Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2011-2391
2. Registrant Information.
Registrant Reference Number: PROSAR Case # 1-26278385
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.
25-MAY-11
5. Location of incident.
Country: CANADA
Prov / State: ALBERTA
6. Date incident was first observed.
25-MAY-11
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. 27884
PMRA Submission No.
EPA Registration No.
Product Name: Par III Turf Herbicide
- 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 (PRESENT AS DIMETHYLAMINE SALT)
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).
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: Male
Age: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Respiratory System
- Symptom - Scratchy throat
- Symptom - Coughing
4. How long did the symptoms last?
Unknown / Inconnu
5. Was medical treatment provided? Provide details in question 13.
Unknown
6. a) Was the person hospitalized?
Unknown
6. b) For how long?
7. Exposure scenario
Non-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)
Unknown
10. Route(s) of exposure.
Respiratory
11. What was the length of exposure?
Unknown / Inconnu
12. Time between exposure and onset of symptoms.
<=30 min / <=30 min
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.)
1-26278385- The reporter indicates he was exposed to an herbicide containing the active ingredients 2, 4-D (dimethylamine salt), MCPP-P (dimethylamine salt), and Dicamba (dimethylamine salt). The caller reports her was applying the product to his neighbors residential lawn within one hour of his initial contact. The caller indicated he may have inhaled some overspray of the product. He reports he has experienced a scratchy throat and cough since that time. The caller was advised of the potential irritant effect of inhalation exposure to this product. He was advised to seek fresh air and monitor for worsening or prolonged symptoms and seek medical care to address his symptoms as needed. The caller did not respond to follow-up attempts.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.