Secretariat is required to collect additional information including physico-chemical and toxicological properties of the pesticide formulation, information on incidents related to the formulation in other States, the existence of handling or applicator restrictions in other states and risk and/or hazard evaluations where available. This information along with the completed form is reviewed by the Chemical Review Committee (CRC). The CRC will decide whether or not to recommend the inclusion of the pesticide formulation in the Rotterdam Convention.

Your cooperation in completing this form and your contribution for the identification of severely hazardous pesticide formulations posing problems under conditions of use is greatly appreciated. If you have any questions or comments relating to the completion of this form please contact the Secretariat at the address below.

Secretariat for the Rotterdam Convention
Plant Protection Service
Plant Production and Protection Division,
FAO
Viale delle Terme di Caracalla
00100 Rome, Italy
Tel: (+39 06) 5705 3441
Fax: (+39 06) 5705 6347
E-mail: [email protected]

Secretariat for the Rotterdam Convention
UNEP Chemicals
11-13, Chemin des Anémones
CH – 1219 Châtelaine, Geneva, Switzerland
Tel: (+41 22) 917 8183
Fax: (+41 22) 797 3460
E-mail: [email protected]

PART A – TRANSMITTAL FORM – DESIGNATED NATIONAL AUTHORITY

INFORMATION REQUIRED FROM A DESIGNATED NATIONAL AUTHORITY

1	Name of the formulation:........................................................................................................
2	Type of formulation: (for example EC, WP, DP, GR, TB)........................................................
3	Trade name and name of producer, if available:.....................................................................
4	Name of the active ingredient or ingredients in the formulation:.......................................................
5	Relative amount of each active ingredient in the formulation:.........................(% concentration).....
6	Attach copy of the label(s), if available (or describe the key aspects of the label: language, etc.)....
7	Common and recognized patterns of use of the formulation within the country – the formulation is registered / permitted for use in the country? what uses are permitted? are there any handling or applicator restrictions specified as a condition of registration; information on the extent of use of the formulation, such as the number of registrations or production or sales quantity (indicate the source of information); other information on how the formulation is commonly/typically used in the country
	(this information should be submitted on a separate sheet attached to the completed form)
8	A clear description of incidents(s) related to the problem, including adverse effects and the way in which the formulation was used (for example Part B pesticide incident report form identifies key elements and appropriate level of detail). Other report formats which may exist at the national level may also be used, provided they contain comparable information.
9	Any regulatory, administrative or other measure taken, or intended to be taken, by the proposing Party in response to such incidents.

Date, signature of DNA and official seal.......................................................................................

PLEASE RETURN THE COMPLETED FORM TO:

PART B - PESTICIDE INCIDENT REPORT FORM

This form should be completed for each individual exposed in a given incident - Where an incident involves more than one formulation please complete Section I and question 13 for each.

I. PRODUCT IDENTITY: What formulation was used when the incident took place.
1.	Name of the formulation:.....................................................................................................
2.	Type of formulation (check one of the following)

Emulsifiable Conc. (EC)	Wettable Powder (WP)	Dustable powder (DP)
Water Soluble Powder (SP)	Ultra Low Volume (ULV)	Tablet (TB)
Granular (GR)	other, please specify:

3.	Trade name and name of producer, if available:............................................
4.	Name of the active ingredient(s) in the formulation:......................................
5.	Relative amount of each active ingredient in the formulation:....................... (% concentration, g/l, etc.)
6.	Attach copy of the label(s), if available.

II. DESCRIPTION OF THE INCIDENT: How the formulation was used.

Date of incident: (MM/DD/Year).................................................................................

Location of incident:

village/city:...............................................................................................

province/state/region:................................................................................

country:....................................................................................................

Person exposed (identity should be checked and recorded before submission of the form)

Sex:

male

female

age:

If age unknown:

child (<14yrs)

adolescent (14-19 yrs)

adult (>19yrs)

10.

