Déclaration d'incident

Sous-formulaire I: Renseignements généraux

1.Type de rapport.

Nouvelle déclaration d'incident

No de la demande: 2009-0008

2. Renseignements concernant le titulaire.

Numéro de référence du titulaire d'homologation: Prosar 1-16390555

Nom du titulaire (nom légal complet, aucune abbréviation): United Agri Products Canada, Inc.

Adresse: 789 Donnybrook Drive

Ville: Dorchester

État: Ontario

Pays: Canada

Code postal /Zip: N0L1G5

3.Choisir le (les) sous-formulaire(s) correspondant à l'incident.

Incident chez l'humain

4. Date à laquelle le titulaire d'homologation a été informé pour la première fois de l'incident.

11-JUL-08

5. Lieu de l'incident.

Pays: CANADA

État: ONTARIO

6. Date de la première observation de l'incident.

20-JUN-08

Description du produit

7. a) Donner le nom de la matière active et, si disponibles, le numéro d'homologation et le nom du produit (incluant tous les mélanges). Si le produit n'est pas homologué, donner le numéro de la demande d'homologation.

Matière(s) active(s)

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ARLA No d'homologation       ARLA No de la demande d'homologation       EPA No d'homologation.

Nom du produit: Unknown Malathion-Based Insecticide

• Matière active
  • MALATHION

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7. b) Type de formulation.

Renseignments sur l'application

8. Est-ce que le produit a été appliqué?

Oui

9. Dose d'application.

Inconnu

10. Site d'application (choisir tout ce qui s'applique).

Site: Res. - Out Home / Rés - à l'ext.maison

11. Donner tout renseignement additionnel concernant l'application (comment le produit a été appliqué, la quantité utilisée, la superficie de la zone traitée, etc.)

The product was applied by a neighbor in an unknown concentration for three weeks prior to the initial report. The exact product name and manufacturer is unknown.

À être déterminé par le titulaire

12. Selon vous, le produit a-t-il été utilisé en conformité avec le mode d'emploi de L'étiquette?

Inconnu

Sous-formulaire II : Incident chez l'humain (Obligation d'utiliser un formulaire séparé pour chaque personne affectée)

1. Source de la déclaration.

Personne affectée

2. Renseignement démographique sur la personne affectée

Sexe: Femme

Âge: Unknown / Inconnu

3. Énumérez tous les symptômes, au moyen des choix suivants.

Système

• Système gastro-intestinal
  • Symptôme - Diarrhée
  • Symptôme - Crampes à l'estomac

• Système respiratoire
  • Symptôme - Respiration faible

4. Quelle a été la durée des symptômes?

Unknown / Inconnu

5. La personne affectée a-t-elle reçu des soins médicaux? Donner les détails à la question 13.

Non

6. a) Est-ce que la personne a été hospitalisée?

Non

6. b) Pendant combien de temps?

7. Scénario d'exposition

Non professionnel

8. Comment l'exposition s'est-elle produite? (cocher tout ce qui s'applique)

Dérive du pesticide à partir de la zone traitée

9.Si l'exposition s'est produite lors du traitement ou au moment du retour dans la zone traitée, de l'équipement de protection individuelle était-il porté? (cocher tout ce qui s'applique)

Inconnu

10. Voie(s) d'exposition.

Peau

Respiratoire

11.Durée de l'exposition?

>1 wk <=1 mo / > 1 sem < = 1 mois

12.Temps écoulé entre l'exposition et l'apparition des symptômes.

Unknown / Inconnu

13.Donner tout détail additionnel au sujet de l'incident (p.ex. description des symptômes tels que la fréquence et la gravité, type de soins médicaux, résultats des tests médicaux, quantité de pesticide à laquelle la personne a été exposée, etc.)

