Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2018-1591

2. Registrant Information.

Registrant Reference Number: SC2040904

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.

18-MAY-17

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

17-MAY-17

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. 28945      PMRA Submission No.       EPA Registration No.

Product Name: Garlon XRT

• Active Ingredient(s)
  • TRICLOPYR

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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: 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 is asking if her throat irritation could have been caused by product application to trees approximately 10 ft from her home. Product was applied 1 day prior to symptoms developing. The symptoms have since resolved.

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: Female

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Sore throat

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)

Drift from the application site

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.

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

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.)

Throat irritation, resolved the next day

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.