Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-1409

2. Registrant Information.

Registrant Reference Number: SC1351540

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.

20-MAR-14

5. Location of incident.

Country: UNITED STATES

Prov / State: CALIFORNIA

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.

Active(s)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 62719-258

Product Name: Turflon Ester Herbicide

• Active Ingredient(s)
  • TRICLOPYR
    • Guarantee/concentration 61.6 %

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7. b) Type of formulation.

Liquid

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

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).

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?

Unknown

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Data Subject

2. Demographic information of data subject

Sex: Male

Age: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

• Eye
  • Symptom - Blurred vision

• General
  • Symptom - Cancer
  • Specify - Prostate cancer

• Respiratory System
  • Symptom - Bronchitis
  • Symptom - Shortness of breath

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?

3

Day(s) / Jour(s)

7. Exposure scenario

Non-occupational

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

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

Other

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.

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.)

3/20/2014 Caller has been living in his home for 12 years and suspects product has been used on the trees, bushes, and grass in his yard periodically during this time. He could not say when or why the product would have been applied on or near his property. Caller is experiencing various health issues. In the last 10 years, he has had prostate cancer which went into remission. He says his eyesight is going bad slowly over the years and just got out of the hospital 3 weeks ago with a diagnosis of bronchitis and a recurrence of his prostate cancer. Caller was in the hospital for 3 days. He says he always wears shoes when he goes outside but does touch the berries from the trees with his hands when he is cleaning them up. He denies any contact with the wet product. Caller mentioned that he was experiencing shortness of breath now which had temporarily improved when he was in the hospital but is now increasing. He complains now that his breathing is continuing to deteriorate.

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. The product use history is extremely vague and lacks any description of a known or defined point of direct exposure to this herbicide. Even had casual or incidental contact with this product occurred, the type of serious complications reported by this patient with a complicated past medical history lack biological plausibility with respect to any type of causal relationship.