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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2016-2343

2. Registrant Information.

Registrant Reference Number: SC1638649

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

Address: 2400, 215-2nd Street S.W.

City: Alberta

Prov / State: Calgary

Country: Canada

Postal Code: T2P 1M4

3. Select the appropriate subform(s) for the incident.

Human

4. Date registrant was first informed of the incident.

01-JUL-15

5. Location of incident.

Country: CANADA

Prov / State: MANITOBA

6. Date incident was first observed.

28-MAY-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)

PMRA Registration No. 28804      PMRA Submission No.       EPA Registration No.

Product Name: Frontline XL

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

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: Unknown / Inconnu

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

Caller states that he was working with the diluted product on 5/26/2015 while wearing gloves. He states that he was working with it 'all day' although there was no direct exposure indicated. Within 24 hours, he developed an upset stomach that lasted for 2 days. On 6/5/2015, he was required to work with the product again (in the same way) and has had diarrhea on and off for the past 4 weeks.

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

  • Gastrointestinal System
    • Symptom - Diarrhea
    • Symptom - Stomachache

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.

No

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Unknown

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

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

10. Route(s) of exposure.

Unknown

11. What was the length of exposure?

Unknown / Inconnu

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.)

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

Would not expect the symptoms to be related to possible exposure to the product as the AIs would not be expected to pose a significant health concern even if incidental contact with diluted herbicide occurred.