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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2008-2357
2. Registrant Information.
Registrant Reference Number: x
Registrant Name (Full Legal Name no abbreviations): x
Address: x
City: x
Prov / State: x
Country: x
Postal Code: X
3. Select the appropriate subform(s) for the incident.
Human
4. Date registrant was first informed of the incident.
24-JAN-085. Location of incident.
Country: CANADA
Prov / State: QUEBEC
6. Date incident was first observed.
05-AUG-05Product 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. 24363 PMRA Submission No. EPA Registration No.
Product Name: SAFER'S TROUNCE INSECTICIDE CONCENTRATE
- Active Ingredient(s)
- POTASSIUM SALTS OF FATTY ACIDS
- PYRETHRINS
PMRA Registration No. 26980 PMRA Submission No. EPA Registration No.
Product Name: VANQUISH HERBICIDE
- Active Ingredient(s)
- DICAMBA (PRESENT AS ACID, AMINE SALT, ESTER, OR SODIUM SALT)
7. b) Type of formulation.
Application Information
8. Product was applied?
Yes
9. Application Rate.
10. Site pesticide was applied to (select all that apply).
Site: Res. - Out Home / Rés - à l'ext.maison
Préciser le type: Lawn
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
Lawn was sprayed and was aired by "vertdure" company to not step on grass for 24 hrs for more information please contact.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: >1 <=6 yrs / > 1 < = 6 ans
3. List all symptoms, using the selections below.
System
- Skin
- Symptom - Rash
- Symptom - Itchy skin
4. How long did the symptoms last?
>1 wk <=1 mo / > 1 sem < = 1 mois
5. Was medical treatment provided? Provide details in question 13.
Yes
6. a) Was the person hospitalized?
Unknown
6. b) For how long?
Unknown
7. Exposure scenario
Non-occupational
8. How did exposure occur? (Select all that apply)
Contact with treated area
Amount of time between application and contact 24
Hour(s) / Heure(s)
What was the activity? playing on lawn
9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)
10. Route(s) of exposure.
Skin
11. What was the length of exposure?
>15 min <=2 hrs / >15 min <=2 h
12. Time between exposure and onset of symptoms.
>30 min <=2 hrs / >30 min <=2 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.)
Stepped on the lawn more than 24hrs after the grass was sprayed in order to play in the back yard. Played for about 45 mins and then developed rash. Rash all over body and lasted ~3 weeks. Appeared to be itchy and gaver her Benadryl. Saw doctor 2 hrs after exposure and was given Benadryl prn. Saw doctor multiple times since incident since diagnosis was unclear, it was suggested that it might be viral but doctors were not certain.
To be determined by Registrant
14. Severity classification.
15. Provide supplemental information here.
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: <=1 yr / < = 1 an
3. List all symptoms, using the selections below.
System
- Skin
- Symptom - Rash
- Symptom - Itchy skin
4. How long did the symptoms last?
>2 mos and <=6mos />2 mois et <=6mois
5. Was medical treatment provided? Provide details in question 13.
Yes
6. a) Was the person hospitalized?
Unknown
6. b) For how long?
Unknown
7. Exposure scenario
Non-occupational
8. How did exposure occur? (Select all that apply)
Contact with treated area
Amount of time between application and contact 24
Hour(s) / Heure(s)
What was the activity? playing on the lawn
9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)
10. Route(s) of exposure.
Skin
11. What was the length of exposure?
>15 min <=2 hrs / >15 min <=2 h
12. Time between exposure and onset of symptoms.
>30 min <=2 hrs / >30 min <=2 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.)
Stepped on the lawn more than 24hrs after the grass was sprayed, in order to play in the back yard. Played for about 45min and then developed rash. Rash all over body and lasted ~ 2 months. Appeared to be itchy and applied corticosteroid cream topically. Saw doctor 2hrs after exposure and given corticosteroid cream and Benadryl prn. Saw doctors multiple times since incident since diagnosis was unclear. It was suggested that it might be viral but doctors were not certain.
