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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2008-1070

2. Registrant Information.

Registrant Reference Number: 1-15203642

Registrant Name (Full Legal Name no abbreviations): Cheminova Canada, Inc.

Address: 2660 Sherwood Heights Dr., Unit 201

City: Oakville

Prov / State: Ontario

Country: Canada

Postal Code: L6J 7Y8

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

Human

4. Date registrant was first informed of the incident.

10-AUG-07

5. Location of incident.

Country: CANADA

Prov / State: SASKATCHEWAN

6. Date incident was first observed.

08-AUG-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. 25831      PMRA Submission No.       EPA Registration No.

Product Name: Nufos 4E

  • Active Ingredient(s)
    • CHLORPYRIFOS

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: unknown

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

Diluted product was sprayed in a field.

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: Female

Age: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

  • Gastrointestinal System
    • Symptom - Diarrhea

4. How long did the symptoms last?

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

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

No

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)

Contact with treated area

Amount of time between application and contact 2

Hour(s) / Heure(s)

What was the activity? Walking

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

Unknown

10. Route(s) of exposure.

Unknown

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>24 hrs <=3 days / >24 h <=3 jours

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.)

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

Given the delay between the symptom and the exposure and that it has resolved, and no other symptoms were noted, it is unlikely it was produced by exposure to this product.