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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2017-2662

2. Registrant Information.

Registrant Reference Number: 5802105

Registrant Name (Full Legal Name no abbreviations): LOVELAND PRODUCTS CANADA INC.

Address: PO Box 5234 |64137 Hwy 543 E

City: HIGH RIVER

Prov / State: ALBERTA

Country: CANADA

3. Select the appropriate subform(s) for the incident.

Human

4. Date registrant was first informed of the incident.

19-MAY-17

5. Location of incident.

Country: CANADA

Prov / State: SASKATCHEWAN

6. Date incident was first observed.

18-MAY-17

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?

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).

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: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

  • Nervous and Muscular Systems
    • Symptom - Shaking
    • Symptom - Disorientation
  • General
    • Symptom - Malaise

4. How long did the symptoms last?

Unknown / Inconnu

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)

Application

Contact with treated area

Amount of time between application and contact 2

Day(s) / Jour(s)

What was the activity? application, subsequent mowing

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.

Respiratory

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.)

MMan sprayed product Par III and has sx's.He works for the town, has sprayed with Par 3 a few days ago, and then 2 days ago he cut the grass around town. Last night he developed shaking, not feeling well, and disorientation. He is stable this am, but some sx's still present. Is this related?It was not on his skin, mainly inhalation exposure.O: shakingdisorientationnot feeling wellA: Acute Adult Inhalation Exposure, sx.R: Would not expect this type of toxicity from this exposure.The sx's do not correlate with exposure to Chlorophenoxy compounds and would not expect systemic toxicity from that typeof exposure.Reviewed Chlorophenoxy exposure with caller irritation is usually all we see with dermal or inhalation exposures.Please cb with any questions.Case # provided.cc(First name Last name) 05/18/17 09:45S: (First name) calling back with update.He did not do the spraying, he just cut the grass, so he did not have subsequent exposures.Just may have inhaled some of the fumes from cutting the grass.What are the recommendations for treating sx's.O:A:R: With just an inhalation exposure of the fumes that night have been kicked up from cutting the grass, would not expectsystemic toxicity.In addition, would not expect toxicity to be delayed 2 days after exposure.Care for sx's of exposure to Chlorophenoxy compounds is decontamination fresh air.He is not experiencing systemic effects from the exposure, so would explore other causes to determine how to treat him.cb prn

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.