Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-3679

2. Registrant Information.

Registrant Reference Number: PROSAR case #: 1-33900214

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.

05-JUN-13

5. Location of incident.

Country: CANADA

Prov / State: MANITOBA

6. Date incident was first observed.

04-JUN-13

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. 27884      PMRA Submission No.       EPA Registration No.

Product Name: Par III Turf Herbicide Canada

• 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)

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

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Headache

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

7. Exposure scenario

Non-occupational

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)

Long-sleeve shirt

Long pants

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.

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

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.)

1-33641432 - The reporter indicated that he was exposed to an herbicide containing the active ingredients 2,4-D, Mecoprop-p and Dicamba. The reporter states that he applied the product outside his daughters home two days prior to initial contact with the registrant. The application took about one hour, the product was diluted according to directions and the reporter was wearing protective clothing including rubber boots during application. No direct exposure was described but the reporter indicated that it was windy during application. The reporter did shower immediately after application. One day later the reporter developed a headache which per the reporter is atypical for him. The reporter was advised that there are numerous possible causes for a headache and the time frame in which his symptom had developed is not consistent with product exposure. Medical attention was recommended for any severe or persistent symptoms. No further information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.