Main activity at time of exposure (check one or more of the following):

application in field

mixing/loading

veterinary therapy

household application

vector control application

human therapy

re-entry to treated field

other, please specify:.......................................................

Was protective clothing used during application?

Yes

If no, please explain why:................................................................................................

If yes, briefly describe (check one or more of the following):

gloves

overalls

eye glasses

respirator

face mask

boots/shoes

long-sleeve shirt

long pants

other, please specify:..................

12.

Information on how product was being used:

(a) Location of exposure/incident (field, garden, greenhouse, house, etc.)...............................

(b) List the animals/crop(s)/stored products treated if relevant:................................................

(c) Application method: (How product was used e.g. hand, bucket & brush, soil injection, spray (backpack, tractor mounted, etc), drip irrigation, aerial (helicopter, plane etc.)):

d) Dose applied/concentration (or amount of pesticide applied).............................................

(e) Duration of the exposure period:

hours

½ day

day

other (specify):...............................................................

13.

If more than one pesticide formulation was used at the same time, please respond to
points i) to iv) below for each formulation. (see also Part I Product Identity)

i) Was the pesticide in its original container?

Yes

ii) Was the label available?

Yes

If Yes, was exposed individual able to read and understand label?

Yes

iii) Does the label include the reported use?

Yes

If no, describe how the use reported above differs from that recommended on the label:
(use a separate page if necessary)

iv) Is the reported incident typical of how the formulation is generally used?

Yes

14.

Climatic conditions under which the incident occurred
(e.g. temperature, relative humidity,...):
................................................................................................................................................

15.

Were other individuals affected in the same incident?

Yes

16.

Include any other details that may be useful in describing the incident and the way in which the formulation was used, in particular how the use reported here reflects common or recognized use patterns for this formulation (additional pages may be attached).

III. DESCRIPTION OF ADVERSE EFFECTS:

17.

Individual’s reaction (check one or more of the following):

dizziness

headache

blurred vision

excessive sweating

hand tremor

convulsion

staggering

narrow pupils/miosis

excessive salivation

nausea/vomiting

other, please specify:

death

18.

Route of exposure (check main route or more than one if applicable)

mouth

skin

eyes

inhalation

other, please specify:............................................................................................

19.

How soon after last use of the formulation were the adverse effects observed:

IV. MANAGEMENT:

20.

Treatment given

Yes

Unknown

Hospitalization:

Yes

Unknown

21.

Include any other details/information regarding treatment including medical intervention/first aid/hospitalization/local practices etc., (additional pages may be attached):

	medical		paramedical		non-medical
	If non-medical, then specify type of person (applicator, formulator, vendor, extension worker, manager, etc.): ................................................................................................................................................

25.	Contact if further information if needed:	Tel:.....................................................................
	Fax:...........................................................	E-mail:................................................................
26.	Has this incident been reported elsewhere?	No	Yes
	If yes, where:.....................

Send the completed incident report form to the Designated National Authority.
(Name and address of the DNA)

V. REPORTING/COMMUNICATION:

Date of data collection/consultation:.......................................................................................

Name and address of investigator/data collector:...................................................................

Category of investigator/data collector:

Secretariat for the Rotterdam Convention on the Prior Informed Consent Procedure for Certain Hazardous Chemicals and Pesticides in International Trade

Introduction to the Severely Hazardous Pesticide Formulation Report Form – Environmental Incidents

The severely hazardous pesticide formulation report form consists of three sections:

Part B can be completed by any competent person. It is designed to provide “a clear description of the incidents related to the problem, including the adverse effects and the way in which the formulation was used” (part 1 paragraph g of Annex IV of the Convention). The form has been constructed around these points. It consists of a series of closed questions or checklist that captures the basic information needed with options for including additional information where it is available.

