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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2018-5187

2. Registrant Information.

Registrant Reference Number: Rocky Mountain Poison and Drug case #5991531

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.

10-OCT-18

5. Location of incident.

Country: CANADA

Prov / State: NOVA SCOTIA

6. Date incident was first observed.

09-OCT-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)

PMRA Registration No. 30654      PMRA Submission No.       EPA Registration No.

Product Name: RAMPART FUNGICIDE

  • Active Ingredient(s)
    • POTASSIUM SALTS OF FATTY ACIDS

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: Female

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

  • Skin
    • Symptom - Irritated skin
    • Symptom - Pruritus
    • Symptom - Burning skin

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.

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)

Application

Drift from the application site

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

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 was spraying Rampart and some misted back onto her face. The product was on her face for about 5 minutes before she went inside and flushed with water. Now her skin is burning and itching, and she denies any improvement in the last 2hours.TOE: 2 hours ago Med Hx: GH, no medications, Allergies: penicillin, clindamycin, codeine O: Dermal irritation, pruritis A: Acute, adult, dermal exposure to Rampart Fungicide, SXSR: Seek medical attention. CB declined.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.