Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2016-5118
2. Registrant Information.
Registrant Reference Number: Rocky Mountain Poison and Drug case #5654894
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.
12-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. 27884
PMRA Submission No.
EPA Registration No.
Product Name: PAR III TURF HERBICIDE
- 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, OR SODIUM SALT)
- MECOPROP-P (PRESENT AS DIMETHYLAMINE SALT)
7. b) Type of formulation.
Application Information
8. Product was applied?
Unknown
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.
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
4. How long did the symptoms last?
>24 hrs <=3 days / >24 h <=3 jours
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)
Contact with treated area
What was the activity? golf
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?
>2 hrs <=8 hrs / >2 h <=8 h
12. Time between exposure and onset of symptoms.
<=30 min / <=30 min
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 was on a golf course and was exposed to an herbicide called "por le gazon par 3" pcp 27884. She was playing golf and walking on the course for 4hours. She was wearing short socks. Happened yesterday. Washed legs 1h post exposure. She is in good health. She has psoriasis. She is allergic to feathers, and dust. She is on acecol and synthroid. O: She has red legs.Onset immediate. Symptoms persist. A: Acute adult dermal exposure herbicide symptomatic R: Wash. Go to Dr if symptoms persist or worsen. CB with questions. PC to follow. (first name last name) 07/19/16 10:35 S: TC to (name). no answer, left message. O: A: R: pc to follow if no cb. (first name last name) 07/23/16 14:05 S: TC to (first name). O: after 5 days her legs have returned to normal.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.