Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-2109

2. Registrant Information.

Registrant Reference Number: Case 5455048 Rocky Mountain Poison and Drug Center

Registrant Name (Full Legal Name no abbreviations): Agrium Advanced Technologies

Address: 10 Craig St.

City: Brantford

Prov / State: ON

Country: CANADA

Postal Code: N3R 7J1

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

Human

4. Date registrant was first informed of the incident.

21-MAY-15

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

19-MAY-15

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

• 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?

Unknown

9. Application Rate.

10. Site pesticide was applied to (select all that apply).

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.

Medical Professional

2. Demographic information of data subject

Sex: Male

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

3. List all symptoms, using the selections below.

System

• Eye
  • Symptom - Irritated eye
  • Symptom - Pain

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?

No

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)

None

10. Route(s) of exposure.

Eye

11. What was the length of exposure?

<=15 min / <=15 min

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.)

Patient 1 Exposure Information Exposure Site: Residence Reason Detail: Handlingtransfermixing UGUnintentional General Occupational: No Acuity: Acute Product Name: Par III Turf Herbicide Time Of Exposure: Immediate Route: Ocular Exposure Duration: Brief Exposed To: Mist In: Both Eyes Patient 1 Clinical Effects Effects Present: Ocular Ocular Irritation/pain Relatedness: Related Onset: Immediate Patient 1 Management Information Type: OnSiteNonHCF Result: Callback declined SubType: Residence Patient 1 Therapy Information Therapy Type: Dilute/irrigate/wash Recommendation: Recommended Patient 1 Outcome Medical Outcome: Minor Effect Duration: Unknown Industry Outcome: Minor Industry Duration: Unknown Causation: Related EPA Code: HD

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

Notes (name) 05/19/15 22:age S: TC from female her husband got the product in his eyes, c/o eye irritation, NOPP GH, no meds, NKA O: eye irritation A: acute adult ocular exposure to par 3, symptomatic R: Irrigate eyes with lukewarm temperature and gentle stream of water 1520 minutes Do not hold the eye open Do not use eye drops If symptoms of pain, redness, irritation or visual disturbances persist, seek immediate opthalmic evaluation. call back declined she will call with further questions. PLEASE SEE ADDITIONAL FILE INCLUDED, from (name) POISON CENTRE