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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2009-4468

2. Registrant Information.

Registrant Reference Number: SC543413

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

Address: 450-1st Street SW, 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


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. 9005      PMRA Submission No.       EPA Registration No.

Product Name: Tordon 22K Herbicide

  • 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).

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

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: Female

Age: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.


  • Nervous and Muscular Systems
    • Symptom - Memory loss
  • Skin
    • Symptom - Blister
    • Symptom - Irritated skin

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)


10. Route(s) of exposure.


11. What was the length of exposure?

<=15 min / <=15 min

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.)

October 5, 2009 Caller states that in July 2008 he placed a bottle in a sealed plastic bag in his yard at the base of a tree. Caller is concerned as product was sitting in the sun all summer. He believes product may have somehow seeped through bottle and bag when it got warm resulting in vapors being blown through an open window of their house. He states that about 1-2 months later, his wife developed blisters on her neck and face. She also started experiencing memory loss. She went to her doctor when her symptoms started and was referred to a specialist. The specialist prescribed Fucidin H cream. Her blisters resolved within a few days, however the blisters have redeveloped sporadically since then, always resolving within a few days. Wife was then sent to a psychologist for memory loss and was prescribed an unknown medication.

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. There is absolutely no physical possibility by which this patient could have experienced an exposure to this herbicide through a sealed plastic container. The speculative exposure scenario described by this reporter is inconceivable. Any relationship between the this stored product and the delayed and sustained development of the complications reported in this case is inconceivable and lacks any biological plausibility.