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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2007-4560

2. Registrant Information.

Registrant Reference Number: 201939

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

Address: 450-1st Street S.W., Suite 2100

City: Calgary

Prov / State: AB

Country: Canada

Postal Code: T2P 5H1

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


4. Date registrant was first informed of the incident.


5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.


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.


PMRA Registration No. 26420      PMRA Submission No.       EPA Registration No.


  • Active Ingredient(s)

7. b) Type of formulation.

Application Information

8. Product was applied?


9. Application Rate.


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

Site: Agricultural-Outdoor/Agricole-extérieur

Préciser le type: Unknown

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

Unspecified application of diluted herbicide with handheld spray.

To be determined by Registrant

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


Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.


2. Demographic information of data subject

Sex: Male

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.


  • Gastrointestinal System
    • Symptom - Other
    • Specify - Pancreatitis
  • Respiratory System
    • Symptom - Respiratory failure

4. How long did the symptoms last?

Unknown / Inconnu

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


6. a) Was the person hospitalized?


6. b) For how long?


7. Exposure scenario


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)

Chemical resistant gloves

Coveralls (non-chemical resistant)

10. Route(s) of exposure.


11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>1 wk <=1 mo / > 1 sem < = 1 mois

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.)

Caller reports that her husband was admitted to the hospital on June 14 with pancreatitis. He had sprayed product with hand held sprayer, on May 28th. Application was uneventful with no known exposure occurring on May 28th. He had worn coveralls and gloves. He did not use a mask, but used some type of winter face covering that caller could not describe very well. He remains hospitalized with his condition worsening 4 days ago when he developed respiratory failure. He is currently on a ventilator. The doctors caring for him did not feel his illness had anything to do with the herbicide application especially since the application was done 17 days prior to the actual onset of illness. Caller denies that the patient was a heavy consumer of alcoholic beverages but did admit that he did drink when he was younger.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.

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 reported signs and symptoms are not specific for the known toxicity of this material given the circumstances of use and lack of any defined point of exposure. Even had dermal exposure to diluted herbicide occurred, the expection of clinical complications would be limited to local dermatitis if product had not been promptly washed from the skin. The delayed onset of pancreatitis 17 days following potential skin contact with diluted herbicide would most certainly not be expected to occur based on currently available scientific data on Remedy Herbicide. As history of alcohol consumption is more consistent with known causes for pancreatitis.