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Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-3532

2. Registrant Information.

Registrant Reference Number: PROSAR Case #1-33821612

Registrant Name (Full Legal Name no abbreviations): Gowan Company

Address: P.O. Box 5569

City: Yuma

Prov / State: AZ

Country: USA

Postal Code: 85366-5569

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

Human

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: SASKATCHEWAN

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.

PMRA Registration No. 25112      PMRA Submission No.       EPA Registration No.

Product Name: Avadex MicroActiv Herbicide (Canada)

• Active Ingredient(s)
  • TRIALLATE

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: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Cardiovascular System
  • Symptom - Chest tightness

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

Unknown

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.

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.)

1-33821612 The reporter indicated that an adult male was exposed to an herbicide containing the active ingredient triallate. The reporter indicated that a (age)year old, (weight) pound male was exposed to the granules one day prior to initial contact with the registrant and during exposure may have inhaled some of the dust. At the time of initial contact the reporter indicated that the patient was suffering from minor tightness in his chest. The reporter was advised to seek medical attention for appropriate diagnosis and treatment of the patient's symptoms. No further information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.