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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2007-4706

2. Registrant Information.

Registrant Reference Number: 2007-17

Registrant Name (Full Legal Name no abbreviations): BASF Canada

Address: 100 Milverton Dr, 5th

City: Mississauga

Prov / State: on

Country: Canada

Postal Code: L5R4H1

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

Human

4. Date registrant was first informed of the incident.

11-JUL-07

5. Location of incident.

Country: CANADA

Prov / State: UNKNOWN

6. Date incident was first observed.

07-JUN-07

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.       PMRA Submission No.       EPA Registration No.

Product Name: Unknown,may be 2,4-D,mecoprop, dicamba

  • Active Ingredient(s)
    • DICAMBA (PRESENT AS ACID, AMINE SALT, ESTER, OR SODIUM SALT)

7. b) Type of formulation.

Application Information

8. Product was applied?

Unknown

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: Female

Age: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

  • Eye
    • Symptom - Tearing
  • Nervous and Muscular Systems
    • Symptom - Headache
  • Gastrointestinal System
    • Symptom - Salivating excessively

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

Non-occupational

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.

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

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.)

Spill of pesticide in fruit cellar storage room. herbicide not identified,may be 2,4-D,mecoprop,dicamaba or a formulation containing all 3.Spill was noted on June 7 or 8.Spill was confined to fruit cellar and did not affect the rest of home until husband opened fruit cellar door to ventilate. The odour spread throughout the home. Spill was cleaned up by husband. Caller has no health questions at this time. went to ED on June 23 to be evaluated and baseline bloodwork was done.Nothing abnormal was noted.MD told her this would be baseline information for comparison if health problems show up later. Symptoms: tearing of eyes, salivation, headache. Symptoms have resolved...husband did not have symptoms at any time.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.