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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2021-3072

2. Registrant Information.

Registrant Reference Number: 2021-25

Registrant Name (Full Legal Name no abbreviations): BASF Canada Inc.

Address: 100 Milverton Drive, 5th Floor

City: Mississauga

Prov / State: Ontario

Country: Canada

Postal Code: L5R 4H1

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

Human

4. Date registrant was first informed of the incident.

08-JUN-21

5. Location of incident.

Country: CANADA

Prov / State: MANITOBA

6. Date incident was first observed.

08-JUN-21

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. 28837      PMRA Submission No.       EPA Registration No.

Product Name: Liberty 150

  • Active Ingredient(s)
    • GLUFOSINATE AMMONIUM
      • Guarantee/concentration 150 g/L

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.

Other

2. Demographic information of data subject

Sex: Male

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

3. List all symptoms, using the selections below.

System

  • Eye
    • Symptom - Blurred vision
    • Symptom - Pain
    • Symptom - Conjunctivitis

4. How long did the symptoms last?

Unknown / Inconnu

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

No

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Occupational

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)

None

10. Route(s) of exposure.

Eye

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 reports that her boyfriend and brother were using the product, about 1 hour before this call. They were using a high pressure hose attached to the product and, somehow, they were sprayed into their faces. They both rinsed their face and eyes for 15-20 minutes then went to seek medical attention at the ER. She reports that they are, both, being released from the ER and were told to get an appt. with an Ophthalmologist in the morning.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

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

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Male

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

3. List all symptoms, using the selections below.

System

  • Eye
    • Symptom - Blurred vision
    • Symptom - Conjunctivitis
    • Symptom - Pain

4. How long did the symptoms last?

Unknown / Inconnu

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

No

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Occupational

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)

None

10. Route(s) of exposure.

Eye

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 reports that her boyfriend and brother were using the product, about 1 hour before this call. They were using a high pressure hose attached to the product and, somehow, they were sprayed into their faces. They both rinsed their face and eyes for 15-20 minutes then went to seek medical attention at the ER. She reports that they are, both, being released from the ER and were told to get an appt. with an Ophthalmologist in the morning.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.