Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-1694

2. Registrant Information.

Registrant Reference Number: DASC150113-00

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-JAN-15

5. Location of incident.

Country: CANADA

Prov / State: SASKATCHEWAN

6. Date incident was first observed.

15-JUN-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. 29985      PMRA Submission No.       EPA Registration No.

Product Name: Tandem A Herbicide

• Active Ingredient(s)
  • PYROXSULAM

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PMRA Registration No. 29965      PMRA Submission No.       EPA Registration No.

Product Name: Tandem B Herbicide

• Active Ingredient(s)
  • FLUROXYPYR 1-METHYLHEPTYL ESTER

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7. b) Type of formulation.

Application Information

8. Product was applied?

No

9. Application Rate.

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

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

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

• Skin
  • Symptom - Inflammation of the skin

4. How long did the symptoms last?

>1 wk <=1 mo / > 1 sem < = 1 mois

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

Yes

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Occupational

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

Application

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

Goggles

Respirator

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.

<=30 min / <=30 min

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 customer was loading Tandem co-pack (Tandem A + Tandem B) into the chem handler of his sprayer tank to spray his wheat and had an alleged allergic reaction (swelling of his cheeks). He claims he was wearing a respirator and goggles. Exposure was to vapours as he was loading the product into the tank. Nurse practioner in (location) saw him on 2 occasions and prescribed pregnasone to treat the reaction. Customer indicated that after a month of treatment he was back to normal. He was not hospitalized.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

n/a