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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-2911

2. Registrant Information.

Registrant Reference Number: A130026518

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

Address: 450-1st Street SW, Suite 2100

City: Calgary

Prov / State: AB

Country: Canada

Postal Code: T2P 5H1

3. Select the appropriate subform(s) for the incident.

Domestic Animal

4. Date registrant was first informed of the incident.

01-MAR-13

5. Location of incident.

Country: UNITED STATES

Prov / State: CALIFORNIA

6. Date incident was first observed.

01-MAR-13

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)

PMRA Registration No.       PMRA Submission No.       EPA Registration No. 62719-4

Product Name: Vikane Gas Fumigant

  • Active Ingredient(s)
    • SULFURYL FLUORIDE
      • Unknown

7. b) Type of formulation.

Other (specify)

gas fumigant

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

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

Site: Res. - In Home / Rés. - à l'int. maison

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

Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding application.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Yes

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Cat / Chat

3. Breed

Domestic short hair

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

6

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Respiratory

9. What was the length of exposure?

<=15 min / <=15 min

10. Time between exposure and onset of symptoms

<=30 min / <=30 min

11. List all symptoms

System

  • Eye
    • Symptom - Tearing
  • General
    • Symptom - Death
  • Respiratory System
    • Symptom - Shortness of breath
  • General
    • Symptom - Vocalizing

12. How long did the symptoms last?

Persisted until death

13. Was medical treatment provided? Provide details in question 17.

Unknown

14. a) Was the animal hospitalized?

Unknown

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Died

16. How was the animal exposed?

Other / Autre

specify Entered structure that was tented for fumigation.

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

3/1/2013 7:29:22 PM - A neighbor's house was tented for fumigation and the pet owner heard his cat crying from under the house and went under the tent to retrieve his cat. He was inside for a couple of minutes. The cat was having severe respiratory issues and discharge from the eyes. Caller's eyes were burning when he went into the house, but is currently asymptomatic. A family member reported that the man is fine and unsure if he went to the hospital or not. The family member also reported that the cat died.


To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Death

19. Provide supplemental information here

The information contained in this report is based on self-reported statements provided to the registrant during telephone Interview(s). These self-reported descriptions of an incident have not been independently verified to be factually correct or complete descriptions of the incident. For that reason, information contained in this report does not and can not form the basis for a determination of whether the reported clinical effects are causally related to exposure to the product identified in the telephone interviews. Domestic cat was inappropriately allowed inside of a tented structure during the fumigation process. The cat owner ignored posted warnings not to reenter the fumigated structure prior to the structure being cleared for safe reentry by the applicator.