1-16390555: A reporter called on 07/11/2008 to report the exposure of herself and her husband to an insecticide containing the active ingredient Malathion. According to the reporter, her neighbor had been spraying the product in an unknown concentration for the 3 weeks prior to the report. The reporter (Ist Subform II) stated that the product has "been taking her breath away" in addition to causing her to have diarrhea and cramps for the past 3 weeks. The reporter also stated that her husband (2nd Subform II) has been having diarrhea, cramps, and occasional tremors for the past 3 weeks. The reporter asked the neighbor what the product was on 07/11/2008 after he accidentally sprayed her with it from the waist down. The reporter was provided the active ingredient name. The reporter obtained the company's name after searching the active ingredient, but she is not sure that the product the neighbor is using is a company product. The reporter wants to know who to call to get her neighbor to stop spraying the product. The reporter was advised that with overexposure to the concentrated active ingredient or chronic exposure to the identified active ingredient, serious signs may occur, including gastrointestinal, respiratory, and neurologic signs. A recommendation was made for the caller to remove her clothing and shower for at least 20 minutes to remove the product from her skin. Another recommendation was made for the reporter and her husband to see their health care provider and inform him/her about their exposure to Malathion. The reporter was advised to call the Department of Public Health or local police if her neighbor continues to spray the product onto their property. The reporter called back on 07/14/2008. She reported that she and her husband did see their health care provider (unknown date). Both the reporter and her husband were feeling better at the time of the follow up report, but the diarrhea persisted. Neither the reporter nor her husband were given any medications for their signs. Their health care provider advised them to let the signs run their course. The reporter stated that she called the Health Department but was told that there are no regulations regarding the product. She also stated that she thinks the neighbor is not diluting the product properly. The reporter stated that other neighbors (3rd Subform II)have had diarrhea as well (unknown details of signs and exposure). The reporter was advised to drink plenty of water to maintain hydration. A recommendation was made to discuss her and her husband's persistent signs with their health care provider. No further information was obtained.

À être déterminé par le titulaire

14. Classification selon la gravité.

Modérée

15. Donner des renseignements additionnels ici.

Sous-formulaire II : Incident chez l'humain (Obligation d'utiliser un formulaire séparé pour chaque personne affectée)

1. Source de la déclaration.

Autre

2. Renseignement démographique sur la personne affectée

Sexe: Homme

Âge: Unknown / Inconnu

3. Énumérez tous les symptômes, au moyen des choix suivants.

Système

• Système gastro-intestinal
  • Symptôme - Diarrhée
  • Symptôme - Crampes à l'estomac

• Systèmes nerveux et musculaire
  • Symptôme - Tremblements musculaires

4. Quelle a été la durée des symptômes?

Unknown / Inconnu

5. La personne affectée a-t-elle reçu des soins médicaux? Donner les détails à la question 13.

Non

6. a) Est-ce que la personne a été hospitalisée?

Non

6. b) Pendant combien de temps?

7. Scénario d'exposition

Non professionnel

8. Comment l'exposition s'est-elle produite? (cocher tout ce qui s'applique)

Dérive du pesticide à partir de la zone traitée

9.Si l'exposition s'est produite lors du traitement ou au moment du retour dans la zone traitée, de l'équipement de protection individuelle était-il porté? (cocher tout ce qui s'applique)

Inconnu

10. Voie(s) d'exposition.

Respiratoire

11.Durée de l'exposition?

>1 wk <=1 mo / > 1 sem < = 1 mois

12.Temps écoulé entre l'exposition et l'apparition des symptômes.

Unknown / Inconnu

13.Donner tout détail additionnel au sujet de l'incident (p.ex. description des symptômes tels que la fréquence et la gravité, type de soins médicaux, résultats des tests médicaux, quantité de pesticide à laquelle la personne a été exposée, etc.)

1-16390555: A reporter called on 07/11/2008 to report the exposure of herself and her husband to an insecticide containing the active ingredient Malathion. According to the reporter, her neighbor had been spraying the product in an unknown concentration for the 3 weeks prior to the report. The reporter (Ist Subform II) stated that the product has "been taking her breath away" in addition to causing her to have diarrhea and cramps for the past 3 weeks. The reporter also stated that her husband (2nd Subform II) has been having diarrhea, cramps, and occasional tremors for the past 3 weeks. The reporter asked the neighbor what the product was on 07/11/2008 after he accidentally sprayed her with it from the waist down. The reporter was provided the active ingredient name. The reporter obtained the company's name after searching the active ingredient, but she is not sure that the product the neighbor is using is a company product. The reporter wants to know who to call to get her neighbor to stop spraying the product. The reporter was advised that with overexposure to the concentrated active ingredient or chronic exposure to the identified active ingredient, serious signs may occur, including gastrointestinal, respiratory, and neurologic signs. A recommendation was made for the caller to remove her clothing and shower for at least 20 minutes to remove the product from her skin. Another recommendation was made for the reporter and her husband to see their health care provider and inform him/her about their exposure to Malathion. The reporter was advised to call the Department of Public Health or local police if her neighbor continues to spray the product onto their property. The reporter called back on 07/14/2008. She reported that she and her husband did see their health care provider (unknown date). Both the reporter and her husband were feeling better at the time of the follow up report, but the diarrhea persisted. Neither the reporter nor her husband were given any medications for their signs. Their health care provider advised them to let the signs run their course. The reporter stated that she called the Health Department but was told that there are no regulations regarding the product. She also stated that she thinks the neighbor is not diluting the product properly. The reporter stated that other neighbors (3rd Subform II)have had diarrhea as well (unknown details of signs and exposure). The reporter was advised to drink plenty of water to maintain hydration. A recommendation was made to discuss her and her husband's persistent signs with their health care provider. No further information was obtained.

