Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-5104

2. Registrant Information.

Registrant Reference Number: DASL12090700

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.

07-SEP-12

5. Location of incident.

Country: UNITED STATES

Prov / State: CALIFORNIA

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. 62719-542

Product Name: Dimension 2EW

• Active Ingredient(s)
  • DITHIOPYR
    • Unknown

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 62719-166

Product Name: Dursban Pro Insecticide

• Active Ingredient(s)
  • CHLORPYRIFOS
    • Unknown

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 62719-145

Product Name: Gallery 75 Dry Flowable Herbicide

• Active Ingredient(s)
  • ISOXABEN
    • Unknown

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 62719-397

Product Name: Kerb 50W Herbicide

• Active Ingredient(s)
  • PROPYZAMIDE

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

Product Name: Surflan A.S. Herbicide-ornamentals

• Active Ingredient(s)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 62719-258

Product Name: Turflon Ester Herbicide

• Active Ingredient(s)
  • TRICLOPYR
    • Unknown

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 62719-250

Product Name: Treflan HFP Herbicide

• Active Ingredient(s)
  • TRIFLURALIN
    • Unknown

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PMRA Registration No. 23003      PMRA Submission No.       EPA Registration No.

Product Name: Dimension Turf Herbicide

• Active Ingredient(s)
  • DITHIOPYR
    • Unknown

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7. b) Type of formulation.

Application Information

8. Product was applied?

Unknown

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.

Other

2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Blood
  • Symptom - Anemia
  • Symptom - Cytopenia

• General
  • Symptom - Cancer
  • Specify - Myelodysplastic Syndrome

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)

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?

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.)

Between the years 1989 and 2011, a plaintiff alleges that through his employment, he was exposed both dermally and through inhalation to the identified products which contained significant concentrations of aromatic solvents: Aliphatic solvents, napthenic solvents, organic solvents, chlorinated solvents, benzene, pesticides, dioxin, as well as other toxic chemicals. He was allegedly first diagnosed with Myelodysplastic Syndrome around February 2011. See attached list of other non Dow AgroScience products referenced in complaint.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.