Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-1408

2. Registrant Information.

Registrant Reference Number: DASL140423-00

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

Address: Suite 2100, 450-1st Street S.W.

City: Alberta

Prov / State: Calgary

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.

23-APR-14

5. Location of incident.

Country: UNITED STATES

Prov / State: CALIFORNIA

6. Date incident was first observed.

22-APR-14

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. 627194

Product Name: Vikane

• Active Ingredient(s)
  • SULFURYL FLUORIDE
    • Unknown

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7. b) Type of formulation.

Other (specify)

Fumigant

Application Information

8. Product was applied?

Yes

9. Application Rate.

18

Units: lbs

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

Site: Res. - Out Home / Rés - à l'ext.maison

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

Fumigator arrived at residence 5:50 PM on 4/22/14 to start aeration procedure. Licensee noted disturbed sand snakes and broken seal (note: the term sand snakes refers to 3-4 foot long tubes filled with sand which act as weights to hold the tent in place).

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: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• General
  • Symptom - Death

4. How long did the symptoms last?

Unknown / Inconnu

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

No

6. a) Was the person hospitalized?

No

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)

None

10. Route(s) of exposure.

Unknown

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.)

Victim was reportedly found on back porch of residence underneath tarp and entangled with what appeared to be a broken trellis. Victim was reportedly a white male and (name). Victim was reported to be shirtless, carried a black T-shirt and wet towel, no identification and had no known affiliation with the property or fumigation company. Victim was reported not inside the house but between the tarp and house. House was reported to be secondary locked. Police were called and they called the fire department. The initial investigation by (name) has found no violation. Police have reported that an autopsy will be conducted.

To be determined by Registrant

14. Severity classification.

Death

15. Provide supplemental information here.