Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-3125

2. Registrant Information.

Registrant Reference Number: Rocky Mountain Poison and Drug case #5482444

Registrant Name (Full Legal Name no abbreviations): LOVELAND Products Canada, Inc.

Address: 789 Donnybrook Drive

City: Dorchester

Prov / State: Ontario

Country: Canada

Postal Code: N0L1G5

3. Select the appropriate subform(s) for the incident.

Human

4. Date registrant was first informed of the incident.

15-JUL-15

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

09-JUN-15

Product Description

7. a) Provide the active ingredient and, if available, the registration number and product name (include all tank mixes). If the product is not registered provide a submission number.

Active(s)

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PMRA Registration No. 27884      PMRA Submission No.       EPA Registration No.

Product Name: PAR III TURF HERBICIDE

• Active Ingredient(s)
  • 2,4-D (PRESENT AS AMINE SALTS : DIMETHYLAMINE SALT, DIETHANOLAMINE SALT, OR OTHER AMINE SALTS)
  • DICAMBA (PRESENT AS ACID, AMINE SALT, ESTER, OR SODIUM SALT)
  • MECOPROP-P (PRESENT AS DIMETHYLAMINE SALT)

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7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

10. Site pesticide was applied to (select all that apply).

Site: Res. - Out Home / Rés - à l'ext.maison

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Unknown

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Medical Professional

2. Demographic information of data subject

Sex: Female

Age: >1 <=6 yrs / > 1 < = 6 ans

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Shortness of breath

• Nervous and Muscular Systems
  • Symptom - Ataxia

• Skin
  • Symptom - Rash

4. How long did the symptoms last?

Unknown / Inconnu

5. Was medical treatment provided? Provide details in question 13.

Yes

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Non-occupational

8. How did exposure occur? (Select all that apply)

Contact with treated area

What was the activity? child playing on lawn

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

None

10. Route(s) of exposure.

Skin

11. What was the length of exposure?

>15 min <=2 hrs / >15 min <=2 h

12. Time between exposure and onset of symptoms.

>30 min <=2 hrs / >30 min <=2 h

13. Provide any additional details about the incident (eg. description of the frequency and severity of the symptoms, type of medical treatment, results from medical tests, outcome of the incident, amount of pesticide exposed to, etc.)

Case Information Date/Time: 07/14/15 10:01Patient 1 Information Patient Female Weight: 40.0 lbs / 18.1 Kgs Pregnant: NA Patient 1 Exposure Information Exposure Site: Residence Caller's Residence Reason Detail: Contaminated Environment UEUnintentional Environmental Occupational: No Acuity: Acute Product Name: Par III Turf Herbicide Time Of Exposure: 1.00 Months ago Route: Dermal Exposure Duration: 1.5 Hours Body Part: Generalized Patient 1 Clinical Effects Effects Present: Respiratory Short of breath Relatedness: Related Onset: 2.00 Hours after exp Effects Present: Neurological Ataxia Relatedness: Related Onset: 2.00 Hours after exp Effects Present: Dermal Rash Relatedness: Related Onset: 3.00 Hours after exp Patient 1 Management Information Type: In HCF Result: Treated Evaluated and Released SubType: Private HCF Provider Patient 1 Therapy Information Therapy Type: Dilute/irrigate/wash Recommendation: Recommended Patient 1 Outcome Medical Outcome: Minor Effect Duration: Unknown Industry Outcome: Minor Industry Duration: Unknown Causation: Related EPA Code: HD

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

Caller states her daughter was exposed to some Par III Turf Herbicide on June 9th. Caller states the townhouse complex that she lived had the lawn sprayed with the Par III Turf Herbicide.Caller states there was no notification that product had been sprayed. Caller states child was outside playing in the lawn and rolling around in the grass for about 1.5 hrs. Caller states about 1 hr later child developed ataxia and shortness of breath. Child took a nap and woke with rash. Caller states child has seen her PMD and was treated with steroids. Caller states she continues to have outbreaks of rash. GH NKDA No meds. Acute pediatric dermal exposure. Exposure: Par III Turf Herbicide R. Reviewed with caller since having ongoing symptoms recommend reevaluation by MD. Caller to call if further concerns or questions. CC/TE Therapies: Dilute/irrigate/wash(Recommended), washed affected areas