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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

Update the report

Incident Report Number: 2012-4520

2. Registrant Information.

Registrant Reference Number: DASL12101500

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.


4. Date registrant was first informed of the incident.


5. Location of incident.


Prov / State: CALIFORNIA

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. 62719-166

Product Name: Dursban Pro

  • Active Ingredient(s)
      • Unknown

PMRA Registration No.       PMRA Submission No.       EPA Registration No. 62719-388

Product Name: Fore 80 WP

  • Active Ingredient(s)
      • Unknown

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

Product Name: 2,4-D

  • Active Ingredient(s)
    • 2,4-D (PRESENT AS ACID)

7. b) Type of formulation.

Application Information

8. Product was applied?


9. Application Rate.


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

Site: Pub. Area - Outdoor/Zone publique - ext

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

Application of various herbicides, pesticides and/or fungicides while working as a golf course superintendent.

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.


2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.


  • General
    • Symptom - Death
    • Symptom - Cancer
    • Specify - leukemia

4. How long did the symptoms last?

Unknown / Inconnu

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)

Contact with treated area

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.)

Family members are alleging that their husband/father developed leukemia and eventually died as a result of his exposure to various herbicides, pesticides and/or fungicides, while working as a golf course superintendent. They allege that the person in question was exposed through dermal contact, ingestion and/or respiration through the air, water and/or ground resulting in bodily, organ, cellular invasion, destruction, damage, mutation and/or change culminating in decedent developing leukemia and his subsequent death on 10/5/10.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.

Status update: Products to add to Section 7a list: Eagle 20 EW, Active Inqredient Mycolbutanil, Registration 62719-463; Lontrel T O, Active Ingredient CIopyralid, Registration 62719-305; Turflon Ester Herbicide, Active Ingredient Triclopyr, Registration 62719-258; Confront Herbicide, Active Ingredient Triclopyr, Registration 62719-92; Kelthane MF Miticide, Active lngredient Docofol; Snapshot 2.5 TG Herbicide, Active lngredient Isoxaben, Registration 62719-175; Proxy Growth Regulator, Active lngredient Ethephon; Compass Fungicide, Active lngredient Trifloxystrobin; Cutrine Plus, Active lngredient Copper as elemental; 6-lron Plus MN; Activator Extract; Aluminum Phosphide, Fumitoxin; Subdue Maxx, Active lngredient Mefenoxam; Daconil Weatherstick, Active Ingredient Chlorothalonil; BarriCade 4FL Herbicide, Active Ingredient Prodiamine; Heritage Fungicide, Active lngredient Azoxystrobin; Insignia WG Fungicide, Active Ingredient Pyraclostrobin; Reward; Trimec; Medallion WSP Fungicide, Active Ingredient Fludioxonil; Chipco 26-GT; Chipco Signature, Active Ingredient Aluminum Tris; Chipco Merit Insecticide, Active Ingredient Imidacloprid; Banner Maxx, Active Ingredient Propiconazole ; 3336 G and 3336 WP, Active Ingredient Thiophanate Methyl; Endorse Fungicide, Active Ingredient Polyoxin D Zinc Salt; Prostar 70 WP, Active Ingredient Flutolanil; Aventis 26 GT, Active Ingredient Iprodione; Drive 75 DF, Active Ingredient Quinclorac; Merit 75WP, Active Ingredient Imidacloprid; SpeedZone, Active Ingredient 2,4-0 and Dicamba; Monument 75 WG, Active Ingredient Trifloxysulfuron-Sodium; Liquid Organic Arsenical Herbicide, Active Ingredient Monosodium Acid Methanearsonate