Health Canada
Symbol of the Government of Canada
Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2017-2263

2. Registrant Information.

Registrant Reference Number: SC1850266

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.

23-JUN-16

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

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)

PMRA Registration No. 29752      PMRA Submission No.       EPA Registration No.

Product Name: ClearView Herbicide

  • Active Ingredient(s)
    • AMINOPYRALID
    • METSULFURON-METHYL

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).

Caller reported that she and her (age) year old grandson were walking in the area where product had been sprayed. She knows product was used there due to a sign that was posted with name of product and stating it had been applied the day before. Her grandson dropped a piece of pear on the ground in this area, picked it up and bit into it. Caller then took it from him. He started having diarrhea 4 hours after this and caller is inquiring whether this could be due to eating fruit that may have come in contact with product.

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: >1 <=6 yrs / > 1 < = 6 ans

3. List all symptoms, using the selections below.

System

  • Gastrointestinal System
    • Symptom - Diarrhea

4. How long did the symptoms last?

Unknown / Inconnu

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

Non-occupational

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

Contact with treated area

What was the activity? Dropped fruit on treated area then ate it

Other

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.

Oral

Unknown

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>2 hrs <=8 hrs / > 2 h < = 8 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.

Medical professional advised that they would not expect child's symptoms to be due to events she has described. Product poses a very low toxicity concern for humans.