Déclaration d'incident

Sous-formulaire I: Renseignements généraux

1.Type de rapport.

Nouvelle déclaration d'incident

No de la demande: 2012-3395

2. Renseignements concernant le titulaire.

Numéro de référence du titulaire d'homologation: SC1006899

Nom du titulaire (nom légal complet, aucune abbréviation): Dow AgroSciences Canada Inc.

Adresse: 450-1st Street SW, Suite 2100

Ville: Calgary

État: AB

Pays: Canada

Code postal /Zip: T2P 5H1

3.Choisir le (les) sous-formulaire(s) correspondant à l'incident.

Incident chez l'humain

Incident chez un animal domestique

4. Date à laquelle le titulaire d'homologation a été informé pour la première fois de l'incident.

13-JUL-12

5. Lieu de l'incident.

Pays: CANADA

État: ALBERTA

6. Date de la première observation de l'incident.

13-JUL-12

Description du produit

7. a) Donner le nom de la matière active et, si disponibles, le numéro d'homologation et le nom du produit (incluant tous les mélanges). Si le produit n'est pas homologué, donner le numéro de la demande d'homologation.

Matière(s) active(s)

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ARLA No d'homologation 28551      ARLA No de la demande d'homologation       EPA No d'homologation.

Nom du produit: Restore A Herbicide

• Matière active
  • AMINOPYRALID

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ARLA No d'homologation 28552      ARLA No de la demande d'homologation       EPA No d'homologation.

Nom du produit: Restore B Herbicide

• Matière active
  • 2,4-D (PRESENT AS AMINE SALTS : DIMETHYLAMINE SALT, DIETHANOLAMINE SALT, OR OTHER AMINE SALTS)

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7. b) Type de formulation.

Renseignments sur l'application

8. Est-ce que le produit a été appliqué?

Oui

9. Dose d'application.

Inconnu

10. Site d'application (choisir tout ce qui s'applique).

Site: Res. - Out Home / Rés - à l'ext.maison

11. Donner tout renseignement additionnel concernant l'application (comment le produit a été appliqué, la quantité utilisée, la superficie de la zone traitée, etc.)

Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding application.

À être déterminé par le titulaire

12. Selon vous, le produit a-t-il été utilisé en conformité avec le mode d'emploi de L'étiquette?

Inconnu

Sous-formulaire II : Incident chez l'humain (Obligation d'utiliser un formulaire séparé pour chaque personne affectée)

1. Source de la déclaration.

Professionnel de la santé

2. Renseignement démographique sur la personne affectée

Sexe: Femme

Âge: >19 <=64 yrs / >19 <=64 ans

3. Énumérez tous les symptômes, au moyen des choix suivants.

Système

• Système gastro-intestinal
  • Symptôme - Vomit

• General
  • Symptôme - Malaise

• Systèmes nerveux et musculaire
  • Symptôme - Mal de tête

4. Quelle a été la durée des symptômes?

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

5. La personne affectée a-t-elle reçu des soins médicaux? Donner les détails à la question 13.

Oui

6. a) Est-ce que la personne a été hospitalisée?

Non

6. b) Pendant combien de temps?

7. Scénario d'exposition

Professionnel

8. Comment l'exposition s'est-elle produite? (cocher tout ce qui s'applique)

Dérive du pesticide à partir de la zone traitée

9.Si l'exposition s'est produite lors du traitement ou au moment du retour dans la zone traitée, de l'équipement de protection individuelle était-il porté? (cocher tout ce qui s'applique)

Aucun

10. Voie(s) d'exposition.

Peau

Respiratoire

11.Durée de l'exposition?

Unknown / Inconnu

12.Temps écoulé entre l'exposition et l'apparition des symptômes.

>2 hrs <=8 hrs / > 2 h < = 8 h

13.Donner tout détail additionnel au sujet de l'incident (p.ex. description des symptômes tels que la fréquence et la gravité, type de soins médicaux, résultats des tests médicaux, quantité de pesticide à laquelle la personne a été exposée, etc.)

