Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2016-3573
2. Registrant Information.
Registrant Reference Number: 2016-IR-03
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
Packaging Failure
4. Date registrant was first informed of the incident.
28-JUN-16
5. Location of incident.
Country: CANADA
Prov / State: SASKATCHEWAN
6. Date incident was first observed.
30-MAY-16
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. 25462
PMRA Submission No.
EPA Registration No.
Product Name: Assure II Herbicide
7. b) Type of formulation.
Application Information
8. Product was applied?
No
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.
Data Subject
2. Demographic information of data subject
Sex: Male
Age: Unknown / Inconnu
3. List all symptoms, using the selections below.
System
- Respiratory System
- Symptom - Difficulty Breathing
4. How long did the symptoms last?
Unknown / Inconnu
5. Was medical treatment provided? Provide details in question 13.
Yes
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)
Pesticide Spill
9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)
10. Route(s) of exposure.
Skin
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.)
On Friday June 3/16, a call was received that on May 30th an employee had spilled some Assure II on themselves . The manager said that the employee grabbed a box of Assure II of the top of the pallet. As he pulled it towards him, some contents from the Assure II jug spilled on him. The employee washed off, changed clothes and went to the hospital for further examination. The retail manager said the employee is sensitive to chemicals and had some reactions to the spill, including breathing and skin irritation. Upon further investigation, they said the Assure II jug was unsealed. All contaminated jugs, clothing and clean up material has been put into a chemical spill drum.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.
Subform VI: Packaging Failure
1. What is the type of packaging that failed?
Jug-plastic / Cruche-plastique
2. Did packaging failure occur during?
Storage
3. Did packaging failure result in?
potential exposure
4. Describe how the packaging failed and the surrounding circumstances, including a description of the potential injury or exposure.
It was determined that the product container was not sealed properly. When the retailer pulled it off the top pallet some product spilled on him.
For Registrant use only
5. Provide supplemental information here.