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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-2157
2. Registrant Information.
Registrant Reference Number: PROSAR # 1-30159110
Registrant Name (Full Legal Name no abbreviations): Loveland 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.
17-MAY-125. Location of incident.
Country: CANADA
Prov / State: QUEBEC
6. Date incident was first observed.
17-MAY-12Product 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: Pub. Area - Outdoor/Zone publique - ext
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
- Gastrointestinal System
- Symptom - Nausea
- Respiratory System
- Symptom - Irritated throat
- Gastrointestinal System
- Symptom - Stomach pain
- Nervous and Muscular Systems
- Symptom - Headache
- General
- Symptom - Pain
- Specify - side pain
4. How long did the symptoms last?
>3 days <=1 wk / >3 jours <=1 sem
5. Was medical treatment provided? Provide details in question 13.
No
6. a) Was the person hospitalized?
No
6. b) For how long?
7. Exposure scenario
Non-occupational
8. How did exposure occur? (Select all that apply)
Drift from the application site
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.
<=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.)
1-30159110- The reporter indicated he had been exposed to an herbicide containing the active ingredients 2,4-D, mecoprop-p, and dicamba. The reporter stated he had just been to a golf course just before the call and the groundskeepers were spraying the green with the product. The caller reports there was a wind and he encountered a taste he assumes was the herbicide. He reports he is not aware of any other exposure (eye, skin, etc). The caller had encountered nausea, throat irritation and abdominal pain in the 15 minutes following the exposure. The caller was advised no harm would be anticipated from this exposure. He was advised of symptomatic care at home and the threshold at which to see a doctor. On follow up six days later the caller indicated he has an intermittent head ache and side pain since the exposure but has not seen a doctor. The caller attributed his symptoms to nerves. No further information is available.
To be determined by Registrant
14. Severity classification.
Moderate
