Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2016-5119
2. Registrant Information.
Registrant Reference Number: Rocky Mountain Poison and Drug case #5658577
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: ALBERTA
6. Date incident was first observed.
19-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: Male
Age: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
4. How long did the symptoms last?
>30 min <=2 hrs / >30 min <=2 h
5. Was medical treatment provided? Provide details in question 13.
Unknown
6. a) Was the person hospitalized?
Unknown
6. b) For how long?
7. Exposure scenario
Occupational
8. How did exposure occur? (Select all that apply)
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
Respiratory
11. What was the length of exposure?
<=15 min / <=15 min
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 stated he was pumping this product up and it "exploded" and splashed all over his face and possibly in his eyes he showered for about 10 mins his eyes feel ok skin feels ok states he read about inhaling it and is concerned about that no coughing, no SOB O: dermal and ocular irritation that has resolved w/ shower A: sx adult herbicide exposure R: rev'd that if this was in his eyes there would be no doubting it would wash skin in shower another 10 mins minimum to make sure all residue is removed wash clothing separately discard any leather that may have come into contact declines fu cb pc prn cc ADDENDUM: rev'd that although it's unlikely to happen: stay hydrated and watch for any sx of delayed chemica pneumonia over the next 2 days if such occurs see MD
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.