The caller stated that County employees came out to their property the morning of Friday, July 13, 2012 to spray diluted Restore Herbicide for weed control primarily for tall buttercup (a noxious weed in AB, which can be toxic to livestock). The County was enforcing the Provincial Weed Control Act. The caller alleged that the County staff were not doing targeted spraying but general over-spray over wide swatches of the property. The caller, her husband and daughter were all outside at the time trying to get them to stop spraying. Apparently, their daughter had been exposed to some of the airborne spray during the application. About 4-5 hours later, the daughter developed a headache, vomiting and general malaise. She was taken to a local ER where she was prescribed an antihistamine. She apparently gradually recovered over the following 3 days. The caller and her husband reported developing general malaise during the 3-days following this incident although the caller was unable to describe how they were exposed to the herbicide other than their reentry to areas they feel were exposed to the herbicide spray. Also, 5 quarter horses were reported to have developed labored breathing since the incident occurred. These horses were within a barn during the herbicide application so it is unclear how the horses would have been exposed to the airborne spray. These horses have received a veterinary evaluation and where prescribed an unspecified medication. The owner does not know what the veterinarian thought was the cause for this illness. The caller denies that it could be related to tall buttercup ingestion because they know how dangerous tall buttercup can be to their horses so they try to keep the horses away from these areas.

À être déterminé par le titulaire

14. Classification selon la gravité.

Modérée

15. Donner des renseignements additionnels ici.

The information contained in this report is based on self-reported statements provided to the registrant during telephone Interview(s). These self-reported descriptions of an incident have not been independently verified to be factually correct or complete descriptions of the incident. For that reason, information contained in this report does not and can not form the basis for a determination of whether the reported clinical effects are causally related to exposure to the product identified in the telephone interviews. The signs and symptoms reported in the human subjects are not consistent with the toxicological profile of these herbicides even had dermal exposure occurred. The only well defined exposure occurred with the daughter, however, her symptoms were delayed in onset and did not involve the development of dermatological symptoms such as rash.

Sous-formulaire II : Incident chez l'humain (Obligation d'utiliser un formulaire séparé pour chaque personne affectée)

1. Source de la déclaration.

Professionnel de la santé

2. Renseignement démographique sur la personne affectée

Sexe: Femme

Âge: >19 <=64 yrs / >19 <=64 ans

3. Énumérez tous les symptômes, au moyen des choix suivants.

Système

• General
  • Symptôme - Malaise

4. Quelle a été la durée des symptômes?

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

5. La personne affectée a-t-elle reçu des soins médicaux? Donner les détails à la question 13.

Inconnu

6. a) Est-ce que la personne a été hospitalisée?

Non

6. b) Pendant combien de temps?

7. Scénario d'exposition

Professionnel

8. Comment l'exposition s'est-elle produite? (cocher tout ce qui s'applique)

Autre

9.Si l'exposition s'est produite lors du traitement ou au moment du retour dans la zone traitée, de l'équipement de protection individuelle était-il porté? (cocher tout ce qui s'applique)

Aucun

10. Voie(s) d'exposition.

Respiratoire

11.Durée de l'exposition?

Unknown / Inconnu

12.Temps écoulé entre l'exposition et l'apparition des symptômes.

Unknown / Inconnu

13.Donner tout détail additionnel au sujet de l'incident (p.ex. description des symptômes tels que la fréquence et la gravité, type de soins médicaux, résultats des tests médicaux, quantité de pesticide à laquelle la personne a été exposée, etc.)

