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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2016-4915

2. Registrant Information.

Registrant Reference Number: 2016-IR-05

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.

Domestic Animal

4. Date registrant was first informed of the incident.

16-AUG-16

5. Location of incident.

Country: UNITED STATES

Prov / State: UNKNOWN

6. Date incident was first observed.

01-AUG-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.       PMRA Submission No.       EPA Registration No. 352-766

Product Name: Lineage Clearstand

  • Active Ingredient(s)
    • IMAZAPYR
      • Unknown
    • METSULFURON-METHYL
      • Unknown

7. b) Type of formulation.

Granular

Dry Flowable (water dispersible granules)

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

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

Site: Industrial / Industriel

Préciser le type: Electrical Utility right of way

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

Applicator applied low-volume backpack mix of 5% Accord + 25.2 oz. Lineage Clearstand per 100 gallons of water; applied to brush on electric ROW. Landowner alleges that horse died from herbicide application on electrical right of way after horse ate the foliage. Habitat is an electric utility ROW where applicator was spraying unwanted brush under power lines. Allege that horse ate treated foliage.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Yes

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Horse / Cheval

3. Breed

unknown

4. Number of animals affected

1

5. Sex

Unknown

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Oral

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

  • General
    • Symptom - Death
    • Specify - unknown

12. How long did the symptoms last?

Persisted until death

13. Was medical treatment provided? Provide details in question 17.

Unknown

14. a) Was the animal hospitalized?

Unknown

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Died

16. How was the animal exposed?

Contact treat.area/Contact surf. traitée

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

Applicator has not gathered all of the information as of today. He is working to collect all of the information on name, address, phone number of landowner, application date, date incident reported to Carroll Electric.


To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Death

19. Provide supplemental information here