Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-4253

2. Registrant Information.

Registrant Reference Number: 2012-IR-10

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

Address: 1919 Minnesota Court

City: Mississauga

Prov / State: ON

Country: Canada

Postal Code: L5M 2J4

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

Human

4. Date registrant was first informed of the incident.

31-JUL-12

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

31-JUL-12

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)

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PMRA Registration No. 27348      PMRA Submission No.       EPA Registration No. 352-656

Product Name: Kocide 2000 Fungicide/Bactericide

• Active Ingredient(s)
  • COPPER AS ELEMENTAL (PRESENT AS COPPER HYDROXIDE)

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7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

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.

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

• Eye
  • Symptom - Tearing

4. How long did the symptoms last?

>24 hrs <=3 days / >24 h <=3 jours

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

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)

Goggles

10. Route(s) of exposure.

Eye

11. What was the length of exposure?

>2 hrs <=8 hrs / >2 h <=8 h

12. Time between exposure and onset of symptoms.

>2 hrs <=8 hrs / > 2 h < = 8 h

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.)

This incident was due to equipment failure - the nozzle came loose and the person was accidentally sprayed with Kocide 2000. The eye was rinsed on and off for 3 hours. The only symptom reported was tearing. The first call came in to the namePoison and Drug Centre at 15:09, and a follow up call was placed around 16:00. At this time the patient reported that the eye was "feeling better".

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.