SEVERELY HAZARDOUS PESTICIDE FORMULATION REPORT FORM - ENVIRONMENTAL INCIDENTS

INTRODUCTION

Purpose of this form

The Severely Hazardous Pesticide Formulation (SHPF) Report Form - Environmental Incident Report Form - was developed to facilitate the identification of candidate formulations with environmental concerns for inclusion in the Rotterdam Convention. A similar form was developed for reporting health incidents. The Convention provides a mechanism for countries to decide whether or not they wish to receive future shipments of such pesticide formulations and for ensuring compliance with these decisions by exporting countries.

What is the Rotterdam Convention?

The Rotterdam Convention on the Prior Informed Consent (PIC) Procedure for Certain Hazardous Chemicals and Pesticides in International Trade promotes a shared responsibility between importing and exporting Parties in the international trade of certain hazardous chemicals. It gives importing countries the power to decide which chemicals they want to receive and to exclude those they cannot manage safely. The Convention includes provisions for developing countries and countries with economy in transition, that are experiencing health or environmental problems with severely hazardous pesticide formulations under conditions of use, to identify such formulations as candidates for inclusion in the Convention. Further information on the operation of the Rotterdam Convention may be found at www.pic.int.

What is the severely hazardous pesticide formulation report form?

The form consists of two parts: – the Transmittal Form (Part A) – is to be used by the Designated National Authority (DNA) to transmit the Environmental Incident Report Form (Part B – EIRF) to the Secretariat. The Environmental Incident Report Form has been developed to meet the information requirements of the Convention, that is a clear description of the environmental incidents related to the use of a severely hazardous pesticide formulation, including the adverse effects and the way in which the formulation was used. Part B of the form consists of a series of closed questions or checklist that captures the basic information needed with options for including additional information where it is available. Although programmes for collecting quantitative information on environmental incidents of pesticides may not be implemented in many countries, use of such national programmes for reporting environmental incidents should be made, where they exist. The format has been developed so that it might be widely used by States, aid agencies, intergovernmental organizations and non-governmental organizations etc., in reporting on environmental incidents related to the use of severely hazardous pesticide formulations. If there are other formats available, they may be used in preparing a submission to the Secretariat and forwarded through the DNA using Part A of the SHPF form provided that they meet the information requirements of Parts 1 and 3 of Annex IV of the Convention. There is some redundancy between Parts A and B of this form. It was thought that this might help countries to consolidate responses by using Part A of the form to report on more than one incident for the same formulation.

What is an environmental incident?

For the purposes of this incident report form, an environmental incident is defined as the contamination of land, water and/or air by a severely hazardous pesticide formulation (SHPF) causing the temporary or permanent impairment or mortality of non-target organisms or biological processes under the “conditions of use” in developing countries or countries with economies in transition (Article 6). In this instance, “conditions of use” does not include accidental spills/leaks, nor deliberate misuse of an SHPF, and is clearly limited to effects caused by a certain formulation of a substance. The following are some examples of potential incidents:

the poisoning of birds or other wildlife that ingest granular insecticides used for soil treatment. Such incidents may result from the application method (e.g. broadcast application rather than injection into the soil) or from the behaviour of non-target organisms (e.g. scavenging of granules).
the poisoning of aquatic organisms due to the contamination of a stream or pond. Such incidents may occur if sufficient buffer zones between treated areas and waterways were not observed.
the severe disturbance of non-target populations (e.g. honey bees, earthworms, beneficial insects).

What happens to the completed form?

Once Part B - Environmental Incident Report Form - has been completed to the extent possible based on the information available, it should be forwarded to the DNA. The DNA is to coordinate the completion of Part A - Transmittal form - and forward the entire document to the Secretariat. The Secretariat is required to collect additional information including physico-chemical and eco-toxicological properties of the pesticide formulation, information on environmental incidents related to the formulation in other States, and the existence of environmental restrictions or environmental guidelines in other states, or relevant evaluations, where available. This information along with the completed form is reviewed by the Chemical Review Committee (CRC). The CRC will decide whether or not to recommend the inclusion of the pesticide formulation in the Rotterdam Convention.

