Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-4874

2. Registrant Information.

Registrant Reference Number: unknown

Registrant Name (Full Legal Name no abbreviations): LOVELAND PRODUCTS CANADA INC

Address: 789 DONNYBROOK DRIVE

City: DORCHESTER

Prov / State: ON

Country: CANADA

Postal Code: N0L 1G5

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

Human

4. Date registrant was first informed of the incident.

27-JUL-12

5. Location of incident.

Country: CANADA

Prov / State: SASKATCHEWAN

6. Date incident was first observed.

27-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. 9382      PMRA Submission No.       EPA Registration No.

Product Name: LAGON 480 E INSECTICIDE

• Active Ingredient(s)
  • DIMETHOATE

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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: Agricultural-Outdoor/Agricole-extérieur

Préciser le type: unknown

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

AERIAL APPLICATION, Roadside workers doing road construction were exposed to spray drift.

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.

Other

2. Demographic information of data subject

Sex: Female

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Nausea

• General
  • Symptom - Discomfort
  • Symptom - Dehydration
  • Symptom - Lightheadedness

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.

No

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

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)

Unknown

10. Route(s) of exposure.

Unknown

11. What was the length of exposure?

>15 min <=2 hrs / >15 min <=2 h

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.)

A roadside paving crew was exposed to pesticide drift from a crop duster airplane adjacent to the target crop field. After exposure to pesticide drift, employees showered, changed clothing, consumed water, and were able to return to work on that same day.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

Incident details provided to registrant by: (name) / Administrator at (company name), (addresss) (phone number) (fax number) on Saturday November 10th, 2012.

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

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Female

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• General
  • Symptom - Discomfort
  • Symptom - Lightheadedness

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.

No

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

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)

Unknown

10. Route(s) of exposure.

Unknown

11. What was the length of exposure?

>15 min <=2 hrs / >15 min <=2 h

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.)

A roadside paving crew was exposed to pesticide drift from a crop duster airplane adjacent to the target crop field. After exposure to pesticide drift, employees showered, changed clothing, consumed water, and were able to return to work on that same day.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

Incident details provided to registrant by: (name) at (company name), (address) Phone: Fax: ( on Saturday November 10th, 2012.

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

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Female

Age: >12 <=19 yrs / >12 <=19 ans

3. List all symptoms, using the selections below.

System

• General
  • Symptom - Discomfort
  • Symptom - Lightheadedness

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.

No

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

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)

Unknown

10. Route(s) of exposure.

Unknown

11. What was the length of exposure?

>15 min <=2 hrs / >15 min <=2 h

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.)

A roadside paving crew was exposed to pesticide drift from a crop duster airplane adjacent to the target crop field. After exposure to pesticide drift, employees showered, changed clothing, consumed water, and were able to return to work on that same day.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

Incident details provided to registrant by: (name) / (company name)., (address) Phone: Fax: (on Saturday November 10th, 2012.