Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-2578

2. Registrant Information.

Registrant Reference Number: NF12061301

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.

13-JUN-12

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

11-JUN-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. 21032      PMRA Submission No.       EPA Registration No.

Product Name: ASSERT 300 SC HERBICIDE

• Active Ingredient(s)
  • IMAZAMETHABENZ

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PMRA Registration No. 22764      PMRA Submission No.       EPA Registration No.

Product Name: CURTAIL M HERBICIDE

• Active Ingredient(s)
  • CLOPYRALID
  • MCPA (PRESENT AS ESTERS)

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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).

The Assert 300 SC was applied diluted significantly in tank mix with Curtail M. Spilled some product over her chest and arms, rinsed and removed clothes within the following 2 hours. That evening, after the exposure, symptoms began to develop.

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: Female

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• General
  • Symptom - Fever
  • Symptom - Sweating

• Gastrointestinal System
  • Symptom - Vomiting

• Nervous and Muscular Systems
  • Symptom - Shaking

4. How long did the symptoms last?

<=30 min / <=30 min

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

Unknown

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.

Skin

11. What was the length of exposure?

>15 min <=2 hrs / >15 min <=2 h

12. Time between exposure and onset of symptoms.

>2 hrs <=8 hrs / > 2 h < = 8 h

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 affected person spilled some diluted product over her chest and arms, but only removed her clothing after 2 hours. She had a cold prior. Later that day she experienced vomiting, shaking, fever and sweats. Symptoms lasted 30 minutes.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.