The caller stated that County employees came out to their property the morning of Friday, July 13, 2012 to spray diluted Restore Herbicide for weed control primarily for tall buttercup (a noxious weed in AB, which can be toxic to livestock). The County was enforcing the Provincial Weed Control Act. The caller alleged that the County staff were not doing targeted spraying but general over-spray over wide swatches of the property. The caller, her husband and daughter were all outside at the time trying to get them to stop spraying. Apparently, their daughter had been exposed to some of the airborne spray during the application. About 4-5 hours later, the daughter developed a headache, vomiting and general malaise. She was taken to a local ER where she was prescribed an antihistamine. She apparently gradually recovered over the following 3 days. The caller and her husband reported developing general malaise during the 3-days following this incident although the caller was unable to describe how they were exposed to the herbicide other than their reentry to areas they feel were exposed to the herbicide spray. Also, 5 quarter horses were reported to have developed labored breathing since the incident occurred. These horses were within a barn during the herbicide application so it is unclear how the horses would have been exposed to the airborne spray. These horses have received a veterinary evaluation and where prescribed an unspecified medication. The owner does not know what the veterinarian thought was the cause for this illness. The caller denies that it could be related to tall buttercup ingestion because they know how dangerous tall buttercup can be to their horses so they try to keep the horses away from these areas.

À être déterminé par le titulaire

14. Classification selon la gravité.

Mineure

15. Donner des renseignements additionnels ici.

The information contained in this report is based on self-reported statements provided to the registrant during telephone Interview(s). These self-reported descriptions of an incident have not been independently verified to be factually correct or complete descriptions of the incident. For that reason, information contained in this report does not and can not form the basis for a determination of whether the reported clinical effects are causally related to exposure to the product identified in the telephone interviews. The signs and symptoms reported in the human subjects are not consistent with the toxicological profile of these herbicides even had dermal exposure occurred. The only well defined exposure occurred with the daughter, however, her symptoms were delayed in onset and did not involve the development of dermatological symptoms such as rash.

Sous-formulaire II : Incident chez l'humain (Obligation d'utiliser un formulaire séparé pour chaque personne affectée)

1. Source de la déclaration.

Professionnel de la santé

2. Renseignement démographique sur la personne affectée

Sexe: Homme

Âge: >19 <=64 yrs / >19 <=64 ans

3. Énumérez tous les symptômes, au moyen des choix suivants.

Système

• General
  • Symptôme - Malaise

4. Quelle a été la durée des symptômes?

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

5. La personne affectée a-t-elle reçu des soins médicaux? Donner les détails à la question 13.

Inconnu

6. a) Est-ce que la personne a été hospitalisée?

Non

6. b) Pendant combien de temps?

7. Scénario d'exposition

Professionnel

8. Comment l'exposition s'est-elle produite? (cocher tout ce qui s'applique)

Autre

9.Si l'exposition s'est produite lors du traitement ou au moment du retour dans la zone traitée, de l'équipement de protection individuelle était-il porté? (cocher tout ce qui s'applique)

Aucun

10. Voie(s) d'exposition.

Respiratoire

11.Durée de l'exposition?

Unknown / Inconnu

12.Temps écoulé entre l'exposition et l'apparition des symptômes.

Unknown / Inconnu

13.Donner tout détail additionnel au sujet de l'incident (p.ex. description des symptômes tels que la fréquence et la gravité, type de soins médicaux, résultats des tests médicaux, quantité de pesticide à laquelle la personne a été exposée, etc.)

The caller stated that County employees came out to their property the morning of Friday, July 13, 2012 to spray diluted Restore Herbicide for weed control primarily for tall buttercup (a noxious weed in AB, which can be toxic to livestock). The County was enforcing the Provincial Weed Control Act. The caller alleged that the County staff were not doing targeted spraying but general over-spray over wide swatches of the property. The caller, her husband and daughter were all outside at the time trying to get them to stop spraying. Apparently, their daughter had been exposed to some of the airborne spray during the application. About 4-5 hours later, the daughter developed a headache, vomiting and general malaise. She was taken to a local ER where she was prescribed an antihistamine. She apparently gradually recovered over the following 3 days. The caller and her husband reported developing general malaise during the 3-days following this incident although the caller was unable to describe how they were exposed to the herbicide other than their reentry to areas they feel were exposed to the herbicide spray. Also, 5 quarter horses were reported to have developed labored breathing since the incident occurred. These horses were within a barn during the herbicide application so it is unclear how the horses would have been exposed to the airborne spray. These horses have received a veterinary evaluation and where prescribed an unspecified medication. The owner does not know what the veterinarian thought was the cause for this illness. The caller denies that it could be related to tall buttercup ingestion because they know how dangerous tall buttercup can be to their horses so they try to keep the horses away from these areas.