Your co-operation in completing this form and your contribution for the identification of severely hazardous pesticide formulations posing environmental problems under conditions of use is greatly appreciated. If you have any questions or comments relating to the completion of this form please contact the Secretariat at the address below.

PART A - TRANSMITTAL FORM - DESIGNATED NATIONAL AUTHORITY

INFORMATION REQUIRED FROM A DESIGNATED NATIONAL AUTHORITY

1 Name of the formulation:.

2 Type of formulation: (for example EC, WP, DP, GR, TB)..........................................................

3 Trade name and name of producer, if available:.........................................................................

4 Name of the active ingredient or ingredients in the formulation:................................................

5 Relative amount of each active ingredient in the formulation:.........(% concentration)..............

6 Attach copy of the label(s), if available (or describe the key aspects of the label: language, etc.).

7 Common and recognized patterns of use of the formulation within the country –

the formulation is registered / permitted for use in the country?
what uses are permitted?
are there any handling or applicator restrictions specified as a condition of registration;
information on the extent of use of the formulation, such as the number of registrations or production or sales quantity (indicate the source of information);
other information on how the formulation is commonly/typically used in the country

(this information should be submitted on a separate sheet attached to the completed form)

8 A clear description of incidents(s) related to the problem, including adverse effects and the way in which the formulation was used (for example Part B pesticide incident report form identifies key elements and appropriate level of detail). Other report formats which may exist at the national level may also be used, provided they contain comparable information.

9 Any regulatory, administrative or other measure taken, or intended to be taken, by the proposing Party in response to such incidents.

Date, signature of DNA and official seal:

PLEASE RETURN THE COMPLETED FORM TO:

PART B – ENVIRONMENTAL INCIDENT REPORT FORM

Note: If the reported incident is associated with the use of a mixture of more than one formulation, Section 2 (Product Identity) should be completed separately for each of the formulations. The remaining Sections of the form that describe how the formulation was used, the incident, adverse effects etc., need only be completed once for each incident.

In order to help keep the form as simple as possible, the term formulation is used throughout and refers to the chemical product (herbicide, insecticide, etc). For those incidents involving more than one formulation, it is understood that the use of this term in Sections 4–7 will refer to the mixture that was applied.

SECTION 1. NUMBER OF FORMULATIONS USED

How many formulations were used when the incident took place? (Please circle or fill in number and proceed as indicated)

a. One formulation was used.

Yes

If yes, complete Section 2 (Product Identity) once.

If no,

b.................... (number) different formulations were used at the same time (e.g. tank mix of a herbicide and a fungicide)

c. Please list the individual formulations here: e.g. Monitor (methamidophos 60 EC)

Formulation 1:...............................................................................................

Formulation 2:...............................................................................................

Formulation 3:...............................................................................................

Please complete Section 2 (Product Identity) for each of the listed formulations.

SECTION 2. PRODUCT IDENTITY: FORMULATION USED AND ITS PREPARATION
Please complete this section for each formulation used

Name of the formulation?

Type of formulation (please tick):

Emulsifiable concentrate (EC)

Wettable powder (WP)

Dustable powder (DP)

Water soluble powder (SP)

Ultra low volume (ULV)

Tablet (TB)

Granular (GR)

Other (please specify): __________________

Trade names and names of the producer/manufacturer, if available:

Name of the active ingredient(s) in the formulation:

What is the name and relative amount of each active ingredient (a.i.) in the formulation?

% concentration:...........................

grams a.i/litre or:............................

ounce a.i /gallon or:.......................

grams a.i./kg or:.............................

ounce a.i/pound:............................

7.	Attach a copy of the label(s) and instructions for use, if available to this form (or describe the key aspects of the label: language, use instructions, etc). Label attached	Yes	No
8.	*What was the intended use (please tick)*

	Insecticide	Herbicide	Tick control	Rodenticide
	Fungicide	Unknown	Other (specify)..............................................

