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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

Update the report

Incident Report Number: 2012-1377

2. Registrant Information.

Registrant Reference Number: DASL283642

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.

23-AUG-10

5. Location of incident.

Country: UNITED STATES

Prov / State: NEW YORK

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. Unknown

Product Name: Dursban

  • Active Ingredient(s)
    • CHLORPYRIFOS
      • Unknown

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

Product Name: Whitmore

  • Active Ingredient(s)
    • PYRETHRINS

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

Product Name: AgrEvo Ficam

  • Active Ingredient(s)
    • DIAZINON

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

Product Name: Phantom

  • Active Ingredient(s)
    • CHLORFENAPYR

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

Product Name: Whitmore PT 270

  • Active Ingredient(s)
    • CHLORPYRIFOS

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

Product Name: AgrEvo Ficam Plus

  • Active Ingredient(s)
    • BENDIOCARB
    • PIPERONYL BUTOXIDE
    • PYRETHRINS

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

Product Name: Prenton Diazinon 5G

  • Active Ingredient(s)
    • DIAZINON

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

Product Name: Campbell Knox-out Flowable Microencapsulated Insecticide

  • Active Ingredient(s)

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

Product Name: Equity

  • Active Ingredient(s)
    • CHLORPYRIFOS
      • Guarantee/concentration 44.6 %

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

Product Name: Sentricon

  • Active Ingredient(s)

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

Product Name: Oraphene

  • Active Ingredient(s)

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

Product Name: PT265

  • Active Ingredient(s)

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

Product Name: PT279

  • Active Ingredient(s)

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

Product Name: Exclude

  • Active Ingredient(s)

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

Product Name: Tempo

  • Active Ingredient(s)

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).

N/A

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 - Other
    • Specify - Cardiac difficulties and acute cardiac symptoms
  • Eye
    • Symptom - Other
    • Specify - Loss of vision
  • Respiratory System
    • Symptom - Difficulty Breathing
  • Reproductive System
    • Symptom - Infertility
    • Specify - impotency
  • Nervous and Muscular Systems
    • Symptom - Abnormal gait
  • Cardiovascular System
    • Symptom - Other
    • Specify - Heart failure
  • Nervous and Muscular Systems
    • Symptom - Stiffness
  • Cardiovascular System
    • Symptom - Chest tightness
  • General
    • Symptom - Weakness
    • Specify - Weakness in the left leg
  • Skin
    • Symptom - Other
    • Specify - Cellulitis on legs
  • Nervous and Muscular Systems
    • Symptom - Difficulty getting up
  • Cardiovascular System
    • Symptom - Arrhythmia
    • Specify - atrial fibrillation
  • Nervous and Muscular Systems
    • Symptom - Other
    • Specify - Sensorimotor peripheral polyneuropathy
    • Symptom - Muscle weakness
    • Specify - Myasthenia Gravis
  • Gastrointestinal System
    • Symptom - Diarrhea
  • Nervous and Muscular Systems
    • Symptom - Loss of coordination
  • Respiratory System
    • Symptom - Other
    • Specify - Acute respiratory symptoms
  • Cardiovascular System
    • Symptom - Other
    • Specify - Congestive heart failure
  • Nervous and Muscular Systems
    • Symptom - Other
    • Specify - diabetic peripheral neuropathy
  • General
    • Symptom - Other
    • Specify - diabetes mellitus

4. How long did the symptoms last?

>6 mos / > 6 mois

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

Yes

6. a) Was the person hospitalized?

Yes

6. b) For how long?

Unknown

7. Exposure scenario

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.

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.)

This person worked from 1994 to 2008 for a pesticide company as an exterminator, salesperson, sales and service manager. His duties included the application of organophoshate and/or carbamate insecticides and pesticides. He began experiencing medical problems in 2007.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.