À être déterminé par le titulaire

14. Classification selon la gravité.

Mineure

15. Donner des renseignements additionnels ici.

The information contained in this report is based on self-reported statements provided to the registrant during telephone Interview(s). These self-reported descriptions of an incident have not been independently verified to be factually correct or complete descriptions of the incident. For that reason, information contained in this report does not and can not form the basis for a determination of whether the reported clinical effects are causally related to exposure to the product identified in the telephone interviews. The signs and symptoms reported in the human subjects are not consistent with the toxicological profile of these herbicides even had dermal exposure occurred. The only well defined exposure occurred with the daughter, however, her symptoms were delayed in onset and did not involve the development of dermatological symptoms such as rash.

Sous-formulaire III : Animal domestique

1. Source de la déclaration

Propriétaire de l'animal

2.Type d'animal touché

Horse / Cheval

3. Race

Quarter Horses

4. Nombre d'animaux touchés

5

5. Sexe:

Femme

6. Âge (fournir un ordre de grandeur si nécessaire)

2

7. Poids (fournir un ordre de grandeur si nécessaire)

Inconnu

8. Voie(s) d'exposition:

Cutanée

Respiratoire

9. Durée de l'exposition?

Unknown / Inconnu

10. Temps écoulé entre l'exposition et l'apparition des symptômes

Unknown / Inconnu

11. Énumérer tous les symptômes

Système

• Système respiratoire
  • Symptôme - Respiration difficile

12. Quelle a été la durée des symptômes?

Unknown / Inconnu

13. Des soins médicaux ont-ils été prodigués? Donner les détails à la question 17.

Oui

14. a) Est-ce que l'animal a-t-il été hospitalisé?

Non

14. b) Combien de temps l'animal était-il hospitalisé?

15. Issue de l'incident

Unknown/Inconnu

16. De quelle manière l'animal a-t-il été exposé?

Other / Autre

17. Donnez tout détail additionnel au sujet de l'incident

(p.ex. description des symptômes tels que la fréquence et la gravité

The caller stated that County employees came out to their property the morning of Friday, July 13, 2012 to spray diluted Restore Herbicide for weed control primarily for tall buttercup (a noxious weed in AB, which can be toxic to livestock). The County was enforcing the Provincial Weed Control Act. The caller alleged that the County staff were not doing targeted spraying but general over-spray over wide swatches of the property. The caller, her husband and daughter were all outside at the time trying to get them to stop spraying. Apparently, their daughter had been exposed to some of the airborne spray during the application. About 4-5 hours later, the daughter developed a headache, vomiting and general malaise. She was taken to a local ER where she was prescribed an antihistamine. She apparently gradually recovered over the following 3 days. The caller and her husband reported developing general malaise during the 3-days following this incident although the caller was unable to describe how they were exposed to the herbicide other than their reentry to areas they feel were exposed to the herbicide spray. Also, 5 quarter horses were reported to have developed labored breathing since the incident occurred. These horses were within a barn during the herbicide application so it is unclear how the horses would have been exposed to the airborne spray. These horses have received a veterinary evaluation and where prescribed an unspecified medication. The owner does not know what the veterinarian thought was the cause for this illness. The caller denies that it could be related to tall buttercup ingestion because they know how dangerous tall buttercup can be to their horses so they try to keep the horses away from these areas.

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À être déterminé par le titulaire

Classification selon la gravité (s'il y a plus d'une catégorie possible, veuillez choisir la plus grave)

Modérée

19. Donner des renseignements additionnels ici

The information contained in this report is based on self-reported statements provided to the registrant during telephone Interview(s). These self-reported descriptions of an incident have not been independently verified to be factually correct or complete descriptions of the incident. For that reason, information contained in this report does not and can not form the basis for a determination of whether the reported clinical effects are causally related to exposure to the product identified in the telephone interviews. Given that the horses were not outside of the barn during the application, there is no apparent exposure via the respiratory route which would potentially explain the development of respiratory symptoms.