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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2008-4675
2. Registrant Information.
Registrant Reference Number: 2020372
Registrant Name (Full Legal Name no abbreviations): Sure-Gro Inc.
Address: 150 Savannah Oaks Dr.
City: Brantford
Prov / State: Ontario
Country: Canada
Postal Code: N3V 1E7
3. Select the appropriate subform(s) for the incident.
Human
4. Date registrant was first informed of the incident.
08-SEP-085. Location of incident.
Country: CANADA
Prov / State: MANITOBA
6. Date incident was first observed.
21-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. 9802 PMRA Submission No. EPA Registration No.
Product Name: WILSON 50% MALATHION LIQUID INSECTICIDE-MITICIDE
- Active Ingredient(s)
- MALATHION
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: Res. - Out Home / Rés - à l'ext.maison
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
Product was applied 3wks ago.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: Male
Age: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Cardiovascular System
- Symptom - Chest tightness
- Respiratory System
- Symptom - Shortness of breath
- Gastrointestinal System
- Symptom - Nausea
- Respiratory System
- Symptom - Coughing
4. How long did the symptoms last?
Unknown / Inconnu
5. Was medical treatment provided? Provide details in question 13.
Unknown
6. a) Was the person hospitalized?
No
6. b) For how long?
7. Exposure scenario
Non-occupational
8. How did exposure occur? (Select all that apply)
Application
9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)
None
Unknown
10. Route(s) of exposure.
Respiratory
11. What was the length of exposure?
>15 min <=2 hrs / >15 min <=2 h
12. Time between exposure and onset of symptoms.
>1 wk <=1 mo / > 1 sem < = 1 mois
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.)
Wife on the line stating her husband was exposed to the product 3 weeks ago and is still symptomatic. 3 weeks ago, the patient was applying the product outside for 30 minutes without wearing any protective gear. Immediately upon using the product, the patient became symptomatic. The patient was nauseous, was coughing and had tightness in his chest. The patient has seen his PCP and the doctor told him to wait it out, now the patient's spouse is calling back because it has been 3 weeks and he still has a hart time catching his breath sometimes. Patient is in good health, high blood pressure medications and no known allergies. 1 person/1 product. The caller was recommended to take her husband back into see his doctor again for another evaluation and possibly a chest x-ray. PC is unsure if the patient's ongoing symptoms are related to the product exposure. Gave the patient PC phone number and case number to give to the doctor if needed and PC will call back in a week for outcome. During the call back the wife had indicated that her husbands symptoms are resolving and that he is schedule for an X-ray the following week. further call backs declined
To be determined by Registrant
14. Severity classification.
Minor
