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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-4643

2. Registrant Information.

Registrant Reference Number: x

Registrant Name (Full Legal Name no abbreviations): x

Address: x

City: x

Prov / State: x

Country: x

Postal Code: X

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

Human

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

23-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)

PMRA Registration No. 27884      PMRA Submission No.       EPA Registration No.

Product Name: Par III

  • 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, POTASSIUM SALT, OR SODIUM SALT)
    • MECOPROP-P (PRESENT AS DIMETHYLAMINE SALT)

7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

2

Other Units: L/ac

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

Site: Agricultural-Outdoor/Agricole-extérieur

Préciser le type: Sod farm

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

Caller reports that her home is surrounded by a sod farm. They spray a pesticide on the sod on Friday and again today.Caller's residence is located at south-east corner of large sod field. Slight breeze would carry any spray mist away from the caller's property.Sprayed Par III (pcpa 27884) 2 L/ac starting at 7:00-7:30 am. Took about 2 hrs to spray 75 acres (1 sprayer tank at 750 gal). Whole field is 200 acres.

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: Female

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

  • Respiratory System
    • Symptom - Sore throat
  • Eye
    • Symptom - Watery eye

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

Unknown

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

Drift from the application site

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.

Respiratory

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.)

The odours and fumes are so strong it gives her family a sore throat and makes their eyes water.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.