Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2016-2344
2. Registrant Information.
Registrant Reference Number: DASC150708-00
Registrant Name (Full Legal Name no abbreviations): Dow AgroSciences Canada Inc.
Address: 2400, 215-2nd Street S.W.
City: Alberta
Prov / State: Calgary
Country: Canada
Postal Code: T2P 1M4
3. Select the appropriate subform(s) for the incident.
Human
4. Date registrant was first informed of the incident.
07-AUG-15
5. Location of incident.
Country: CANADA
Prov / State: SASKATCHEWAN
6. Date incident was first observed.
07-JUL-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)
PMRA Registration No. 14879
PMRA Submission No.
EPA Registration No.
Product Name: Lorsban 4E
7. b) Type of formulation.
Application Information
8. Product was applied?
Unknown
9. Application Rate.
10. Site pesticide was applied to (select all that apply).
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: Male
Age: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Eye
- Symptom - Other
- Specify - Crusted
- Symptom - Red eye
4. How long did the symptoms last?
Unknown / Inconnu
5. Was medical treatment provided? Provide details in question 13.
No
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)
Pesticide Spill
9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)
Chemical resistant gloves
Coveralls (non-chemical resistant)
Respirator
10. Route(s) of exposure.
Eye
11. What was the length of exposure?
<=15 min / <=15 min
12. Time between exposure and onset of symptoms.
<=30 min / <=30 min
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.)
Grower was mixing product into his chem handler wearing full PPE (coveralls, chem-resistant gloves and footwear, respirator), with the exception of proper eye protection (he was wearing sun glasses instead of safety glasses or goggles). The product splashed up underneath the growers sunglasses into his eyes. He immediately responded by washing out his eyes for 30 mins with water. Grower was advised that he should seek medical help if his symptoms worsen, of if he develops any other symptoms which concern him.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.
Grower attended a Pesticide Applicators Course in 1994 or 1995.