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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2009-1546

2. Registrant Information.

Registrant Reference Number: USDAS-090302

Registrant Name (Full Legal Name no abbreviations): Dow AgroSciences, LLC

Address: 9330 Zionsville Road

City: Indianapolis

Prov / State: IN

Country: United States

Postal Code: 46260

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

Human

4. Date registrant was first informed of the incident.

02-MAR-09

5. Location of incident.

Country: UNITED STATES

Prov / State: FLORIDA

6. Date incident was first observed.

06-MAY-05

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. 62719-324

Product Name: Rodeo Herbicide

  • Active Ingredient(s)
    • GLYPHOSATE
      • Guarantee/concentration 53.8 %

7. b) Type of formulation.

Liquid

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: Outdoor facility; occupational

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

Allegation of exposure while working outdoors in unrelated occupation; aerial application

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.

Other

2. Demographic information of data subject

Sex: Male

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

3. List all symptoms, using the selections below.

System

  • Renal System
    • Symptom - Dialysis required
  • Gastrointestinal System
    • Symptom - Tingling in mouth
    • Specify - tongue tingling
  • Nervous and Muscular Systems
    • Symptom - Headache
  • General
    • Symptom - Pain

4. How long did the symptoms last?

Anticip. permanent/Permanence anticipée

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

Yes

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)

Drift from the application site

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

Unknown

10. Route(s) of exposure.

Respiratory

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.

Major

15. Provide supplemental information here.

Claimant alledges symptoms due to one time exposure during an aerial application of product while he instructed a fire arms course outdoors.