Incident Report

Subform I: General Information

1. Report Type.

Update the report

Incident Report Number: 2013-3836

2. Registrant Information.

Registrant Reference Number: SC1182527

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.

Human

4. Date registrant was first informed of the incident.

08-JUN-13

5. Location of incident.

Country: UNITED STATES

Prov / State: FLORIDA

6. Date incident was first observed.

01-JUN-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)

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

Product Name: Vikane Gas Fumigant

• Active Ingredient(s)
  • SULFURYL FLUORIDE
    • Guarantee/concentration 99.8 %

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

3. List all symptoms, using the selections below.

System

• General
  • Symptom - Fever

• Nervous and Muscular Systems
  • Symptom - Headache
  • Symptom - Muscle pain
  • Specify - backache
  • Symptom - Stiffness
  • Specify - stiffness of neck

4. How long did the symptoms last?

Unknown / Inconnu

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

Yes

6. a) Was the person hospitalized?

Yes

6. b) For how long?

4

Day(s) / Jour(s)

7. Exposure scenario

Non-occupational

8. How did exposure occur? (Select all that apply)

Contact with treated area

Amount of time between application and contact 6

Day(s) / Jour(s)

What was the activity? Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding the activity

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

None

10. Route(s) of exposure.

Respiratory

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>24 hrs <=3 days / >24 h <=3 jours

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.)

June 8, 2013: Patient's cousin called to report an incident. Home was fumigated on May 23 (Thurs), and the tent removed on Fri 5/24 at 8AM. They were cleared to go back in on 5/24 at 6pm, but did not actually re-enter home until Monday ( 5/27 ). The caller's cousin entered the home May 30. On Saturday (6/1) about noon she began to have a headache and fever (after staying 2 nights in home). The caller took her to hospital, and had temp of 104F with headache, backache, and stiffness of neck. She was released on Wed (June 4) but symptoms returned and was re-admitted on Thursday. The treatment this patient received as well as a diagnosis is not known.

To be determined by Registrant

14. Severity classification.

Major

15. 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. Re-entry into a treated dwelling is not permitted until Vikane levels drop below 1 ppm, a level known to be well below the threshold for potential toxicity. There would have been no significant quantities of sulfuryl fluoride in this home 6 days after the home was officially cleared for safe reentry. This is the time by which this patient reentered the home. This patients signs and symptoms are more consistent with an infectious etiology. A link between this patient's illness and the use of Vikane in the home 8 days prior to her onset of illness is biologically implausible.