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
- Nervous and Muscular Systems
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
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
- 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