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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-1282
2. Registrant Information.
Registrant Reference Number: PROSAR Case#: 1-27081390
Registrant Name (Full Legal Name no abbreviations): Valent Canada, Inc.
Address: 6-130 Research Lane
City: Guelph
Prov / State: Ontario
Country: Canada
Postal Code: N1G 5G3
3. Select the appropriate subform(s) for the incident.
Human
4. Date registrant was first informed of the incident.
08-AUG-115. Location of incident.
Country: UNITED STATES
Prov / State: FLORIDA
6. Date incident was first observed.
06-AUG-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. 869-174
Product Name: Green Light BT Worm Killer
- Active Ingredient(s)
- BACILLUS THURINGIENSIS SUBSPECIES KURSTAKI (ALL STRAINS)
7. b) Type of formulation.
Liquid
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: Unknown / Inconnu
3. List all symptoms, using the selections below.
System
- Nervous and Muscular Systems
- Symptom - Coma
- Gastrointestinal System
- Symptom - Vomiting
- Nervous and Muscular Systems
- Symptom - Unconsciousness
- Symptom - Seizure
4. How long did the symptoms last?
>8 hrs <=24 hrs / > 8 h < = 24 h
5. Was medical treatment provided? Provide details in question 13.
Yes
6. a) Was the person hospitalized?
Yes
6. b) For how long?
Unknown
7. Exposure scenario
Non-occupational
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)
None
10. Route(s) of exposure.
Oral
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.)
1-27081390- The reporter indicates he was exposed to a pesticide containing the active ingredient Bacillus thuringiensis. The reporter indicated he had applied the product to tomatoes in his residential vegetable garden ten days prior to his initial contact. Application was not described. He reported seven days later he had picked the fruit, washed it, and had eaten it. He reported eighteen hours later he vomited, collapsed, went into a coma, and "basically had a seizure". He was taken to the hospital where he was treated. He did not describe the treatment or diagnostics done but his initial contact with the registrant was two days later at which point he indicated he was at home and was still struggling to determine the cause for his illness. The reporter indicated he had called a public poison control center regarding the potential exposure and was told the exposure would not be expected to be associated with the illness. This was validated for the reporter by the registrant. The symptoms described would not be expected to be linked to the exposure described. He was encouraged to continue working with his doctor to determine the cause of his illness. No further information is available.
To be determined by Registrant
14. Severity classification.
Major
