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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-2821

2. Registrant Information.

Registrant Reference Number: 2010-01

Registrant Name (Full Legal Name no abbreviations): Interprovincial Cooperative Limited (IPCO)

Address: 945 Marion Street

City: Winnipeg

Prov / State: Manitoba

Country: Canada

Postal Code: R2J 0K7

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


4. Date registrant was first informed of the incident.


5. Location of incident.

Country: CANADA

Prov / State: MANITOBA

6. Date incident was first observed.


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.


PMRA Registration No. 27802      PMRA Submission No.       EPA Registration No.

Product Name: IPCO MCPA Ester 600 Herbicide

  • Active Ingredient(s)

7. b) Type of formulation.

Application Information

8. Product was applied?


9. Application Rate.


10. Site pesticide was applied to (select all that apply).

Site: Agricultural-Outdoor/Agricole-extérieur

Préciser le type: Wheat

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

Farmer sprayed one field June 7, 2010 with MCPA Ester 600. He applied the same product for a second time on June 11, 2010. The day after the second application he had stomach cramps and diarrhea. He said he was wearing safety equipment, including goggles, and neoprene gloves during the application..

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?


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: Male

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

3. List all symptoms, using the selections below.


  • Gastrointestinal System
    • Symptom - Diarrhea
    • Symptom - Stomach cramps

4. How long did the symptoms last?

>24 hrs <=3 days / >24 h <=3 jours

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


6. a) Was the person hospitalized?


6. b) For how long?

7. Exposure scenario


8. How did exposure occur? (Select all that apply)


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

Long-sleeve shirt


Chemical resistant gloves

10. Route(s) of exposure.


11. What was the length of exposure?

>2 hrs <=8 hrs / >2 h <=8 h

12. Time between exposure and onset of symptoms.

>8 hrs <=24 hrs / > 8 h < = 24 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.)

Grower complained of stomach cramps and diarrhea next day after spraying. He went to a local clinic/hospital in (name) and saw a doctor. The doctor suspected flu, but asked what he had sprayed just to be sure there was no other factor affecting his condition. After recieving the initial call from the grower, IPCO followed up with calls to both the grower and hospital/doctor. The grower was feeling much better (June 17th/10) and the doctor felt the grower simply had the flu.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.