Incident Report

Subform I: General Information

1. Report Type.

Update the report

Incident Report Number: 2012-4195

2. Registrant Information.

Registrant Reference Number: DASL12082200

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

Address: Suite 2100, 450 - 1 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.

22-AUG-12

5. Location of incident.

Country: UNITED STATES

Prov / State: ALABAMA

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.       PMRA Submission No.       EPA Registration No. Unknown

Product Name: Dursban and Chlorpuophos

• Active Ingredient(s)
  • CHLORPYRIFOS
    • Unknown

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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: Unknown / Inconnu

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

Unknown

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

• General
  • Symptom - Other
  • Specify - lead poisoning
  • Symptom - Other
  • Specify - arsenic poisoning
  • Symptom - Other
  • Specify - heavy metal poisoning

• Nervous and Muscular Systems
  • Symptom - Other
  • Specify - progressive neuropathy
  • Symptom - Other
  • Specify - degenerative disease including lower back

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

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.

Unknown

11. What was the length of exposure?

>1 yr / > 1 an

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.)

An individual working as a pest control service technician was applying products from May 1998 through January 2011. He alleges that while working in this field he experienced "toxic exposure, lead poisoning, arsenic poisoning, heavy metal poisoning, progressive neuropathy, degenerative disease, including degeneration of his lower back while working in the line and course of his employment, severe and lasting mental and emotional trauma.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.