Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2023-6069

2. Registrant Information.

Registrant Reference Number: I23034

Registrant Name (Full Legal Name no abbreviations): Interprovincial Cooperative Ltd.

Address: 945 Marion Street

City: Winnipeg

Prov / State: Manitoba

Country: Canada

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

Human

4. Date registrant was first informed of the incident.

28-APR-23

5. Location of incident.

Country: CANADA

Prov / State: MANITOBA

6. Date incident was first observed.

28-APR-23

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. 34377      PMRA Submission No.       EPA Registration No.

Product Name: IPCO Avant Herbicide

• Active Ingredient(s)
  • PINOXADEN

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7. b) Type of formulation.

Application Information

8. Product was applied?

No

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.

Data Subject

2. Demographic information of data subject

Sex: Female

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Eye
  • Symptom - Irritated eye

• Gastrointestinal System
  • Symptom - Burning mouth

• Respiratory System
  • Symptom - Burning nose

• Skin
  • Symptom - Burns (superficial)

• Eye
  • Symptom - Other
  • Specify - Sensitive

4. How long did the symptoms last?

>3 days <=1 wk / >3 jours <=1 sem

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

Yes

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)

Pesticide Spill

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

Eye

Oral

Respiratory

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.)

Operators disconnected two pressurized hoses resulting in getting sprayed by Pinoxaden / Avant product. Between the two individuals they got varying degrees of chemical in eyes, mouth, nose plus inhaled the vapours from the spray. Administered First Aid. Diphoterine and Saline eyewash. Plumbed eyewash and showers used. Called 911 and had Fire department first responders assess and provide guidance. Sent off site in a taxi for medical treatment at the Hospital. X-rays and blood work analyzed to check for adverse effects. They were released from the hospital in the early hours of Saturday morning, April 29th.Update on April 30th:Eeyes are alright but sensitive, a chemical burn in part of her mouth. Lab work came back with no organ damage.

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.

Data Subject

2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Eye
  • Symptom - Irritated eye

• Respiratory System
  • Symptom - Burning nose

• Eye
  • Symptom - Other
  • Specify - Sensitive

4. How long did the symptoms last?

>3 days <=1 wk / >3 jours <=1 sem

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

Yes

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)

Pesticide Spill

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

Eye

Respiratory

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.)

Operators disconnected two pressurized hoses resulting in getting sprayed by Pinoxaden product. Between the two individuals they got varying degrees of chemical in eyes, mouth, nose plus inhaled the vapours from the spray. Administered First Aid. Diphoterine and Saline eyewash. Plumbed eyewash and showers used. Called 911 and had Fire department first responders assess and provide guidance. Sent off site in a taxi for medical treatment at the Hospital. X-rays and blood work analyzed to check for adverse effects. They were released from the hospital in the early hours of Saturday morning, April 29th. Update on April 30th: Feeling ok, eyes are alright but sensitive. Lab work came back with no organ damage.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.