Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-5339

2. Registrant Information.

Registrant Reference Number: SC1667047

Registrant Name (Full Legal Name no abbreviations): Dow AgroSciences Canada Inc.

Address: 450-1st Street SW, Suite 2100

City: Calgary

Prov / State: AB

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.

15-AUG-15

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

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. 30914      PMRA Submission No.       EPA Registration No.

Product Name: Curtail M Herbicide

• Active Ingredient(s)
  • CLOPYRALID
  • MCPA (PRESENT AS ESTERS)

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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: Res. - Out Home / Rés - à l'ext.maison

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

Man used this product around the home. No other information available.

To be determined by Registrant

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

No

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

• Cardiovascular System
  • Symptom - Tachycardia
  • Symptom - Irregular heart rate
  • Symptom - Hypotension

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

No

6. b) For how long?

Unknown

7. Exposure scenario

Non-occupational

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

Application

What was the activity? Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding the activity

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.

Unknown

11. What was the length of exposure?

>15 min <=2 hrs / >15 min <=2 h

12. Time between exposure and onset of symptoms.

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

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.)

8/15/2015 An ER doctor called about a patient with a prior history of atrial fibrillation who presented with issues related to his atrial fibrillation and was wondering if use of the product without a mask could aggravate his condition. Patient used this product about 10 hours prior to his presentation around the home. The patient used the product for about 1 hour and without a mask. There was no known exposure. No problems noted until about 9-10 hours after use when the patient presented to the ER. Patient has a history of hypotension and A-Fib that is not treated. MD did not wish to discuss case further when prompted with additional questions. It is not known if the patient received any treatments. MD did not want further follow-up.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.

The information contained in this report is based on self-reported statements provided to the registrant during telephone Interview(s). These self-reported descriptions of an incident have not been independently verified to be factually correct or complete descriptions of the incident. For that reason, information contained in this report does not and can not form the basis for a determination of whether the reported clinical effects are causally related to exposure to the product identified in the telephone interviews. Exposure history appears to be somewhat speculative, and it is unclear as to how the exposure occurred or to what extent an exposure occurred. If direct inhalation of airborne spray occurred, respiratory irritation may occur however such symptoms are typically immediate in onset and are transient in nature. These symptoms were not reported. Based on the known toxicological profile of this pesticide, and the delayed onset of cardiac symptoms, this patients illness is not expected following incidental skin contact or possible inhalation. The reported symptoms are likely related to the individuals prior cardiac history.