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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2009-1570
2. Registrant Information.
Registrant Reference Number: 2009-05
Registrant Name (Full Legal Name no abbreviations): United Agri Products Canada Inc.
Address: 789 donnybrook Drive
City: Dorchester
Prov / State: Ontario
Country: Canada
Postal Code: N0L 1G5
3. Select the appropriate subform(s) for the incident.
Human
Packaging Failure
4. Date registrant was first informed of the incident.
05-MAY-095. Location of incident.
Country: CANADA
Prov / State: ALBERTA
6. Date incident was first observed.
04-MAY-09Product 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. 9382 PMRA Submission No. EPA Registration No.
Product Name: Lagon 480
- Active Ingredient(s)
- DIMETHOATE
7. b) Type of formulation.
Application Information
8. Product was applied?
No
9. Application Rate.
10. Site pesticide was applied to (select all that apply).
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?
Unknown
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: Female
Age: >64 yrs / > 64 ans
3. List all symptoms, using the selections below.
System
- Nervous and Muscular Systems
- Symptom - Headache
- Gastrointestinal System
- Symptom - Nausea
4. How long did the symptoms last?
Unknown / Inconnu
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)
Other
9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)
10. Route(s) of exposure.
Respiratory
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.)
Foil cap under screw-top lid of a pesticide jug was folded. One once of product was lost. This jug was on the same transport trailer as a shipment for a natural food store. Persons at the natural food store felt the symptoms after their shipment was unloaded.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.
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: Female
Age: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Gastrointestinal System
- Symptom - Nausea
- Nervous and Muscular Systems
- Symptom - Headache
4. How long did the symptoms last?
Unknown / Inconnu
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)
Other
9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)
10. Route(s) of exposure.
Respiratory
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.)
Foil cap under screw-top lid of a pesticide jug was folded. One once of product was lost. This jug was on the same transport trailer as a shipment for a natural food store. Persons at the natural food store felt the symptoms after their shipment was unloaded.
To be determined by Registrant
14. Severity classification.
Minor
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: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Nervous and Muscular Systems
- Symptom - Headache
- Gastrointestinal System
- Symptom - Nausea
4. How long did the symptoms last?
Unknown / Inconnu
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)
Other
9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)
10. Route(s) of exposure.
Respiratory
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.)
Foil cap under screw-top lid of a pesticide jug was folded. One once of product was lost. This jug was on the same transport trailer as a shipment for a natural food store. Persons at the natural food store felt the symptoms after their shipment was unloaded.
To be determined by Registrant
14. Severity classification.
Minor
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: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Gastrointestinal System
- Symptom - Nausea
- Nervous and Muscular Systems
- Symptom - Headache
4. How long did the symptoms last?
Unknown / Inconnu
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)
Other
9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)
10. Route(s) of exposure.
Respiratory
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.)
Foil cap under screw-top lid of a pesticide jug was folded. One once of product was lost. This jug was on the same transport trailer as a shipment for a natural food store. Persons at the natural food store felt the symptoms after their shipment was unloaded.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.
Subform VI: Packaging Failure
1. What is the type of packaging that failed?
Jug-plastic / Cruche-plastique
2. Did packaging failure occur during?
Transportation
3. Did packaging failure result in?
potential exposure
4. Describe how the packaging failed and the surrounding circumstances, including a description of the potential injury or exposure.
an ounce of product leaked from one jug from 1 of two cases. Other non-pesticide product on the same truck may have been affected. Four females, non-pregnant, could smell pesticide as they disposed of their shipment over a three hour period.
