Incident Report

Subform I: General Information

1. Report Type.

Update the report

Incident Report Number: 2009-5394

2. Registrant Information.

Registrant Reference Number: Prosar 1-20979121

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: N0L1G5

3. Select the appropriate subform(s) for the incident.

Human

4. Date registrant was first informed of the incident.

10-DEC-09

5. Location of incident.

Country: CANADA

Prov / State: NOVA SCOTIA

6. Date incident was first observed.

Unknown

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)

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PMRA Registration No. 27884      PMRA Submission No.       EPA Registration No.

Product Name: Par III Turf Herbicide CANADA

• Active Ingredient(s)
  • 2,4-D (PRESENT AS AMINE SALTS : DIMETHYLAMINE SALT, DIETHANOLAMINE SALT, OR OTHER AMINE SALTS)
  • DICAMBA (PRESENT AS ACID, AMINE SALT, ESTER, OR SODIUM SALT)
  • MECOPROP P-ISOMER PRESENT AS DIMETHYLAMINE SALT

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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).

The product was applied in 1997 outside the reporter's residence. The product was applied outside at a different location in 2006.

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: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Seizure
  • Specify - myoclonic seizure

• Skin
  • Symptom - Lesion
  • Specify - Scabs and scarring
  • Symptom - Flushed
  • Specify - flushing
  • Symptom - Other
  • Specify - Fallicullar eczema

• Cardiovascular System
  • Symptom - Chest pain
  • Symptom - Tachycardia

• Respiratory System
  • Symptom - Bronchitis
  • Specify - Chronic Bronchitis
  • Symptom - Other
  • Specify - Emphysema
  • Symptom - Difficulty Breathing
  • Specify - Trouble breathing

• Nervous and Muscular Systems
  • Symptom - Unconsciousness
  • Specify - Loss of conciousness

4. How long did the symptoms last?

Unknown / Inconnu

5. Was medical treatment provided? Provide details in question 13.

Yes

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)

Drift from the application site

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

Unknown

10. Route(s) of exposure.

Skin

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.)

1-20979121: A reporter called on 12/10/2009 to report her exposure on two separate occasions to an herbicide containing the active ingredients 2,4-D, Mecoprop, and Dicamba. According to the reporter, the product was sprayed outside her home in 1997. The reporter indicates that the product drifted into her home and resulted in her having seizures for the next 8 years whenever she was around other chemicals. In 2006, the reporter was walking past someone spraying the product and sustained dermal and respiratory exposure. The reporter indicated that this exposure resulted in exacerbation of a previous skin condition and led to flushing, scabs, and scarring of her skin. She did see a physician sometime following the second exposure. The reporter stated that she is using topical cortisone for follicular eczema at the time of the report. The reporter was advised that the product may result in minor skin or respiratory irritation following dermal or respiratory contact. Rinsing skin and symptomatic care is generally all that is required for dermal exposures. Individual sensitivities are treated symptomatically, and dermal absorption is not expected. The reporter was advised that excessive exposure to the product may irritate pre-existing skin and respiratory disorders. Signs would not be expected to persist for 3 years as described. No further information was obtained.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.