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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-1203

2. Registrant Information.

Registrant Reference Number: DASL150313-00

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.

13-MAR-15

5. Location of incident.

Country: UNITED STATES

Prov / State: CALIFORNIA

6. Date incident was first observed.

12-MAR-15

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)

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

Product Name: Vikane

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

7. b) Type of formulation.

Other (specify)

Gas

Application Information

8. Product was applied?

Yes

9. Application Rate.

24.7

Units: lbs

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).

A single story, multi-family residential building started fumigation for drywood termites on March 11, 2015. The size of the area treated was 66 cu ft. The area was inspected prior to and during application for hazards and enforcing safety policies and procedures according to their company policies.

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

  • General
    • Symptom - Death

4. How long did the symptoms last?

Persisted until death

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)

Contact with treated area

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.

Skin

Eye

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.)

The fumigation company was notified by the fire department that they had found a deceased male individual at the fumigation site on March 11, 2015. A neighbor had called 911 when they noticed a light on in the house during the second day of the fumigation. The fumigation company received a phone call from the coroner on the morning of March 12. The job site was brought down on March 12 at approximately 2:00 pm, with final clear given at 4 pm. When the crews showed up to do the CAP, the job site appeared to be normal on March 11 at approx 1130 am. However, when the crews showed up to drop the tarps they noticed the tarps had been reclosed sloppily. The deceased individual was later identified as the (age) year old son of one of the tenants. Police report and coroner's report are unavailable at this time.

To be determined by Registrant

14. Severity classification.

Death

15. Provide supplemental information here.

n/a