Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-5338

2. Registrant Information.

Registrant Reference Number: SC1670199

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.

20-AUG-15

5. Location of incident.

Country: CANADA

Prov / State: SASKATCHEWAN

6. Date incident was first observed.

14-AUG-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. 29651      PMRA Submission No.       EPA Registration No.

Product Name: PrePass XC A Herbicide

• Active Ingredient(s)
  • FLORASULAM

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PMRA Registration No. 29652      PMRA Submission No.       EPA Registration No.

Product Name: PrePass XC B Herbicide

• Active Ingredient(s)
  • GLYPHOSATE (PRESENT AS DIMETHYLAMINE SALT)

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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.

Medical Professional

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 - Blister

4. How long did the symptoms last?

>3 days <=1 wk / >3 jours <=1 sem

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

Non-occupational

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

Pesticide Spill

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.

Skin

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>3 days <=1 wk / >3 jours <=1 sem

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.)

A man had an unspecified amount of Prepass product in a backpack sprayer that spilled onto his left arm. He reportedly washed the arm off an unspecified period of time later. Three to four days after exposure, he developed fluid filled blisters which have been treated with a prescribed Bactroban ointment. As of August 20th, the arm is now healing and has scabs.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.

A 3-4 day delay in the onset of symptoms is uncharacteristic of what is expected following dermal exposure. If contact dermatitis were to occur, symptoms would typically be more immediate in onset.