Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2019-2672

2. Registrant Information.

Registrant Reference Number: ROCKY MOUNTAIN Case 6072115

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

Address: 789 DONNYBROOK DRIVE

City: DORCHESTER

Prov / State: ONTARIO

Country: CANADA

Postal Code: N0L 1G5

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

Human

4. Date registrant was first informed of the incident.

03-JUN-19

5. Location of incident.

Country: CANADA

Prov / State: MANITOBA

6. Date incident was first observed.

29-MAY-19

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 POTASSIUM 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

• General
  • Symptom - Pain

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?

No

6. b) For how long?

7. Exposure scenario

Unknown

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

Application

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?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>24 hrs <=3 days / >24 h <=3 jours

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 1 Exposure Information: Application Mishap - UG-Unintentional General Occupational: No Acuity: Acute Product Name: Par III Turf Herbicide (Pour Le Gazon Par III)Time Of Exposure: 2.00 Days ago Route: Dermal Exposure Duration: Unknown Body Part: Legs Patient 1 Clinical Effects Effects Present: Miscellaneous - Pain (other) Relatedness: Not related Onset: 1.00 Days after exp Patient 1 Management InformationT ype: On-Site Non-HCF Result: Caller encouraged to call with any questions, concerns or additional symptoms Sub-Type: Residence Patient 1 Therapy Information Therapy Type: Medication Recommendation: Performed Patient 1 Outcome Medical Outcome: Unrelated Effect Effect Duration:Industry Outcome: Minor Industry Duration: Unknown Causation: Not Related EPA Code: H-D Notes: The caller was applying an herbicide and got some on his legs. TOE: 2 days ago. Yesterday he developed some musclepain/soreness. SX persist today.Arthritis; no meds; beesO: Muscle painA: Acute; adult; dermal; Par III Turf Herbicide; SXR: Call transferred to CSPI (name).(name) 05/31/19 16:03S: Speaking with patient.Reviewed hx as in initial note.States he just recently took some OTC pain med to help symptoms.O: muscle pain 1 day after exposure.Denies any skin irritationA: Acute adult exposure to herbicide. Sx.R: Sx not consistent with history of exposure.Referred for medical eval of any sx that are prolonged or severe. cc/krd

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.