Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2018-3417

2. Registrant Information.

Registrant Reference Number: Rocky Mountain Poison and Drug case #5969919

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.

13-AUG-18

5. Location of incident.

Country: CANADA

Prov / State: MANITOBA

6. Date incident was first observed.

10-AUG-18

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)

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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 (PRESENT AS AMINE SALT)

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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

• Gastrointestinal System
  • Symptom - Sore throat

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

Unknown

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

Poisoning from ingestion of the pesticide

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.

Oral

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.)

Patient drank a swallow of diluted PAR lll Turf Herbicide thinking it was water, TOE 10 minutes ago.Rinsed mouth right away, drank small sips of water. Denies nausea. Caller did not have packaging of product. Activeingredient is chlorophenoxy herbicide.Generally Healthy, No Known Allergies, no medicationsO: Symptomatic, throat irritationA: Acute adult unintentional ingestion of diluted PAR lll Turf Herbicide. Symptomatic, throat irritationR: Chlorophenoxy compounds can cause mild irritation of the gastrointestinal mucosa. Sip on water, not enough to causestomach upset. If any swelling of tongue or throat or difficulty breathing, go in to the emergency department right away

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.