Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-4884

2. Registrant Information.

Registrant Reference Number: PROSAR case #: 1-34208773

Registrant Name (Full Legal Name no abbreviations): United Agri 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.

04-JUL-13

5. Location of incident.

Country: CANADA

Prov / State: BRITISH COLUMBIA

6. Date incident was first observed.

03-JUL-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)

---

PMRA Registration No. 9382      PMRA Submission No.       EPA Registration No.

Product Name: Lagon 480 E

• Active Ingredient(s)
  • DIMETHOATE

---

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: >1 <=6 yrs / > 1 < = 6 ans

3. List all symptoms, using the selections below.

System

• General
  • Symptom - Fever

• Nervous and Muscular Systems
  • Symptom - Headache

• Gastrointestinal System
  • Symptom - Vomiting

• General
  • Symptom - Lethargy
  • Symptom - Malaise

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)

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

10. Route(s) of exposure.

Unknown

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.)

1-34208773 - The reporter indicated that an insecticide containing the active ingredients dimethoate and cyclohexanone were applied to blueberry bushes near his house one day prior to initial contact with the registrant. The reporter cannot identify a route of exposure and is confident that there was no contact with the wet product, there was no odor associated with the product, and none of the treated fruit trees have fruit that could be consumed. Several hours after application, caller's young male child became ill, slept in very late the following morning, developed a headache, fever, and vomited one time. He also reports that his girlfriend's young daughter is also ill and slept late the following morning as well. The reporter considers that the children may have had contact with the dried product as they like to play outside without shoes on their feet. The reporter was advised that possible skin contact with the dry product is not expected to cause toxicity associated with organophosphates, although minor skin irritation is possible. The reporter was further advised that fever is inconsistent with exposure to organophosphates. Medical attention was recommended for any severe or persistent symptoms. The reporter did not respond to follow up inquiry. No further information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

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: Female

Age: >1 <=6 yrs / > 1 < = 6 ans

3. List all symptoms, using the selections below.

System

• General
  • Symptom - Lethargy
  • Symptom - Malaise

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

Unknown

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

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

10. Route(s) of exposure.

Unknown

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.)

1-34208773 - The reporter indicated that an insecticide containing the active ingredients dimethoate and cyclohexanone were applied to blueberry bushes near his house one day prior to initial contact with the registrant. The reporter cannot identify a route of exposure and is confident that there was no contact with the wet product, there was no odor associated with the product, and none of the treated fruit trees have fruit that could be consumed. Several hours after application, caller's young male child became ill, slept in very late the following morning, developed a headache, fever, and vomited one time. He also reports that his girlfriend's young daughter is also ill and slept late the following morning as well. The reporter considers that the children may have had contact with the dried product as they like to play outside without shoes on their feet. The reporter was advised that possible skin contact with the dry product is not expected to cause toxicity associated with organophosphates, although minor skin irritation is possible. The reporter was further advised that fever is inconsistent with exposure to organophosphates. Medical attention was recommended for any severe or persistent symptoms. The reporter did not respond to follow up inquiry. No further information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.