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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2011-2413
2. Registrant Information.
Registrant Reference Number: PROSAR Case 1 26235222
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
Domestic Animal
4. Date registrant was first informed of the incident.
22-MAY-115. Location of incident.
Country: CANADA
Prov / State: QUEBEC
6. Date incident was first observed.
21-MAY-11Product 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. PMRA Submission No. EPA Registration No. Unknown
Product Name: Captan 80 Fungicide
- Active Ingredient(s)
- CAPTAN
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: Unknown / Inconnu
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
The caller did indicate he had applied the product to an orchard, but did not indicate if this was a commercial setting or what crop was involved.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
- Skin
- Symptom - Irritated skin
- Symptom - Erythema
- Symptom - Hives
- Symptom - Dry skin
- Symptom -
- Specify - goose bumps
- Symptom - Red skin
- Specify - redness on face
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?
Unknown
6. b) For how long?
7. Exposure scenario
Unknown
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.
Skin
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 26235222 The caller reports her boyfriend was exposed to a fungicide containing the active ingredient Captan. The reporter indicates the adult male Subform 2, 1 was mixing the product for application to an unspecified crop in an unspecified capacity the day prior to the initial contact with the registrant. He was reported to spill concentrate on himself. She did not specify the location of his body that met contact with the product. She did not specify any decontamination measures following the exposure. She reports the exposed individual had developed goose bumps and redness on his face, chest, and neck shortly after exposure exact time frame not disclosed.The caller indicated they were about to seek medical attention for the exposed individual and were calling for advice. The caller was advised of the potential irritant effect following dermal contact, proper decontamination and the threshold at which to seek medical attention. On follow up the exposed individual was spoken to. He indicated he was diagnosed with a hypersensitivity response. He was given oral diphenhydramine and prednisone. His symptoms were responding favorably. He indicated the physician had stated the reaction was to the product, but also indicated no allergy testing was done. The party spoken to at that time indicated his mother Subform 2, 2 had itchy eyes that have gotten worse since the day of the original contact with the registrant. Further, his two year male one hundred forty pound Bernese mountain dog Subform 3, 1 had been lame since that time as well. The caller indicated no exposure to his mother or dog. It was told to the caller that the signs and symptoms seen in his mother and dog would be unexpected to be related to the product use and was advised to seek veterinary or medical care for the affected individuals to determine the appropriate care and etiology of their signs or symptoms. No further information is available.
To be determined by Registrant
14. Severity classification.
Moderate
15. Provide supplemental information here.
Subform II: Human Incident Report (A separate form for each person affected)
1. Source of Report.
Other
2. Demographic information of data subject
Sex: Female
Age: >64 yrs / > 64 ans
3. List all symptoms, using the selections below.
System
- Skin
- Symptom - Pruritus
- Eye
- Symptom - Itchy eye
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)
Contact with treated area
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.
Unknown
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 26235222 The caller reports her boyfriend was exposed to a fungicide containing the active ingredient Captan. The reporter indicates the adult male Subform 2, 1 was mixing the product for application to an unspecified crop in an unspecified capacity the day prior to the initial contact with the registrant. He was reported to spill concentrate on himself. She did not specify the location of his body that met contact with the product. She did not specify any decontamination measures following the exposure. She reports the exposed individual had developed goose bumps and redness on his face, chest, and neck shortly after exposure exact time frame not disclosed.The caller indicated they were about to seek medical attention for the exposed individual and were calling for advice. The caller was advised of the potential irritant effect following dermal contact, proper decontamination and the threshold at which to seek medical attention. On follow up the exposed individual was spoken to. He indicated he was diagnosed with a hypersensitivity response. He was given oral diphenhydramine and prednisone. His symptoms were responding favorably. He indicated the physician had stated the reaction was to the product, but also indicated no allergy testing was done. The party spoken to at that time indicated his mother Subform 2, 2 had itchy eyes that have gotten worse since the day of the original contact with the registrant. Further, his two year male one hundred forty pound Bernese mountain dog Subform 3, 1 had been lame since that time as well. The caller indicated no exposure to his mother or dog. It was told to the caller that the signs and symptoms seen in his mother and dog would be unexpected to be related to the product use and was advised to seek veterinary or medical care for the affected individuals to determine the appropriate care and etiology of their signs or symptoms. No further information is available.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
Bernese mountain dog
4. Number of animals affected
1
5. Sex
6. Age (provide a range if necessary )
2
7. Weight (provide a range if necessary )
140
lbs
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- Nervous and Muscular Systems
- Symptom - Difficulty getting up
12. How long did the symptoms last?
Unknown / Inconnu
13. Was medical treatment provided? Provide details in question 17.
Unknown
14. a) Was the animal hospitalized?
Unknown
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Unknown/Inconnu
16. How was the animal exposed?
Contact treat.area/Contact surf. traitée
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
1 26235222 The caller reports her boyfriend was exposed to a fungicide containing the active ingredient Captan. The reporter indicates the adult male Subform 2, 1 was mixing the product for application to an unspecified crop in an unspecified capacity the day prior to the initial contact with the registrant. He was reported to spill concentrate on himself. She did not specify the location of his body that met contact with the product. She did not specify any decontamination measures following the exposure. She reports the exposed individual had developed goose bumps and redness on his face, chest, and neck shortly after exposure exact time frame not disclosed.The caller indicated they were about to seek medical attention for the exposed individual and were calling for advice. The caller was advised of the potential irritant effect following dermal contact, proper decontamination and the threshold at which to seek medical attention. On follow up the exposed individual was spoken to. He indicated he was diagnosed with a hypersensitivity response. He was given oral diphenhydramine and prednisone. His symptoms were responding favorably. He indicated the physician had stated the reaction was to the product, but also indicated no allergy testing was done. The party spoken to at that time indicated his mother Subform 2, 2 had itchy eyes that have gotten worse since the day of the original contact with the registrant. Further, his two year male one hundred forty pound Bernese mountain dog Subform 3, 1 had been lame since that time as well. The caller indicated no exposure to his mother or dog. It was told to the caller that the signs and symptoms seen in his mother and dog would be unexpected to be related to the product use and was advised to seek veterinary or medical care for the affected individuals to determine the appropriate care and etiology of their signs or symptoms. No further information is available.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Moderate
