Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-1857

2. Registrant Information.

Registrant Reference Number: DASL150501-00

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.

01-MAY-15

5. Location of incident.

Country: UNITED STATES

Prov / State: HAWAII

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. 62719-47

Product Name: Dursban TC

• Active Ingredient(s)
  • CHLORPYRIFOS
    • Unknown

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7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

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

Site: Pub. Area - Outdoor/Zone publique - ext

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

A pest control operator worked from 1988-1991 and used the product as part of his job. No additional information on 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.

Other

2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Reproductive System
  • Symptom - Infertility
  • Specify - developed infertility

• General
  • Symptom - Cancer
  • Specify - diagnosed with stage IV metastic right lung adenocarcinoma

• Nervous and Muscular Systems
  • Symptom - Depression
  • Symptom - Other
  • Specify - Mood disorders

• General
  • Symptom - Other
  • Specify - diagnosed with Klinefelter's syndrome
  • Symptom - Death

4. How long did the symptoms last?

Persisted until death

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

Yes

6. a) Was the person hospitalized?

Unknown

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)

Unknown

10. Route(s) of exposure.

Unknown

11. What was the length of exposure?

>1 yr / > 1 an

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 subject died of lung cancer on (date). It has been alleged that exposure to the product when he worked as a pesticide applicator contributed to the development of the disease. He was diagnosed with "stage IV metastic right lung adenocarcinoma" on 12/12/11. There are also references to possible work-place exposure to asbestos and chlordane and to the fact that his infertilitly was originally attributed to Klinefelter's syndrome, a genetic disorder.

To be determined by Registrant

14. Severity classification.

Death

15. Provide supplemental information here.

n/a