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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-0348

2. Registrant Information.

Registrant Reference Number: 110079031-A

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.

24-JUN-11

5. Location of incident.

Country: UNITED STATES

Prov / State: COLORADO

6. Date incident was first observed.

24-JUN-11

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. 62719-48

Product Name: Curtail Herbicide

  • Active Ingredient(s)
    • 2,4-D (PRESENT AS LOW VOLATILE ESTERS)
      • Guarantee/concentration 38.4
    • CLOPYRALID
      • Guarantee/concentration 7.5

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: Res. - Out Home / Rés - à l'ext.maison

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

Dog owner was told that the chemicals were used after the grass was mowed (after one of her dog's died).

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: Female

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

  • Eye
    • Symptom - Burning eye
  • Nervous and Muscular Systems
    • Symptom - Headache

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)

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.

Eye

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.)

On June 24th, the landlord stated that they hadn't sprayed the chemical two weeks after her dog died. Owner stated that her dog passed away less than two weeks ago and cannot remember the date nor does she know when the chemicals were applied. There are two chemicals that were applied. Owner has the material data sheet for one of them ( Agent 1). Owner stated that pet number one is unable to use his back legs and is dragging himself. Upon recollection owner thinks the dog died three weeks ago on a Wednesday. Owner also stated that she had headaches and burning eyes at home. Owner states the dog has lost 20 lbs since the first of the year.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

Subform III: Domestic Animal Incident Report

1. Source of Report

Medical Professional

2. Type of animal affected

Dog / Chien

3. Breed

Labrador Retriever

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

7

7. Weight (provide a range if necessary )

73

lbs

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

  • Nervous and Muscular Systems
    • Symptom - Paralysis
  • Gastrointestinal System
    • Symptom - Weight loss

12. How long did the symptoms last?

Unknown / Inconnu

13. Was medical treatment provided? Provide details in question 17.

Yes

14. a) Was the animal hospitalized?

Unknown

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Unknown/Inconnu

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

On June 24th, the landlord stated that they hadn't sprayed the chemical two weeks after her dog died. Owner stated that her dog passed away less than two weeks ago and cannot remember the date nor does she know when the chemicals were applied. There are two chemicals that were applied. Owner has the material data sheet for one of them ( Agent 1). Owner stated that pet number one is unable to use his back legs and is dragging himself. Upon recollection owner thinks the dog died three weeks ago on a Wednesday. Owner also stated that she had headaches and burning eyes at home. Owner states the dog has lost 20 lbs since the first of the year.


To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Major

19. Provide supplemental information here

Subform III: Domestic Animal Incident Report

1. Source of Report

Medical Professional

2. Type of animal affected

Dog / Chien

3. Breed

Labrador Retriever

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

11

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

  • Blood
    • Symptom - Thrombocytopenia
  • General
    • Symptom - Death
  • Renal System
    • Symptom - Renal failure
    • Specify - chronic renal failure
  • Respiratory System
    • Symptom - Difficulty Breathing

12. How long did the symptoms last?

Persisted until death

13. Was medical treatment provided? Provide details in question 17.

Yes

14. a) Was the animal hospitalized?

Unknown

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

On June 24th, the landlord stated that they hadn't sprayed the chemical two weeks after her dog died. Owner stated that her dog passed away less than two weeks ago and cannot remember the date nor does she know when the chemicals were applied. There are two chemicals that were applied. Owner has the material data sheet for one of them ( Agent 1). Owner stated that pet number one is unable to use his back legs and is dragging himself. Upon recollection owner thinks the dog died three weeks ago on a Wednesday. Owner also stated that she had headaches and burning eyes at home. Owner states the dog has lost 20 lbs since the first of the year.


To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Death

19. Provide supplemental information here