Are there any use restrictions or prohibitions regarding the use of this formulation or the active ingredient (e.g. use of safety equipment, application restrictions)?

Yes (please specify)

10.

Was the formulation used as purchased or was it changed in any way?

Used as purchased

Changed (please specify how):
....................................................................................................................

11.

Was the formulation in its original container?

No (go to b)

Yes (go to Question 13)

b. Did the repackaged formulation have a copy of the label attached?

Yes

12.

Preparation of formulation:

a. Was the formulation (as outlined in Questions 2–8) mixed with a carrier or diluent before use (e.g. mixed with liquid, powder, bran)?

No (go to Question 13)

Yes

If yes,

b. How was the mixture prepared (e.g. mixed with water, diesel)?
...................................................................................................................

c. What was the mixing ratio? (circle appropriate unit)

............ litre or kg/lbs of formulation per.............. litre or kg/lbs of carrier/diluent

d. Was the mixture used immediately or was it stored?

Used immediately

Stored (please specify)

For how long?................................ hours/days/weeks (circle appropriate unit)

13.

Application rate:

a. What was the application rate used?

......... e.g.: g a.i./ha; litre/ha; lb/acre (circle appropriate unit) or specify...............

b. How much of the chemical product / or active ingredient (a.i.) was used?

For multiple applications, please estimate the total amount released. (circle appropriate unit)

Total amount:................. (L; gallons; kg; or lb)

Concentration:................ (g a.i./L; oz a.i./gallon; g a.i./kg; or oz a.i./lbs)

SECTION 3. DESCRIPTION OF APPLICATION

14.

Location where the formulation was used?

Nearest village/city:........................................................................................

Province/state/region/district:..........................................................................

Country:............................................................................................................

15.

Date of application(s)

a. What were the date(s) (if known) the formulation was used?

Beginning:................................................ End:................................................

16.

Was it a single or multiple application?

Single application

Multiple application (please specify)

Number of applications:.......................................................................

Approximate date of each application:..................................................

17.

Were any other pesticides used in the same area at the time of the incident

18.

Treated area and target pest:

a. What was the type of crop or situation treated (e.g. maize, grassland, forest, pond)?.......................

b. What was the target pest (e.g. weeds in maize, locusts in grasslands, moths in forests, mosquitoes in ponds)?.........

19.

Conduct of application

a. How was the formulation applied (method of application)?

By hand

Backpack sprayer

Tractor-mounted sprayer

Aircraft

In-furrow applicator

Hand-held sprayer

Other method (please specify)....................................................................

b. What were the weather conditions at the time of application?

Temperature:

Hot

Warm

Cool

Sunny or cloudy:

Rain:

Light

Medium

Heavy

Wind speed:

Light

Strong

Direction:......................................................................................................

General description of conditions:...............................................................

c. What were the weather conditions for the few days after application?

Temperature:

Hot

Warm

Cool

Sunny or cloudy:

Rain:

Light

Medium

Heavy

Wind speed:

Light

Strong

Direction:.......................................................................................................

General description of conditions:.................................................................

20.

Please provide any relevant information regarding the person applying the formulation (e.g. level of training, literacy)

SECTION 4. DESCRIPTION OF THE INCIDENT
21.	What was the date when the incident was first noticed?

22.

Location of the incident. Was the location of the incident, the same location of the area treated? Please indicate where the incident occurred (be as specific as possible).

Yes (as specified in Section 3 Question 14)

No (please specify Geographical coordinates, if available)

Village/city:.......................................................................................................

Province/state/region/district:...........................................................................

Country:............................................................................................................

23.

