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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-2453

2. Registrant Information.

Registrant Reference Number: 2012-IR-08

Registrant Name (Full Legal Name no abbreviations): E.I. du Pont Canada Company

Address: 7070 Mississauga Road

City: Mississauga

Prov / State: ON

Country: Canada

Postal Code: LN 5M8

3. Select the appropriate subform(s) for the incident.


4. Date registrant was first informed of the incident.


5. Location of incident.


Prov / State: MICHIGAN

6. Date incident was first observed.


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.


PMRA Registration No.       PMRA Submission No.       EPA Registration No. 352-793

Product Name: DuPont Imprelis Herbicide

  • Active Ingredient(s)

7. b) Type of formulation.


Application Information

8. Product was applied?


9. Application Rate.


10. Site pesticide was applied to (select all that apply).

Site: Res. - Out Home / Rés - à l'

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

Product was applied to a yard by the homeowners landscapers.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?


Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.


2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.


  • General
    • Symptom - Cancer
    • Specify - skin cancer "merkel cell carcinoma"

4. How long did the symptoms last?

Unknown / Inconnu

5. Was medical treatment provided? Provide details in question 13.


6. a) Was the person hospitalized?


6. b) For how long?

7. Exposure scenario


8. How did exposure occur? (Select all that apply)

Contact with treated area

What was the activity? re-entry

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)


10. Route(s) of exposure.


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.)

On may 18 and 21st, "the person" talked to (name) poison control centre (RMPC) to report that Imprelis had been used on his property and he believed that skin cancer appeared on his body in April 2011. He further stated that imprelis killed his pine trees and six other trees and he believed that exposure from contact with dirt and grass in his yard "may have aggitated it or something" (refereing to the skin cancer). No specific time of exposure or duration of exposure to the product was given. The product was applied by his landscapers.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.

(name) reported that information was read to "the person" from the MSDS for Imprelis including, "none of the components present in this material at concentrations equal to or greater than 0.1% are listed by (name), (name) or (name), as a carcinogen. And "SKIN Contact: the material is not likely to be hazardous by skin contact, but cleansing the skin after use is advisable. He was also told to follow up with a physician.