Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-1658

2. Registrant Information.

Registrant Reference Number: SC808075

Registrant Name (Full Legal Name no abbreviations): Dow AgroSciences Canada Inc.

Address: 450 1st Street SW, Suite 2100

City: Calgary

Prov / State: AB

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-JUN-11

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

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)

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PMRA Registration No. 29334      PMRA Submission No.       EPA Registration No.

Product Name: Garlon RTU

• Active Ingredient(s)
  • TRICLOPYR

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PMRA Registration No. 28434      PMRA Submission No.       EPA Registration No.

Product Name: Garlon Ultra

• Active Ingredient(s)
  • TRICLOPYR

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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: Agricultural-Outdoor/Agricole-extérieur

Préciser le type: Unknown

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

Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding application.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Yes

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: Male

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Dermatitis
  • Symptom - Itchy skin
  • Symptom - Rash

4. How long did the symptoms last?

>24 hrs <=3 days / >24 h <=3 jours

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

No

6. a) Was the person hospitalized?

No

6. b) For how long?

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)

None

10. Route(s) of exposure.

Unknown

11. What was the length of exposure?

>1 mo <= 6 mos / > 1 mois < = 6 mois

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.)

Caller is a dermatologist, whose adult male patient came to him yesterday, complaining of developing contact dermatitis on his hands and arms whenever he uses Garlon RTU at work. His symptoms readily resolve within 2 3 days when he is away from work or is not using Garlon RTU. The patient denies using protective equipment and acknowledges that he gets the chemical on his clothing and skin regularly. What is confusing to the patient and the doctor is that the patient used to use Garlon Ultra in 2010 and did not experience these problems. The patient has not received an specific treatments. The physician was informed that if either herbicide gets on the skin for a sustained period of time, then contact dermatitis is a possible outcome. The focus should be on preventing exposure to the clothing and skin through proper application technique and use of personal protective equipment.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.