Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2016-5115

2. Registrant Information.

Registrant Reference Number: Rocky Mountain Poison and Drug case #5634510

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.

11-AUG-16

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

31-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)

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PMRA Registration No. 19146      PMRA Submission No.       EPA Registration No.

Product Name: COPPER SPRAY FUNGICIDE

• Active Ingredient(s)
  • COPPER AS ELEMENTAL (PRESENT AS COPPER OXYCHLORIDE)

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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: Unknown / Inconnu

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

Caller states he contracted with a company to do spraying of crabapple trees. (Has used them in past years also) Copper Oxide was used PCP 19146 Trees were sprayed May 3rd, 10th and 24th. (age) yo female was playing with the caller's dog in the garden on May 18th (8 days after last sprayed) Noticed red foot inflammation felt something in her foot immediately. She has had hospital care for leg swelling, irritation of skin on the top of her foot She had shoes on when playing with the dog O: leg swelling and irritated skin on the top of foot A: Acute adult possible dermal exposure to Copper Oxide sxs R: Would not relate sxs to possible dermal exposure. Skin irritation at most possible. Call with questions

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: Female

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

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Edema
  • Symptom - Irritated skin

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?

Unknown

6. b) For how long?

7. Exposure scenario

Non-occupational

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

Contact with treated area

Amount of time between application and contact 14

Day(s) / Jour(s)

What was the activity? walking

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

10. Route(s) of exposure.

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.)

Caller states he contracted with a company to do spraying of crabapple trees. (Has used them in past years also) Copper Oxide was used PCP 19146 Trees were sprayed May 3rd, 10th and 24th. (age) yo female was playing with the caller's dog in the garden on May 18th (8 days after last sprayed) Noticed red foot inflammation felt something in her foot immediately. She has had hospital care for leg swelling, irritation of skin on the top of her foot She had shoes on when playing with the dog O: leg swelling and irritated skin on the top of foot A: Acute adult possible dermal exposure to Copper Oxide sxs R: Would not relate sxs to possible dermal exposure. Skin irritation at most possible.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

Would not relate sxs to possible dermal exposure.