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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2023-5280

2. Registrant Information.

Registrant Reference Number: 69606

Registrant Name (Full Legal Name no abbreviations): ADAMA Agricultural Solutions Canada Ltd.

Address: 300 - 191 Lombard Avenue

City: Winnipeg

Prov / State: Manitoba

Country: Canada

Postal Code: R3B 0X1

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: ALBERTA

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. 29052      PMRA Submission No.       EPA Registration No.


  • 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).

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?


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

1. Source of Report.

Data Subject

2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.


  • Skin
    • Symptom - Other
    • Specify - Burning sensation

4. How long did the symptoms last?

Unknown / Inconnu

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


6. a) Was the person hospitalized?


6. b) For how long?

7. Exposure scenario


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

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?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>8 hrs <=24 hrs / > 8 h < = 24 h

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.)

Hx: The caller got some concentrate on his wrist last night. He rinsed it really thoroughly and there is not any visible irritation but it has a burning sensation that's really bothering him. A:- This product contains a pyrethroid insecticide.- Skin exposure may cause a burning, itching, tingling, or numbness sensation.- Symptoms typically develop soon after the exposure and resolve spontaneously within 24 hours.- Remove contaminated clothing and rinse exposed skin with running water for at least 20 minutes.- If symptoms develop, you may apply a light coating of Vitamin E oil every four hours as needed. Vitamin Eoil may help reduce the intensity and duration of the sensation.- Consult a health care professional if symptoms persist for more than 24 hours.- Please call back with any additional questions or concerns.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.

Label Directions Not Followed