Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-3124

2. Registrant Information.

Registrant Reference Number: Rocky Mountain Poison and Drug case #5468928

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.

15-JUL-15

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

13-JUL-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?

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).

Caller has a landowner that sprayed weeds in surrounding area, using Par III, killed the grass, he may have mixed it to strong and it misted onto his garden

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: Unknown

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

3. List all symptoms, using the selections below.

System

• General
  • Symptom - Fever

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)

Other

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

10. Route(s) of exposure.

Oral

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.)

Case Information Date/Time: 07/14/15 11:44 Company: (name) Retail Call Type: Exposure Specialist: (name) Contact/Caller Information Caller 1: (name)Title: Address: Relation: Family Father City, State, Zip, Cntry: (city), AB, (postal code), Canada Call Site: Residence Caller's Residence Phone: (phone number) Product 1 Product Name: Par III Herbicide Category: OtherUnknown Formulation: Liquid Active Ingredient(s): Product 2 Product Name: Par III Turf Herbicide Category: Pesticide Professional Division: Loveland Products Formulation: Liquid PCP Code: 27884 Active Ingredient(s): DMA Salt of 2,4D, DMA Salt of Dicamba, DMA Salt of MCPPP Patient 1 Information Patient Name: Gender: Unknown Receptor: Human Address: Age: (age)years Weight: Not Specified City, State, Zip, Cntry: USA Phone: Patient 1 Exposure Information Exposure Site: Residence Reason Detail: ChildPet Direct Access UGUnintentional General Occupational: No Acuity: Acute Product Name: Par III Herbicide Time Of Exposure: 1.00 Days ago Route: Ingestion Amount Of Exposure: tastelickdrop Certainty: estimate Patient 1 Clinical Effects Effects Present: Miscellaneous Feverhyperthermia Relatedness: Not related Onset: 1.00 Days ago Effects Present: Gastrointestinal Gastric Upset Relatedness: Not related Onset: 1.00 Days ago Patient 1 Management Information Type: OnSiteNonHCF Result: Caller encouraged to call with any questions, concerns or additional symptoms SubType: Residence Patient 1 Therapy Information Therapy Type: Dilute/irrigate/wash Recommendation: Performed Patient 1 Outcome Medical Outcome: Unrelated Effect Effect Duration: Industry Outcome: Minor Industry Duration: Unknown Causation: Not Related EPA Code: HD Patient 2 Information Patient Name: Gender: Unknown Receptor: Human Address: Age: (age) years Weight: Not Specified City, State, Zip, Cntry: USA Phone: Patient 2 Exposure Information Exposure Site: Residence Reason Detail: ChildPet Direct Access UGUnintentional General Occupational: No Acuity: Acute Product Name: Par III Herbicide Time Of Exposure: 1.00 Days ago Route: Ingestion Amount Of Exposure: tastelickdrop Certainty: estimate Patient 2 Clinical Effects Effects Present: Miscellaneous Feverhyperthermia Relatedness: Not related Onset: 1.00 Days ago Effects Present: Gastrointestinal Gastric Upset Relatedness: Not related Onset: 1.00 Days ago Patient 2 Management Information Type: OnSiteNonHCF Result: Caller encouraged to call with any questions, concerns or additional symptoms SubType: Residence Patient 2 Therapy Information Therapy Type: Dilute/irrigate/wash Recommendation: Performed Patient 2 Outcome Medical Outcome: Unrelated Effect Effect Duration: Industry Outcome: Minor Industry Duration: Unknown Causation: Not Related EPA Code: HD

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

(name) 07/14/15 11:44 S: Caller has a landowner that sprayed weeds in surrounding area, using Par III, killed the grass, he may have mixed it to strong and it misted onto his garden. His kids ate a couple of rasberries and they are sick today. They have MD at 3pm TOE: yesterday Sx's started last night O: fever stomach upset A: Acute Peds Taste Ingestion of Par III herbicide, sx. R: Would not expect this is related. A taste exposure of the wet product would not likely cause any sx's. Larger ingestions of wet product could cause skin irritation, GI upset. Since this was on the plants for a week before ingestion,. it was likely dry and should not cause sx's. CB with any questions or concerns. ......ROCKY MOUNTAIN REPORT ATTACHED.....