Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2016-7288

2. Registrant Information.

Registrant Reference Number: x

Registrant Name (Full Legal Name no abbreviations): x

Address: x

City: x

Prov / State: x

Country: x

Postal Code: X

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

Human

4. Date registrant was first informed of the incident.

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)

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PMRA Registration No. 27846      PMRA Submission No.       EPA Registration No.

Product Name: Premium 3 Way XP

• 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, POTASSIUM SALT, OR SODIUM SALT)
  • MECOPROP-P (PRESENT AS DIMETHYLAMINE SALT)

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PMRA Registration No. 17511      PMRA Submission No.       EPA Registration No.

Product Name: IPCO 2,4-D Amine 600

• Active Ingredient(s)
  • 2,4-D (PRESENT AS AMINE SALTS : DIMETHYLAMINE SALT, DIETHANOLAMINE SALT, OR OTHER AMINE SALTS)

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PMRA Registration No. 28840      PMRA Submission No.       EPA Registration No.

Product Name: VP 480 Herbicide

• Active Ingredient(s)
  • GLYPHOSATE (PRESENT AS DIMETHYLAMINE SALT)

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7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

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).

The girls were playing on the teeter totters and (School) a few days after pesticides were sprayed all over that area. I did not know pesticides were used so at first I did not even correlate that this was what irritated the girls skin. Two active ingredients were applied. Glyphosate (VP480 Herbicide, PCP#28840) was applied with long spray wands directed to weeds around the playground equipment. It was reported that the application was made from within inches of the weeds. The other products sprayed contained 2,4-D, dicamba, and mecoprop-p (Premium 3 Way XP, PCP#27846 and IPCO 2,4-D Amine 600, PCP#17511) applied low to the ground and large droplet-size spray nozzles were used to avoid any potential for drift.

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: Female

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

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Red skin
  • Symptom - Itchy skin
  • Symptom - Rash

4. How long did the symptoms last?

>24 hrs <=3 days / >24 h <=3 jours

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

Non-occupational

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

Contact with treated area

What was the activity? Playing on teeter totter.

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 / <=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.)

Red itchy and sore rash all over the backs of the girls thighs. Within minutes of playing on playground equipment that an area (that I was unaware) was sprayed with pesticides days earlier. No medical treatment was needed and rash subsided after a day. The girls were playing on the teeter totters and (name) Elementary School a few days after pesticides were sprayed all over that area. I did not know pesticides were used so at first I did not even correlate that this was what irritated my girls skin. They have played on the equipment in shorts and skirts plenty of times without getting a rash and this was the only occasion. After Pesticides were used, that they developed a problem. I spoke with the principal and tried to report it to (first name, last name) the maintenance coordinator at (name) School Division. But I never received a response back from him. I do not have the exact date but the girls were exposed during the school week following the weekend spraying at the playground. (school) has the exact pesticides that were used.

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.

Other

2. Demographic information of data subject

Sex: Female

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

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Red skin
  • Symptom - Itchy skin
  • Symptom - Rash

4. How long did the symptoms last?

>24 hrs <=3 days / >24 h <=3 jours

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

Non-occupational

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

Contact with treated area

What was the activity? Playing on the teeter totter

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 / <=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.)

Red itchy and sore rash all over the backs of the girls thighs. Within minutes of playing on playground equipment that an area (that I was unaware) was sprayed with pesticides days earlier. No medical treatment was needed and rash subsided after a day. The girls were playing on the teeter totters and (name) Elementary School a few days after pesticides were sprayed all over that area. I did not know pesticides were used so at first I did not even correlate that this was what irritated my girls skin. They have played on the equipment in shorts and skirts plenty of times without getting a rash and this was the only occasion. After Pesticides were used, that they developed a problem. I spoke with the principal and tried to report it to (first name, last name) the maintenance coordinator at (name) School Division. But I never a received response back from him. I do not have the exact date but the girls were exposed during the school week following the weekend spraying at the playground. (school) has the exact pesticides that were used.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.