Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2009-2315
2. Registrant Information.
Registrant Reference Number: 2009-IR-04
Registrant Name (Full Legal Name no abbreviations): E. I. du Pont Canada Company
Address: P.O. box 2300, Streetsville
City: Mississauga
Prov / State: ON
Country: Canada
Postal Code: L5M 2J4
3. Select the appropriate subform(s) for the incident.
Human
4. Date registrant was first informed of the incident.
06-JUL-09
5. Location of incident.
Country: CANADA
Prov / State: SASKATCHEWAN
6. Date incident was first observed.
30-JUN-09
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.
Active(s)
PMRA Registration No. 28262
PMRA Submission No.
EPA Registration No.
Product Name: Express SG Herbicide, Refine SG Toss-N-Go Herbicide
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).
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: >12 <=19 yrs / >12 <=19 ans
3. List all symptoms, using the selections below.
System
- Respiratory System
- Symptom - Respiratory distress
- Specify - mild respiratory distress
- Respiratory System
- Symptom - Respiratory irritation
4. How long did the symptoms last?
>2 hrs <=8 hrs / > 2 h < = 8 h
5. Was medical treatment provided? Provide details in question 13.
No
6. a) Was the person hospitalized?
Unknown
6. b) For how long?
7. Exposure scenario
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)
10. Route(s) of exposure.
Skin
Eye
Oral
Respiratory
11. What was the length of exposure?
<=15 min / <=15 min
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.)
Person, (age) years of age, was instructed to pour the bags back into the machine and the dust flew everywhere, concerned she may have tasted and inhaled some. Mild respiratory distress began at an unknown time, eye irritation, respiratory irritation, "I just don't feel good".
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.
Recommened that person thorough irriagation and change clothing as soon as possible. Poison control centre called person approximately 2 hours later, and persons eyes are sore, muscle aches and feels tired. Person was able to shower and rinse eyes. Still driving home. No medicated eye drops. Cool cloth to closed eyes when person gets home. Poison control called person the following day to follow up. Symptoms resolved later that first evening. Feels much better.