Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2016-7530

2. Registrant Information.

Registrant Reference Number: DASLLC071216

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

Address: 2400, 215-2nd Street S.W.

City: Alberta

Prov / State: Calgary

Country: Canada

Postal Code: T2P 1M4

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

Domestic Animal

4. Date registrant was first informed of the incident.

12-JUL-16

5. Location of incident.

Country: UNITED STATES

Prov / State: PENNSYLVANIA

6. Date incident was first observed.

Unknown

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.       PMRA Submission No.       EPA Registration No. 62719-519

Product Name: Milestone

• Active Ingredient(s)
  • AMINOPYRALID
    • Unknown

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 62719-324

Product Name: Rodeo

• Active Ingredient(s)
  • GLYPHOSATE
    • Unknown

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 228-534

Product Name: Polaris

• Active Ingredient(s)
  • IMAZAPYR
    • Unknown

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7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

10. Site pesticide was applied to (select all that apply).

Site: Other / Autre

Préciser le type: Right-of-way

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

A utility applicator treated some vegetation in a pasture on a right-of-way. The contractor informed me that less than 16 oz of end use diluted product was likely used in that area and the primary species that were treated were bush honey suckle and autumn olive.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Unknown

Subform III: Domestic Animal Incident Report

1. Source of Report

Medical Professional

2. Type of animal affected

Cow / Vache

3. Breed

Bull

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Unknown

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

• General
  • Symptom - Death

12. How long did the symptoms last?

Unknown / Inconnu

13. Was medical treatment provided? Provide details in question 17.

Unknown

14. a) Was the animal hospitalized?

No

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Died

16. How was the animal exposed?

Contact treat.area/Contact surf. traitée

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

The property owner is now alleging that one of their cattle (a bull) is dead as a result of the application.

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To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Death

19. Provide supplemental information here