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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2016-3572

2. Registrant Information.

Registrant Reference Number: 2016-IR-04

Registrant Name (Full Legal Name no abbreviations): E.I. du Pont Canada Company

Address: 1919 Minnesota Court

City: Mississauga

Prov / State: ON

Country: Canada

Postal Code: L5M 2J4

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

Human

4. Date registrant was first informed of the incident.

10-JUN-16

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

Unknown

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. 31685      PMRA Submission No.       EPA Registration No.

Product Name: Travallas Herbicide

  • Active Ingredient(s)
    • FLUROXYPYR 1-METHYLHEPTYL ESTER
    • METSULFURON-METHYL
    • THIFENSULFURON METHYL

PMRA Registration No. 31916      PMRA Submission No.       EPA Registration No.

Product Name: SIMPLICITY GODRI HERBICIDE

  • Active Ingredient(s)
    • PYROXSULAM

7. b) Type of formulation.

Application Information

8. Product was applied?

No

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.

Data Subject

2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

  • Liver
    • Symptom - Enlargement of the liver
  • Gastrointestinal System
    • Symptom - Nausea

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

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?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>8 hrs <=24 hrs / > 8 h < = 24 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.)

Short note just to inform you that we had a call / contact from a grower about a mixing issue with our offering Travallas, used in combination with two other products Simplicity GoDri (Dow herbicide) and LI-700 (Loveland adjuvant / surfactant). After the mixing incident, the grower contacted our Representative again and below is a brief summary from our Grower Specialist Representative is below (typed on hand held I assume and I dont know the exact date of the contact I just learned of this today): customer called last night, his brother is not feeling well. He has an enlarged liver and spleen. He is going for an ultrasound as the doctor are not sure what he had. He wash/cleaning the sprayer last Tuesday without using proper PPE. He is wondering if we had a doctor on staff or if he could get more information about Travallas. He allready contact Dow without getting much info. He also felt not well either but only the day after cleaning the sprayer (puffy eye and upset stomach) I check all 3 labels and recommend to take all 3 to his Doctor. This is not a registered tank mix from our product label.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

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

1. Source of Report.

Data Subject

2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

  • General
    • Symptom - Malaise
    • Specify - felt not well
  • Eye
    • Symptom - Swollen eye
    • Specify - puffy eye
  • Gastrointestinal System
    • Symptom - Stomachache
    • Specify - upset stomach

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

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

Unknown

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>8 hrs <=24 hrs / > 8 h < = 24 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.)

Short note just to inform you that we had a call / contact from a grower about a mixing issue with our offering Travallas, used in combination with two other products Simplicity GoDri (Dow herbicide) and LI-700 (Loveland adjuvant / surfactant). After the mixing incident, the grower contacted our Representative again and below is a brief summary from our Grower Specialist Representative is below (typed on hand held I assume and I dont know the exact date of the contact I just learned of this today): customer called last night, his brother is not feeling well. He has an enlarged liver and spleen. He is going for an ultrasound as the doctor are not sure what he had. He wash/cleaning the sprayer last Tuesday without using proper PPE. He is wondering if we had a doctor on staff or if he could get more information about Travallas. He allready contact Dow without getting much info. He also felt not well either but only the day after cleaning the sprayer (puffy eye and upset stomach) I check all 3 labels and recommend to take all 3 to his Doctor. This is not a registered tank mix from our product label.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.