Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2017-4613
2. Registrant Information.
Registrant Reference Number: DASLLC052517
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.
Human
Domestic Animal
Environment
4. Date registrant was first informed of the incident.
25-MAY-17
5. Location of incident.
Country: UNITED STATES
Prov / State: ARKANSAS
6. Date incident was first observed.
28-SEP-16
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
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: Agricultural-Outdoor/Agricole-extérieur
Préciser le type: ROW lines
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
Applicator sprayed rights-of-way last fall (September 28, 2016). Landowner alleges that the applicator sprayed around power lines and killed his shrubs and vines. He also stated his cat died and that his wife has been sick since October.
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.
Medical Professional
2. Demographic information of data subject
Sex: Female
Age: Unknown / Inconnu
3. List all symptoms, using the selections below.
System
- General
- Symptom - Malaise
- Specify - Just reported as feeling sick
4. How long did the symptoms last?
Unknown / Inconnu
5. Was medical treatment provided? Provide details in question 13.
Unknown
6. a) Was the person hospitalized?
Unknown
6. b) For how long?
7. Exposure scenario
Non-occupational
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.
Unknown
11. What was the length of exposure?
Unknown / Inconnu
12. Time between exposure and onset of symptoms.
Unknown / Inconnu
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.)
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.
Subform III: Domestic Animal Incident Report
1. Source of Report
Medical Professional
2. Type of animal affected
Cat / Chat
3. Breed
Unknown
4. Number of animals affected
1
5. Sex
Unknown
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?
Unknown
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
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here
Subform IV: Environment (includes plants insects and wildlife)
1. Type of organism affected
Trees or shrubs / Arbre ou arbuste
2. Common name(s)
Shrubs and vines
3. Scientific name(s)
Unknown
4. Number of organisms affected
Unknown
5. Description of site where incident was observed
Fresh water
Terrestrial
Roadside
Salt Water
6. Check all symptoms that apply
Death
7. Describe symptoms and outcome (died, recovered, etc.).
8. a) Was the incident a result of (select all that apply)
Application
N/A
8. b) i) How many times has the product been applied this year?
Unknown
8. b) ii) What was the date of the last application?
28-SEP-16
9. Did it rain
9. a) During application?
Unknown
9. b) Up to 3 days after application?
Unknown
10. a) Was there a buffer zone?
Unknown
10. b) What type?
10. c) What was the size of the buffer zone?
11. a) Were environmental samples collected and analysed?
No
To be determined by Registrant
12. Severity classification (if there is more than one possible classification, select the most severe)
Minor
13. Please provide supplemental information here