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)
PMRA Registration No.
PMRA Submission No.
EPA Registration No. 62719-519
Product Name: Milestone
PMRA Registration No.
PMRA Submission No.
EPA Registration No. 62719-324
Product Name: Rodeo
PMRA Registration No.
PMRA Submission No.
EPA Registration No. 228-534
Product Name: Polaris
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
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.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here