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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2007-8820

2. Registrant Information.

Registrant Reference Number: IRF#117

Registrant Name (Full Legal Name no abbreviations): Chemtura Canada Co./Cie

Address: 25 Erb Street

City: Elmira

Prov / State: ON

Country: Canada

Postal Code: N3B 3A3

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


4. Date registrant was first informed of the incident.


5. Location of incident.

Country: CANADA


6. Date incident was first observed.


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.


PMRA Registration No. 12533      PMRA Submission No.       EPA Registration No.

Product Name: Casoron G-4 Granular Herbicide

  • Active Ingredient(s)

7. b) Type of formulation.

Application Information

8. Product was applied?


9. Application Rate.


10. Site pesticide was applied to (select all that apply).

Site: Personal use / Usage personnel

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

Caller (as per her description): Casoron G-4 Group 20 Herbicide Application Date: approximately 3 weeks ago Application Duration : less than 5 minutes Caller noted that a respirator is not specified on the label and was not worn. Caller also noted that it was not windy or she would have worn one. Caller had also used product many times in the past without incident.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?


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: Unknown / Inconnu

3. List all symptoms, using the selections below.


  • Respiratory System
    • Symptom - Respiratory irritation
  • General
    • Symptom - Taste altered
    • Specify - pungent taste
  • Respiratory System
    • Symptom - Coughing
  • Gastrointestinal System
    • Symptom - Dry mouth
  • Cardiovascular System
    • Symptom - Palpitations
    • Specify - heart palpitations (but said she was not sure if she had 'worked herself up")

4. How long did the symptoms last?

Unknown / Inconnu

5. Was medical treatment provided? Provide details in question 13.


6. a) Was the person hospitalized?


6. b) For how long?

7. Exposure scenario


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


9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)


10. Route(s) of exposure.



11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>8 hrs <=24 hrs / > 8 h < = 24 h

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.)

Application of the product took approximately 5 minutes. Initially the caller experienced a pungent taste and respiratory irritation. Approximately 12 hours after the product had been applied, the caller experienced a cough, dry mouth and heart palpitations. She indicated that she was not sure if the heart palpitations were because she "worked herself up". The caller went to a doctor and has reportedly had some tests done (she named heart and salivary gland tests). She reported that she had provided the product information to the doctors who "did not seem concerned". Caller also reported that she applied the product again, two weeks after the incident without any difficulty.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.