Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-3468

2. Registrant Information.

Registrant Reference Number: SC1421211

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.

11-JUL-14

5. Location of incident.

Country: UNITED STATES

Prov / State: TEXAS

6. Date incident was first observed.

01-JUL-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. 62719-552

Product Name: Remedy Ultra Herbicide

• Active Ingredient(s)
  • TRICLOPYR
    • Guarantee/concentration 60.45 %

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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?

No

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

• General
  • Symptom - Edema

• Skin
  • Symptom - Blister
  • Symptom - Burns (2nd or 3rd degree)
  • Symptom - Erythema
  • Symptom - Irritated skin
  • Symptom - Peeling skin
  • Symptom - Other
  • Specify - Infection

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

Occupational

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

Application

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.

Unknown

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.)

7/11/2014 Caller's husband mixed the product with diesel and applied it with a four-wheeler from a sprayer onto the cacti around him on 07/01/2014. He was wearing shorts, but had tennis shoes and socks on. He does not know of any direct exposure to the product. On 07/03/2014 he noticed that the skin was red around his ankles and feet. This worsened into blisters. On 07/08/2014 he went to the hospital and was admitted, and has been in the hospital since. Husband has second degree burns on his ankle on his left leg and top of his foot. Caller confirms that husband has some burns on his feet where his shoe would have covered while spraying. His skin is peeling, red, swollen, blistered, painful, and has drainage. They think the burn is infected and are treating him for infection with intravenous antibiotics. Caller confirmed that the doctors do not know what caused the burns.

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. Direct exposure to this herbicide is not evident in this incident. The delayed onset of the patient symptoms > 48 hours after application is not suggestive of a likely temporal relationship for toxicity, nor would they be expected symptoms at the level of severity reported should contact to airborne spray have occurred. Usually complications such as immediate onset of acute eye, skin and respiratory irritation may be seen following exposure to spray drift. Eye and respiratory symptoms were not reported in this incident, and the dermal symptoms reported were localized to areas where contact with the product would not have occurred even with drift exposure. The differential diagnosis for a skin condition of this nature would include multiple potential etiologies which, in addition to this product, include such factors as plant allergens, poison ivy, poison oak, food, medications, dietary supplements, infectious pathogens, heat exposure, insect bites, etc.