Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-2189

2. Registrant Information.

Registrant Reference Number: A150032169

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.

Domestic Animal

4. Date registrant was first informed of the incident.

13-MAR-15

5. Location of incident.

Country: UNITED STATES

Prov / State: TEXAS

6. Date incident was first observed.

13-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)

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

Product Name: Vikane Gas Fumigant

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

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7. b) Type of formulation.

Other (specify)

Gas

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

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).

Dog was found under the fumigation tent. It is unknown how long he was under it.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Unknown

Subform III: Domestic Animal Incident Report

1. Source of Report

Medical Professional

2. Type of animal affected

Dog / Chien

3. Breed

Golden Retriever Mix

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

2

7. Weight (provide a range if necessary )

50

lbs

8. Route(s) of exposure

Respiratory

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

• Respiratory System
  • Symptom - Heavy breathing

• General
  • Symptom - Lethargy

• Skin
  • Symptom - Erythema

• Respiratory System
  • Symptom - Dyspnea

• Cardiovascular System
  • Symptom - Abnormally fast heart rate
  • Symptom - Tachycardia

• General
  • Symptom - Other
  • Specify - High temperature
  • Symptom - Hyperthermia

• Nervous and Muscular Systems
  • Symptom - Ataxia

• Blood
  • Symptom - Hypocalcemia
  • Specify - Hypocalcemia severe
  • Symptom - Hypernatremia
  • Specify - Hypernatremia mild
  • Symptom - Blood urea nitrogen increased
  • Specify - Azotemia moderate

• General
  • Symptom - Death

12. How long did the symptoms last?

>8 hrs <=24 hrs / > 8 h < = 24 h

13. Was medical treatment provided? Provide details in question 17.

Yes

14. a) Was the animal hospitalized?

Unknown

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Died

16. How was the animal exposed?

Contact treat.area/Contact surf. traitée

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

House was tented and the dog was supposed to be in a kennel on the property but escaped and went to the house. Veterinary care was provided and it was noted that the dog had hookworms. The dog died during the night of March 13, 2015.

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To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Death

19. Provide supplemental information here

n/a