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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2008-3751
2. Registrant Information.
Registrant Reference Number: PLR.Incd.PMRA.080923
Registrant Name (Full Legal Name no abbreviations): Diacon Technologies Ltd.
Address: 135 - 11960 Hammersmith Way
City: Richmond
Prov / State: BC
Country: Canada
Postal Code: V7A 5C9
3. Select the appropriate subform(s) for the incident.
Human
4. Date registrant was first informed of the incident.
10-SEP-085. Location of incident.
Country: CANADA
Prov / State: BRITISH COLUMBIA
6. Date incident was first observed.
28-AUG-08Product 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. 27136 PMRA Submission No. EPA Registration No.
Product Name: Mycostat P20
- Active Ingredient(s)
- PROPICONAZOLE
PMRA Registration No. 25744 PMRA Submission No. EPA Registration No.
Product Name: MYCOSTAT Q
- Active Ingredient(s)
- DIDECYL DIMETHYL AMMONIUM CHLORIDE
7. b) Type of formulation.
Application Information
8. Product was applied?
Yes
9. Application Rate.
8Other Units: ug/cm2
10. Site pesticide was applied to (select all that apply).
Site: Industrial / Industriel
Préciser le type: Sawmill
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
Spraybox application system.To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
No
Subform II: Human Incident Report (A separate form for each person affected)
1. Source of Report.
Other
2. Demographic information of data subject
Sex: Male
Age: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Skin
- Symptom - Rash
4. How long did the symptoms last?
>3 days <=1 wk / >3 jours <=1 sem
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
Occupational
8. How did exposure occur? (Select all that apply)
Contact with treated area
What was the activity? Pulling freshly treated lumber.
9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)
Long-sleeve shirt
Long pants
Chemical resistant gloves
10. Route(s) of exposure.
Skin
11. What was the length of exposure?
>2 hrs <=8 hrs / >2 h <=8 h
12. Time between exposure and onset of symptoms.
>2 hrs <=8 hrs / > 2 h < = 8 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.)
The worker was sent to the doctor, but no medication was prescribed.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.
Worker's long sleeve shirt was contaminated with the pesticide product and a rash was developed on his arm. He was wearing an apron which did not adequately protect his abdomen and a rash was developed on his torso.
