Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2011-5356
2. Registrant Information.
Registrant Reference Number: DASL111110
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.
10-NOV-11
5. Location of incident.
Country: UNITED STATES
Prov / State: NEW JERSEY
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.
PMRA Submission No.
EPA Registration No. 62719-166
Product Name: Dursban, Dursban Pro Insecticide, Suspend SC
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).
Application of products by hand sprayer. Amount of products and size of treated areas unknown.
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
- Cardiovascular System
- Symptom - Irregular heart rate
- Blood
- Symptom - Anemia
- Symptom - Leukopenia
4. How long did the symptoms last?
Persisted until death
5. Was medical treatment provided? Provide details in question 13.
Yes
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
Contact with treated area
What was the activity? Pest Control Operator for Exterminating Company
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?
>1 yr / > 1 an
12. Time between exposure and onset of symptoms.
>6 mos / > 6 mois
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 allegation has been made by a person in (state) relating to the injuries and death of her husband due to exposure to toxic chemicals, including but not limited to chlorpyrifos. It was alleged that the individual was exposed on a daily basis to dilute and concentrated chemicals from October, 1996 to December, 2007. Medical attention was first sought on November 20, 2005. It was further alleged that inadequate protective equipment was worn and that as a direct result the individual died of brain cancer on (date).
To be determined by Registrant
14. Severity classification.
Death
15. Provide supplemental information here.