Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-2299

2. Registrant Information.

Registrant Reference Number: PROSAR 1-22344119

Registrant Name (Full Legal Name no abbreviations): Gowan Company

Address: P.O. Box 5569

City: Yuma

Prov / State: Arizona

Country: USA

Postal Code: 85366-5569

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

Human

4. Date registrant was first informed of the incident.

22-APR-10

5. Location of incident.

Country: UNITED STATES

Prov / State: MICHIGAN

6. Date incident was first observed.

19-APR-10

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)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 10163-283

Product Name: Eptam 7-E Selective Herbicide Emulsifiable Liquid

• Active Ingredient(s)
  • EPTC
    • Guarantee/concentration 87.8 %

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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: Unknown / Inconnu

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?

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: Male

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

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Coughing
  • Symptom - Shortness of breath

• Gastrointestinal System
  • Symptom - Salivating excessively
  • Symptom - Vomiting
  • Symptom - Diarrhea

• Renal System
  • Symptom - Inappropriate urination

• Eye
  • Symptom - Watery eye

• Respiratory System
  • Symptom - Respiratory congestion
  • Specify - Congestion

4. How long did the symptoms last?

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

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

Yes

6. a) Was the person hospitalized?

Yes

6. b) For how long?

7

Day(s) / Jour(s)

7. Exposure scenario

Unknown

8. How did exposure occur? (Select all that apply)

Application

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.

Skin

Respiratory

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.)

1-22344119: The reporter, a physician, notified the registrant on 4/22/10 of the exposure of a (age) year old male to an herbicide product containing the active ingredient EPTC. The patient had been applying the product during windy weather, and had experienced some dermal and inhalation exposures as a result. The reporter was advised that the product could serve as a cholinesterase inhibitor if a high enough concentration were ingested in sufficient amounts ¿¿¿ otherwise it would act as an irritant by any route of exposure. Several follow-up calls were placed. The patient had initially presented to a health care facility on 4/19/10, demonstrating significant ¿¿¿SLUDGE¿¿¿ symptoms including coughing and shortness of breath. The symptoms were perceived as being secondary to an exposure that involved a cholinesterase inhibitor; carbamate toxicity was presumed based on an MSDS sent to the health care facility from an unknown poison center. No cholinesterase testing was performed ¿¿¿ treatment was all empirical. The patient was intubated and placed in the ICU where he was treated with atropine to control secretions. The patient was extubated on 4/22/10. By 4/26/10, the patient was still hospitalized but was no longer manifesting symptoms consistent with a cholinergic crisis. He was walking on his own and had a good prognosis. The concentration of the product at the time of the application was not known.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.