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Consumer Product Safety

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-11

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

21-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.       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

19. Provide supplemental information here