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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-2114

2. Registrant Information.

Registrant Reference Number: x

Registrant Name (Full Legal Name no abbreviations): x

Address: x

City: x

Prov / State: x

Country: x

Postal Code: X

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: ALBERTA

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. 28751      PMRA Submission No.       EPA Registration No.


  • 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).

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

N/A (No pesticide applied - ingested orally)

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.


2. Demographic information of data subject

Sex: Female

Age: >1 <=6 yrs / > 1 < = 6 ans

3. List all symptoms, using the selections below.


  • Nervous and Muscular Systems
    • Symptom - Unconsciousness
    • Specify - falling in and out of consciousness

4. How long did the symptoms last?

Unknown / Inconnu

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


6. a) Was the person hospitalized?


6. b) For how long?


Day(s) / Jour(s)

7. Exposure scenario


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

Poisoning from ingestion of the pesticide

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


10. Route(s) of exposure.


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.)

Youth discovered in cab of vehicle falling in and out of consciousness by family member. Transported to nearest hospital emergency ward where she remained for 3-4 hours and then air medi-vac to the (name) Children's Hospital, (city). Medical treatment/medication/test results/long term effects = unknown. Youth released from hospital on 07/05/2011. Next visit scheduled with family physician in two weeks. Youth appears to have made a full recovery. Youth was playing in cab of pick up truck and six(6) X 250 ml bottles of pesticide were in a glad garbage bag partially hidden under the front passenger's seat. It is unknown how long the youth was exposed to the pesticide but it is estimaed to be within a short period of time.Alberta Agriculture and Rural Development (Registrant # number) was notified of the incident on May 10, 2011. On April 29th the youths father (agricultural producer) received the product from an authorized Municipality. The product remained in the cab of his truck until the incident occurred. It is believed the youth discovered the product, removed the lid and seal and ingested the product. Father estimated that approx one inch of product was missing from the bottle. He reported that the secondary seal was found inside the black cap. The bottle in question along with one other bottle were taken to the hospital. The remaining four were returned.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.