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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-0456

2. Registrant Information.

Registrant Reference Number: DASL101019

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.


4. Date registrant was first informed of the incident.


5. Location of incident.


Prov / State: WASHINGTON

6. Date incident was first observed.


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.


PMRA Registration No.       PMRA Submission No.       EPA Registration No. 62719-12

Product Name: Telone C-17

  • Active Ingredient(s)
      • Unknown
      • Unknown

PMRA Registration No.       PMRA Submission No.       EPA Registration No.

Product Name: Ammonium sulfate

  • Active Ingredient(s)

7. b) Type of formulation.


Application Information

8. Product was applied?


9. Application Rate.

10. Site pesticide was applied to (select all that apply).

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?


Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Data Subject

2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.


  • Respiratory System
    • Symptom - Asthma
  • Eye
    • Symptom - Irritated eye
  • Skin
    • Symptom - Irritated skin
  • Nervous and Muscular Systems
    • Symptom - Headache
  • Gastrointestinal System
    • Symptom - Other
    • Specify - severe, permanent injury

4. How long did the symptoms last?

Anticip. permanent/Permanence anticipée

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


6. a) Was the person hospitalized?


6. b) For how long?

7. Exposure scenario


8. How did exposure occur? (Select all that apply)

Pesticide Spill

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)


10. Route(s) of exposure.


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.)

Person is alleging that on or about 7/23/08, while engaged in the course and scope of his employment as a trainman for BNSF, he was exposed to "toxic substances and/or gasses that leaked from" tank car DCLX 3057 owned by Dow AgroSciences, including but not limited to Telone C-17 and chloropicrin causing him severe, permanent and disabling injuries. Severe and permanent injuries, including, but not limited to, his gastrointestinal system, respiratory system, headaches, skin and eye irritation and an increased risk to develop further disorders and diseases. Individual is also claiming that on or about 12/27/07, while working on or about a tank car owned by (name), he was exposed to "unknown toxic substances and/or gasses that leaked from said tank car, including but not limited to ammonia sulfate."

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.

Report from (name), Pulmonologist: Diagnosis: Occupational asthma, specifically irritant variety, also referred to as the reactive airways dysfunction syndrome (RADS), more probable than not, related to the exposure to Telone C-17 on July 23, 2008. Dr. (name) believes the patient needs additional aggressive therapy directed at the underlying airways inflammation, specifically inhaled corticosteroids under the guidance of a pulmonary specialist or occupational medicine physician. Unable to state that the 12127/07 incident involving ammonium sulfate caused any long-term effects.