Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-2397

2. Registrant Information.

Registrant Reference Number: SC977972

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.

22-MAY-12

5. Location of incident.

Country: UNITED STATES

Prov / State: CALIFORNIA

6. Date incident was first observed.

22-MAR-12

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.       PMRA Submission No.       EPA Registration No. 62719-4

Product Name: Vikane Gas Fumigant

• Active Ingredient(s)
  • SULFURYL FLUORIDE
    • Unknown

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7. b) Type of formulation.

Other (specify)

Gas fumigant

Application Information

8. Product was applied?

No

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?

Unknown

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

3. List all symptoms, using the selections below.

System

• Cardiovascular System
  • Symptom - Chest pain

• Renal System
  • Symptom - Creatinine increased
  • Specify - creatine phosphokinase Elevated

• Nervous and Muscular Systems
  • Symptom - Other
  • Specify - Unspecified myopathy

• General
  • Symptom - Lethargy
  • Symptom - Pain

• Nervous and Muscular Systems
  • Symptom - Muscle weakness

• General
  • Symptom - Flu-like symptoms
  • Specify - ill with what he described as cold and flu symptoms
  • Symptom - Malaise
  • Symptom - Fatigue

• Gastrointestinal System
  • Symptom - Weight loss

• Nervous and Muscular Systems
  • Symptom - Depression

• General
  • Symptom - Insomnia
  • Specify - problems sleeping

• Nervous and Muscular Systems
  • Symptom - Muscle spasm

4. How long did the symptoms last?

Unknown / Inconnu

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

Yes

6. a) Was the person hospitalized?

Yes

6. b) For how long?

8

Day(s) / Jour(s)

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.

Skin

Eye

Respiratory

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>1 wk <=1 mo / > 1 sem < = 1 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.)

The caller was assisting in a fumigation one of the connections on the product cylinder ruptured spraying out the fumigant from the cylinder. He was standing within several feet and was sprayed in the face and eyes, and inhaled some product. He immediately left the area and washed his face though did not report any symptoms at that time. The caller was not exactly sure of the date that this specifically occurred but does recall that within a few days he began to feel ill with what he described as cold and flu symptoms also noting some fatigue, malaise, and lethargy. He also noted he would seem to have episodes of coughing in the morning as well. On the morning of February 27 he woke up and indicated he felt like he was paralyzed from the waist up. His girlfriend drove him to a local hospital where he was evaluated. They had performed some unspecified blood tests and an chest x-ray, but were not apparently able to identify a specific cause. He returned to the hospital on or about March 1 with complaints of chest pain. He was discharged home about 7-8 days following initial admission. No specific cause of the symptoms was identified but was sent home with instructions to consume plenty of fluids and was given prescriptions for diazepam, and oxycodone for pain and for the muscle spasms. He indicates that he is still having muscle weakness and fatigue, and has experienced weight loss, depression, and problems sleeping and eating since all this occurred.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.

The information contained in this report is based on self-reported statements provided to the registrant during telephone Interview(s). These self-reported descriptions of an incident have not been independently verified to be factually correct or complete descriptions of the incident. For that reason, information contained in this report does not and can not form the basis for a determination of whether the reported clinical effects are causally related to exposure to the product identified in the telephone interviews. Typically, health related complicates linked to significant exposure to Vikane are immediate and acute in onset. The delayed and insidious onset of the multitude of complications in this patient over a 2 month period are not consistent with the toxicological profile of Vikane.