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Incident Report
Subform I: General Information
1. Report Type.
Update the report
Incident Report Number: 2011-3126
2. Registrant Information.
Registrant Reference Number: DAS110621
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
Domestic Animal
4. Date registrant was first informed of the incident.
21-JUN-115. Location of incident.
Country: CANADA
Prov / State: ALBERTA
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)PMRA Registration No. 28517 PMRA Submission No. EPA Registration No.
Product Name: Milestone Herbicide
- Active Ingredient(s)
- AMINOPYRALID
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: Pub. Area - Outdoor/Zone publique - ext
Préciser le type: Roadside weed control
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 - Malaise
- Specify - felt ill
4. How long did the symptoms last?
Unknown / Inconnu
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
Non-occupational
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)
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.)
An applicator was applying the product to a roadside for weed control and he approached a pastured area where horses were grazing. The booms were turned off in this area and the farmer saw this and waved. The farmer left for a period of time and returned to find a horse deceased. A local veterinarian was called and an autopsy was performed. The farmer claimed he felt ill and was advised to seek medical attention.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.
Subform III: Domestic Animal Incident Report
1. Source of Report
Other
2. Type of animal affected
Horse / Cheval
3. Breed
unknown
4. Number of animals affected
1
5. Sex
Unknown
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- General
- Symptom - Death
12. How long did the symptoms last?
Unknown / Inconnu
13. Was medical treatment provided? Provide details in question 17.
No
14. a) Was the animal hospitalized?
No
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Died
16. How was the animal exposed?
Other / Autre
specify unknown
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
An applicator was applying the product to a roadside for weed control and he approached a pastured area where horses were grazing. The booms were turned off in this area and the farmer saw this and waved. The farmer left for a period of time and returned to find a horse deceased. A local veterinarian was called and an autopsy was performed. The farmer claimed he felt ill and was advised to seek medical attention.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
