Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2016-5116

2. Registrant Information.

Registrant Reference Number: Rocky Mountain Poison and Drug case #5638284

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: QUEBEC

6. Date incident was first observed.

06-JUL-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. 27818      PMRA Submission No.       EPA Registration No.

Product Name: SALVO 2,4-D ESTER 700 HERBICIDE

• Active Ingredient(s)
  • 2,4-D (PRESENT AS LOW VOLATILE ESTERS)

---

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).

TC from he was spraying the product today and it sprayed in his face the wand he was using was cracked, TOE 5 hours ago. He is now complaining his eyes are burning and feeling nausea GH, no meds, NKA O: eye irritation, nausea A: acute adult ocular exposure and taste ingestion of herbicide, symptomatic R: advised he seek medical attention in ER since symptoms have persist, caller is reluctant to be seen.

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: Male

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

3. List all symptoms, using the selections below.

System

• Eye
  • Symptom - Irritated eye

• Gastrointestinal System
  • Symptom - Nausea

4. How long did the symptoms last?

Unknown / Inconnu

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

No

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Non-occupational

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

Application

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.

Skin

Eye

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.)

TC from he was spraying the product today and it sprayed in his face the wand he was using was cracked, TOE 5 hours ago. He is now complaining his eyes are burning and feeling nausea GH, no meds, NKA O: eye irritation, nausea A: acute adult ocular exposure and taste ingestion of herbicide, symptomatic R: advised he seek medical attention in ER since symptoms have persist, caller is reluctant to be seen.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.