Please indicate where the incident occurred and the size of the area affected, by completing all areas of the following table that apply. Please be as specific as possible; mark all boxes as appropriate:

Environment Affected	Size of area or volume affected (write a number)	Units (circle appropriate units)
Land		m²
Home garden		hectare (ha)
Farm field		km²
Grassland		acre
Other...............................		Other (specify)...............................
Fresh Water		Surface Area
Fish pond		m², ha, km²,acre or
Stream		Other (specify)..............................
River
Lake		Volume
Sediments		L, m³ or
Other...............................		Other (specify)...............................
Salt Water		Surface Area
Estuary		m², ha, km² or
Bay		Other (specify)..............................
Ocean		Volume
Sediments		L, m³ or
Other...............................		Other (specify)...............................

24.	Please draw a rough map of the area around the incident. (Indicate scale if possible). Use the box below or attach to the back of this form. Please include: a. the area affected; b. any nearby waterways that were, or could be, affected and the direction of water flow; c. location of any affected non-target organisms that were found; d. location where the formulation was applied; e. any other details which may further clarify the incident (e.g. topography, soil properties, water table).

25.	Please describe any other details, additional information or facts that are not captured elsewhere in this form that further explain the cause of the incident, how it occurred, the result and any remediation efforts (attach extra pages if required).

SECTION 5. DESCRIPTION OF ADVERSE EFFECTS
26.	Identify the non-target organism(s) adversely affected in the incident, including the number affected. Please be as specific as possible (common names and if possible scientific names) and complete as much as possible. Examples are provided in the table below.

SPECIES OF ANIMAL OR PLANT	NUMBER OR PROPORTION AFFECTED	AGE OR DEVELOPMENT STAGE (E.G. JUVENILE, LARVAL, SEEDLING)	OBSERVATIONS (E.G. ABNORMAL MORPHOLOGY OR BEHAVIOUR, TOXICOLOGICAL SYMPTOMS)	DURATION OF EFFECT (INCLUDING DATE OF DEATH OR RECOVERY)
Examples
Terrestrial vertebrate e.g. Domestic cattle	10	Adults	Excessive salivating, loss of balance, lethargy.	Recovered 26 May 2002
Birds - e.g. Mallard ducks	40	Adults and juveniles	Disoriented, ruffled appearance, head lesions	Recovered 30 May 2002
	6	juveniles	Disoriented, lethargy	Recovered 21 May 2002
	5	juveniles	Disoriented, lethargy	Died 22 May 2002
Fish e.g. various species	numerous	All size classes	Dead fish on riverbank up to 3km downstream of treatment area	No information
Invertebrates e.g. honey bee	100 colonies	Foraging during peak of flowering period	Colonies dead	All cases reported within 20 days post-application
Vegetation e.g. grassland	4 acres	Flowering	Wilted, yellowing	Dead patches

27.	Was there any indirect evidence of severe hazards to non-target organisms (e.g. unexpected population declines, disappearance of certain species in the incident area)?
	No	Yes (Please describe these effects)

28.	Please provide any other relevant information such as:
	a. links between the use of the formulation (Section 4) and observed effects in non target organisms (question 26): .....................................................................................................................................

b. any analytical measurements, if available, which confirm residues of active ingredient(s) in soil, water, air or biological tissues

Yes

SECTION 6. MANAGEMENT
29.	What practical steps (if any) were taken at the time the incident occurred to limit or stop its further impact on the environment (excluding administrative and regulatory actions)?

30.	What steps (if any) were taken to clean up the area after the incident or to rehabilitate any species affected in the incident?

SECTION 7. REPORTING/COMMUNICATION
31.	Date of data collection/consultation:.......................................................
32.	Name and address of investigator/data collector:

33.	Category of investigator/data collector (e.g. environmental scientist, agricultural officer, government representative):

34.	Contact if further information needed: Telephone:........................................................................................ Fax:.................................................................................................... E-mail:................................................................................................
35.	Has this incident been reported elsewhere? No Yes (who was it reported to) ..........................................................................................................................
36.	Have similar incidents happened in that area before?

	No	Yes
	If yes, were they reported?
	No	Yes
*Please send the completed incident report form to the Designated National Authority.* (Name and address of the DNA)

DNA- please attach all forms to Part A – Transmittal Form