Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-1540

2. Registrant Information.

Registrant Reference Number: DAS110216

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

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

City: Calgary

Prov / State: Alberta

Country: Canada

Postal Code: T2P 5H1

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

Human

4. Date registrant was first informed of the incident.

16-FEB-11

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

Unknown

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. 29334      PMRA Submission No.       EPA Registration No.

Product Name: Garlon RTU

• Active Ingredient(s)
  • TRICLOPYR

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7. b) Type of formulation.

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).

Product was applied for stump treatment.

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

• Skin
  • Symptom - Itchy skin
  • Symptom - Red skin
  • Symptom - Peeling skin
  • Symptom - Inflammation of the skin

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?

No

6. b) For how long?

7. Exposure scenario

Occupational

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.

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.)

A Hydro One seasonal employee was applying Garlon RTU at the end of January for stump treatment. The employee was wearing the appropriate PPE and experienced, what was thought to be, an allergic reaction that lasted 3 weeks. The individual went to the emergency ward of the hospital and later visited his family doctor (week of Feb 21) who recommended the employee see an allergist ASAP. The employee was removed from working with Garlon RTU and after 3-4 days of exposure the symptoms began to subside.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.