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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2008-2572

2. Registrant Information.

Registrant Reference Number: 2007-1

Registrant Name (Full Legal Name no abbreviations): Interprovincial Cooperative Limited (IPCO)

Address: 945 Marion Street

City: Winnipeg

Prov / State: MB

Country: Canada

Postal Code: R2J 0K7

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. 27819      PMRA Submission No.       EPA Registration No.

Product Name: IPCO 2,4-D Ester 700

  • 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: 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).

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: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.


  • Respiratory System
    • Symptom - Sore throat

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?

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.)

The farmer called up with a complaint about a sore throat after exposure to 2,4-D Ester 700 fumes. He was not wearing a respirator but it is unknown whether any other personal protective equipment was worn. He was concerned because he has had previous reactions to 2,4-D Ester. He went to the doctor on July 9, 2007. IPCO called back to follow up on incident. The doctors diagnosis was that he had an infection and the sore throat was not related to the product (2,4-D Ester 700). He is presently on antibiotics and is feeling better.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.