À être déterminé par le titulaire

14. Classification selon la gravité.

Modérée

15. Donner des renseignements additionnels ici.

Sous-formulaire II : Incident chez l'humain (Obligation d'utiliser un formulaire séparé pour chaque personne affectée)

1. Source de la déclaration.

Autre

2. Renseignement démographique sur la personne affectée

Sexe: Inconnu

Âge: Unknown / Inconnu

3. Énumérez tous les symptômes, au moyen des choix suivants.

Système

• Système gastro-intestinal
  • Symptôme - Diarrhée

4. Quelle a été la durée des symptômes?

Unknown / Inconnu

5. La personne affectée a-t-elle reçu des soins médicaux? Donner les détails à la question 13.

Inconnu

6. a) Est-ce que la personne a été hospitalisée?

Inconnu

6. b) Pendant combien de temps?

7. Scénario d'exposition

Non professionnel

8. Comment l'exposition s'est-elle produite? (cocher tout ce qui s'applique)

Autre

9.Si l'exposition s'est produite lors du traitement ou au moment du retour dans la zone traitée, de l'équipement de protection individuelle était-il porté? (cocher tout ce qui s'applique)

Inconnu

10. Voie(s) d'exposition.

Inconnu

11.Durée de l'exposition?

Unknown / Inconnu

12.Temps écoulé entre l'exposition et l'apparition des symptômes.

Unknown / Inconnu

13.Donner tout détail additionnel au sujet de l'incident (p.ex. description des symptômes tels que la fréquence et la gravité, type de soins médicaux, résultats des tests médicaux, quantité de pesticide à laquelle la personne a été exposée, etc.)

1-16390555: A reporter called on 07/11/2008 to report the exposure of herself and her husband to an insecticide containing the active ingredient Malathion. According to the reporter, her neighbor had been spraying the product in an unknown concentration for the 3 weeks prior to the report. The reporter (Ist Subform II) stated that the product has "been taking her breath away" in addition to causing her to have diarrhea and cramps for the past 3 weeks. The reporter also stated that her husband (2nd Subform II) has been having diarrhea, cramps, and occasional tremors for the past 3 weeks. The reporter asked the neighbor what the product was on 07/11/2008 after he accidentally sprayed her with it from the waist down. The reporter was provided the active ingredient name. The reporter obtained the company's name after searching the active ingredient, but she is not sure that the product the neighbor is using is a company product. The reporter wants to know who to call to get her neighbor to stop spraying the product. The reporter was advised that with overexposure to the concentrated active ingredient or chronic exposure to the identified active ingredient, serious signs may occur, including gastrointestinal, respiratory, and neurologic signs. A recommendation was made for the caller to remove her clothing and shower for at least 20 minutes to remove the product from her skin. Another recommendation was made for the reporter and her husband to see their health care provider and inform him/her about their exposure to Malathion. The reporter was advised to call the Department of Public Health or local police if her neighbor continues to spray the product onto their property. The reporter called back on 07/14/2008. She reported that she and her husband did see their health care provider (unknown date). Both the reporter and her husband were feeling better at the time of the follow up report, but the diarrhea persisted. Neither the reporter nor her husband were given any medications for their signs. Their health care provider advised them to let the signs run their course. The reporter stated that she called the Health Department but was told that there are no regulations regarding the product. She also stated that she thinks the neighbor is not diluting the product properly. The reporter stated that other neighbors (3rd Subform II)have had diarrhea as well (unknown details of signs and exposure). The reporter was advised to drink plenty of water to maintain hydration. A recommendation was made to discuss her and her husband's persistent signs with their health care provider. No further information was obtained.

À être déterminé par le titulaire

14. Classification selon la gravité.

Mineure

15. Donner des renseignements additionnels ici.