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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2017-5453
2. Registrant Information.
Registrant Reference Number: ENG20170001
Registrant Name (Full Legal Name no abbreviations): Engage Agro Corporation
Address: 1030 Gordon St.
City: Guelph
Prov / State: Ontario
Country: Canada
Postal Code: N1G 4X5
3. Select the appropriate subform(s) for the incident.
Human
4. Date registrant was first informed of the incident.
12-SEP-175. Location of incident.
Country: CANADA
Prov / State: ONTARIO
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. 15032 PMRA Submission No. EPA Registration No.
Product Name: Basamid Granular Soil Fumigant
- Active Ingredient(s)
- DAZOMET
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.
Other
2. Demographic information of data subject
Sex: Male
Age: Unknown / Inconnu
3. List all symptoms, using the selections below.
System
- Skin
- Symptom - Burns (superficial)
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
Unknown
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)
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.
Unknown / Inconnu
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.)
Worker handling a bag of Dazomet and it spilled between his sock and his leg. He removed the Basamid from his socks with his hands. The reporter of the incident indicated there was skin burn on his ankle region and hand. The reporter of the incident sought medical advice from a doctor.
To be determined by Registrant
14. Severity classification.
Minor
