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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-2592

2. Registrant Information.

Registrant Reference Number: DASL13030100

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.



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. Unknown

Product Name: Dursban

  • Active Ingredient(s)
      • Unknown

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: Other / Autre

Préciser le type: various locations

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

This person worked as a pest control operator from (year to year) and (year) at various locations and over the years, he was exposed to the product via inhalation/respiratory/ingestion/oral/skin and dermal.

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 - Pain
    • Symptom - Weakness
    • Symptom - Malaise
    • Specify - loss of general health, strength and vitality
    • Symptom - Other
    • Specify - limitation from performing normal activities
  • Blood
    • Symptom -
    • Specify - Monoclonal Gammopathy

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

What was the activity? exterminator

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.)

This person worked as a pest control operator from (year to year) and (year) at various locations (City of (name) Housing Authority, (name) and name) Over the years, he claims he was exposed to the product via inhalation/respiratory/ingestion/oral/skin and dermal. He has been diagnosed in March 2011 with Monoclonal Gammopathy of Undetermined Significance (MGUS). This disease causes great pain, suffering and inconvenience; limitation and preclusion from performing normal activities; great emotional distress, loss of general health, strength and vitality.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.