Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-3230

2. Registrant Information.

Registrant Reference Number: NEU 30012 2JUN15 1

Registrant Name (Full Legal Name no abbreviations): W. Neudorff GmbH KG

Address: #11-6782 Veyaness Road

City: Saanichton

Prov / State: BC

Country: Canada

Postal Code: V8M 2C2

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

Human

4. Date registrant was first informed of the incident.

05-JUN-15

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

02-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. 30012      PMRA Submission No.       EPA Registration No.

Product Name: Finalsan Pro Commercial Concentrate

• Active Ingredient(s)
  • AMMONIUM SALT OF FATTY ACID

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7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

16.67

Units: %

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

Site: Unknown / Inconnu

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

Hard surfaces were sprayed for vegetation control at a commercial property.

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.

Other

2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Rash

4. How long did the symptoms last?

>3 days <=1 wk / >3 jours <=1 sem

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

Occupational

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

Application

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

Unknown

10. Route(s) of exposure.

Skin

11. What was the length of exposure?

>2 hrs <=8 hrs / >2 h <=8 h

12. Time between exposure and onset of symptoms.

>2 hrs <=8 hrs / > 2 h < = 8 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.)

While spraying hard surface areas for vegetation control, applicator bent over to avoid an air conditioning unit. While doing so, spray solution from backpack unit leaked from lid and spilled onto applicators back. He did not notice until completing the application when he felt a burning sensation on his back. He removed his shirt and rinsed off with water and then showered. He experienced an irritating rash which persisted for several days causing him to visit a physician.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.