Health Canada
Symbol of the Government of Canada
Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-4160

2. Registrant Information.

Registrant Reference Number: PROSAR Case # 1-27227634

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.

23-AUG-11

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

22-AUG-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?

Unknown

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).

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.

Medical Professional

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 - Shortness of breath
  • Nervous and Muscular Systems
    • Symptom - Agitation
    • Symptom - Muscle pain

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

Unknown

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)

Unknown

10. Route(s) of exposure.

Respiratory

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.)

1-27227634- The reporter, a nurse, indicated a patient had been exposed an herbicide containing the active ingredients 2,4-d, mecoprop-p, and dicamba. The reporter stated an adult male patient had presented to them the day prior with the primary complaint of shortness of breath, agitation and muscle aches. The patient had indicted he had been exposed to the product one week prior to his presentation via inhalation. The caller was charged by the treating physician to determine the potential for harm the exposure posed. The reporter had no further detail regarding the patient, his care, or the exposure incident. The reporter was advised of the potential for transitory respiratory irritation following exposure by this route and the potential for exacerbation of underlying respiratory conditions. But, she was advised systemic harm would not be anticipated by this route. It was likely due to the time line and the spectrum of symptoms the patients health concern was unrelated to the described exposure. No follow up was obtained from the reporter. No further information is available.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.