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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2018-2520

2. Registrant Information.

Registrant Reference Number: GCMB0001

Registrant Name (Full Legal Name no abbreviations): Gowan Canada

Address: 135 Innovation Drive, Suite 100

City: Winnepeg

Prov / State: Manitoba

Country: Canada

Postal Code: R3T 6A8

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


4. Date registrant was first informed of the incident.


5. Location of incident.

Country: CANADA

Prov / State: MANITOBA

6. Date incident was first observed.


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.


PMRA Registration No. 21012      PMRA Submission No.       EPA Registration No.

Product Name: Edge Manufacturing Concentrate

  • Active Ingredient(s)

7. b) Type of formulation.

Application Information

8. Product was applied?


9. Application Rate.


10. Site pesticide was applied to (select all that apply).

Site: Agricultural-Outdoor/Agricole-extérieur

Préciser le type: Don't know

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

Ground rig. Liquid application.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?


Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.


2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.


  • Eye
    • Symptom - Burning eye
  • General
    • Symptom - Chemical taste in mouth
  • Skin
    • Symptom - Blister

4. How long did the symptoms last?

>2 hrs <=8 hrs / > 2 h < = 8 h

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


6. a) Was the person hospitalized?


6. b) For how long?


Hour(s) / Heure(s)

7. Exposure scenario


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

Drift from the application site

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


10. Route(s) of exposure.





11. What was the length of exposure?

<=15 min / <=15 min

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.)

The supervisor reported one of their maintenance technicians was exposed to spray drift from sprayer application equipment operating in the field surrounding the utility site. The applicator was unware of the technician on site and when operating close to access road resulted in exposure by the technician to spray drift carried by breeze. The applicator stopped when seeing the technician who was experiencing burning in his eyes. The technician eyes were flushed on site and he was then taken to the local hospital where he received further treatment including an examination by an eye specialist. He was released from the hospital following the exam. The technician also reported sense of taste from in his mouth at time of the drift exposure. He also experienced some skin blistering at the back of neck, it was further indicated he has sensitive skin.The applicator was applying 1.3L of ethalfluralin manufacturing concentrate (EMC) per acre in a carrier mixture of 28-0-0 liquid fertilizer and water. The MSDS for 28-0-0 fertilizer, which is also an eye and skin irritant, has been provided to the supervisor.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.