Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-6139

2. Registrant Information.

Registrant Reference Number: 2010-IR-05

Registrant Name (Full Legal Name no abbreviations): E. I. du Pont Canada Company

Address: P.O. Box 2300, Streetsville

City: Mississauga

Prov / State: Ontario

Country: Canada

Postal Code: L5M 2J4

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

Human

4. Date registrant was first informed of the incident.

13-DEC-10

5. Location of incident.

Country: UNITED STATES

Prov / State: PENNSYLVANIA

6. Date incident was first observed.

12-OCT-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. 352-507

Product Name: DuPont(tm) Tersan(r) 1991 DF Turf

• Active Ingredient(s)
  • BENOMYL

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7. b) Type of formulation.

Application Information

8. Product was applied?

Unknown

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?

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: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• General
  • Symptom - Cancer
  • Specify - contracting Acute Myelogenous Leukemia"
  • Symptom - Death

4. How long did the symptoms last?

Persisted until death

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

Occupational

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

Application

Other

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

Eye

Oral

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.)

In a complaint filed with the (name) County Court of (city,state), (name), Executor of the Estate of (name), decedent of plaintiff, states that during his father's employment as a "green's keeper, maintenance man and/or golf course superintendant" from about (year), his job responsibilities brought him into direct contact with numerous pesticide products. Amoung the numerous different pesticide products and pesticide active ingredients listed in the court filing is "location,year". Mr. (name) is alleging that the contact with one or more of the named pesticide products in the Complaint resulted in the decedent's "suffering sever and serious injuries and damages", contracting "Acute Myelogenous Leukemia".

To be determined by Registrant

14. Severity classification.

Death

15. Provide supplemental information here.