Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2018-2520
2. Registrant Information.
Registrant Reference Number: GCMB0001
Registrant Name (Full Legal Name no abbreviations): Gowan Canada
Address: 135 Innovation Drive, Suite 100
City: Winnepeg
Prov / State: Manitoba
Country: Canada
Postal Code: R3T 6A8
3. Select the appropriate subform(s) for the incident.
Human
4. Date registrant was first informed of the incident.
24-MAY-18
5. Location of incident.
Country: CANADA
Prov / State: MANITOBA
6. Date incident was first observed.
22-MAY-18
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. 21012
PMRA Submission No.
EPA Registration No.
Product Name: Edge Manufacturing Concentrate
7. b) Type of formulation.
Application Information
8. Product was applied?
Yes
9. Application Rate.
Unknown
10. Site pesticide was applied to (select all that apply).
Site: Agricultural-Outdoor/Agricole-extérieur
Préciser le type: Don't know
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
Ground rig. Liquid application.
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
Yes
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
- General
- Symptom - Chemical taste in mouth
4. How long did the symptoms last?
>2 hrs <=8 hrs / > 2 h < = 8 h
5. Was medical treatment provided? Provide details in question 13.
Yes
6. a) Was the person hospitalized?
Yes
6. b) For how long?
4
Hour(s) / Heure(s)
7. Exposure scenario
Non-occupational
8. How did exposure occur? (Select all that apply)
Drift from the application site
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
Eye
Oral
Respiratory
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.)
The supervisor reported one of their maintenance technicians was exposed to spray drift from sprayer application equipment operating in the field surrounding the utility site. The applicator was unware of the technician on site and when operating close to access road resulted in exposure by the technician to spray drift carried by breeze. The applicator stopped when seeing the technician who was experiencing burning in his eyes. The technician eyes were flushed on site and he was then taken to the local hospital where he received further treatment including an examination by an eye specialist. He was released from the hospital following the exam. The technician also reported sense of taste from in his mouth at time of the drift exposure. He also experienced some skin blistering at the back of neck, it was further indicated he has sensitive skin.The applicator was applying 1.3L of ethalfluralin manufacturing concentrate (EMC) per acre in a carrier mixture of 28-0-0 liquid fertilizer and water. The MSDS for 28-0-0 fertilizer, which is also an eye and skin irritant, has been provided to the supervisor.
To be determined by Registrant
14. Severity classification.
Moderate
15. Provide supplemental information here.