Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-2423

2. Registrant Information.

Registrant Reference Number: 2014-IR-02

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.

26-JUN-14

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

25-JUN-14

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. 25462      PMRA Submission No.       EPA Registration No. 352-541

Product Name: Assure II Herbicide

• Active Ingredient(s)
  • QUIZALOFOP P-ETHYL

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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).

workplace

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

• General
  • Symptom - Lethargy
  • Specify - sluggish

4. How long did the symptoms last?

Unknown / Inconnu

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)

Application

Pesticide Spill

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.

Skin

11. What was the length of exposure?

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

12. Time between exposure and onset of symptoms.

>8 hrs <=24 hrs / > 8 h < = 24 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.)

Person was spraying with Assure II herbicide the day previous and is feeling sluggish the following day. He got some on his skin and showered immediately after. Some spilled on his forearm and face. None was ingested. He states that is was hot and humid but that he does stay well hydrated.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

adult acute occupational herbicide dermal exposure with skin. Recommended to keep hydrated. Unlikely symptoms are related, per MSDS product is low in toxicity and barely will cause dermal irritation. He declined a follow up call.