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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2013-6014
2. Registrant Information.
Registrant Reference Number: 1-35031848
Registrant Name (Full Legal Name no abbreviations): Loveland Products, Inc.
Address: P.O. Box 1286 (80632-1286)
City: Greeley
Prov / State: Colorado
Country: USA
3. Select the appropriate subform(s) for the incident.
Human
4. Date registrant was first informed of the incident.
24-SEP-135. Location of incident.
Country: CANADA
Prov / State: ALBERTA
6. Date incident was first observed.
Unknown
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. 27884 PMRA Submission No. EPA Registration No.
Product Name: Par III Turf Herbicide
- 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)
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.
Other
2. Demographic information of data subject
Sex: Male
Age: >1 <=6 yrs / > 1 < = 6 ans
3. List all symptoms, using the selections below.
System
- Gastrointestinal System
- Symptom - Gagging
- Symptom - Nausea
- Respiratory System
- Symptom - Coughing
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)
Contact with treated area
Amount of time between application and contact 24
Hour(s) / Heure(s)
What was the activity? Playing with a ball in the application area
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?
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.)
1-35031848 - The reporter indicated that his grandson was exposed to an herbicide containing the active ingredients 2,4-D, Mecoprop-p and Dicamba. The reporter stated that his (age)-month-old grandson was playing ball in the application area about 24 hours after the product had been applied and afterwards the child was coughing and gagging like he was attempting to vomit. Per the reporter when his grandson was in the application area the product was completely dry and the only contact the patient could have had was with dried residue. The reporter was advised that the described symptoms would not be expected after contact with the dried residue. No further information is available.
To be determined by Registrant
14. Severity classification.
Minor
