Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2018-2091

2. Registrant Information.

Registrant Reference Number: DASLLC2238609

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

Address: 215-2nd Street SW, Suite 2400

City: Calgary

Prov / State: AB

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.

22-MAY-18

5. Location of incident.

Country: UNITED STATES

Prov / State: LOUISIANA

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.       PMRA Submission No.       EPA Registration No. 62719-220

Product Name: Hatchet Insecticide

• Active Ingredient(s)
  • CHLORPYRIFOS
    • Guarantee/concentration 44.9 %

---

7. b) Type of formulation.

Application Information

8. Product was applied?

Unknown

9. Application Rate.

Unknown

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).

Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding application.

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.

Other

2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Diarrhea

• General
  • Symptom - Death

• Nervous and Muscular Systems
  • Symptom - Other
  • Specify - Stupor/Obtundation

4. How long did the symptoms last?

Persisted until death

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

No

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

Unknown

7. Exposure scenario

Non-occupational

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

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.

Unknown

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.)

5/22/2018 Caller is an investigator with the Louisiana Forensic Center. Caller reports that one person has died and two other people are in intensive care after possible exposure to the product in a trailer home. The men were disoriented and covered in diarrhea when they were found. 5/23/2018 The pathologists' office summarizes that there were five victims in a trailer potentially exposed to the product. The product container was found in the laundry room of the trailer house, and was sealed with a plastic screw top. Responding emergency medical services noted a noxious smell outside and inside the trailer. The first victim is deceased, and an autopsy will be performed today. Two other victims are in the intensive care unit of a local hospital. The other two victims were noted to have disorientation and emesis, but were released from the hospital.

To be determined by Registrant

14. Severity classification.

Death

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. The product use history is extremely vague and lacks any description of a known or defined point of direct exposure to this product. Without more information it would be very difficult to determine a relationship between any possible exposure to the product and the events reported.

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Diarrhea

• Nervous and Muscular Systems
  • Symptom - Other
  • Specify - Stupor/Obtundation

4. How long did the symptoms last?

Unknown / Inconnu

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

Yes

6. a) Was the person hospitalized?

Yes

6. b) For how long?

Unknown

7. Exposure scenario

Non-occupational

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

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.

Unknown

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.)

5/22/2018 Caller is an investigator with the Louisiana Forensic Center. Caller reports that one person has died and two other people are in intensive care after possible exposure to the product in a trailer home. The men were disoriented and covered in diarrhea when they were found. 5/23/2018 The pathologists' office summarizes that there were five victims in a trailer potentially exposed to the product. The product container was found in the laundry room of the trailer house, and was sealed with a plastic screw top. Responding emergency medical services noted a noxious smell outside and inside the trailer. The first victim is deceased, and an autopsy will be performed today. Two other victims are in the intensive care unit of a local hospital. The other two victims were noted to have disorientation and emesis, but were released from the hospital.

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. The product use history is extremely vague and lacks any description of a known or defined point of direct exposure to this product. Without more information it would be very difficult to determine a relationship between any possible exposure to the product and the events reported.

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Diarrhea

• Nervous and Muscular Systems
  • Symptom - Other
  • Specify - Stupor/Obtundation

4. How long did the symptoms last?

Unknown / Inconnu

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

Yes

6. a) Was the person hospitalized?

Yes

6. b) For how long?

Unknown

7. Exposure scenario

Non-occupational

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

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.

Unknown

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.)

5/22/2018 Caller is an investigator with the Louisiana Forensic Center. Caller reports that one person has died and two other people are in intensive care after possible exposure to the product in a trailer home. The men were disoriented and covered in diarrhea when they were found. 5/23/2018 The pathologists' office summarizes that there were five victims in a trailer potentially exposed to the product. The product container was found in the laundry room of the trailer house, and was sealed with a plastic screw top. Responding emergency medical services noted a noxious smell outside and inside the trailer. The first victim is deceased, and an autopsy will be performed today. Two other victims are in the intensive care unit of a local hospital. The other two victims were noted to have disorientation and emesis, but were released from the hospital.

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. The product use history is extremely vague and lacks any description of a known or defined point of direct exposure to this product. Without more information it would be very difficult to determine a relationship between any possible exposure to the product and the events reported.

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Unknown

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Vomiting

• Nervous and Muscular Systems
  • Symptom - Other
  • Specify - Stupor/Obtundation

4. How long did the symptoms last?

Unknown / Inconnu

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

Yes

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)

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.

Unknown

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.)

5/22/2018 Caller is an investigator with the Louisiana Forensic Center. Caller reports that one person has died and two other people are in intensive care after possible exposure to the product in a trailer home. The men were disoriented and covered in diarrhea when they were found. 5/23/2018 The pathologists' office summarizes that there were five victims in a trailer potentially exposed to the product. The product container was found in the laundry room of the trailer house, and was sealed with a plastic screw top. Responding emergency medical services noted a noxious smell outside and inside the trailer. The first victim is deceased, and an autopsy will be performed today. Two other victims are in the intensive care unit of a local hospital. The other two victims were noted to have disorientation and emesis, but were released from the hospital.

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. The product use history is extremely vague and lacks any description of a known or defined point of direct exposure to this product. Without more information it would be very difficult to determine a relationship between any possible exposure to the product and the events reported.

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Unknown

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Vomiting

• Nervous and Muscular Systems
  • Symptom - Other
  • Specify - Stupor/Obtundation

4. How long did the symptoms last?

Unknown / Inconnu

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

Yes

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)

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.

Unknown

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.)

5/22/2018 Caller is an investigator with the Louisiana Forensic Center. Caller reports that one person has died and two other people are in intensive care after possible exposure to the product in a trailer home. The men were disoriented and covered in diarrhea when they were found. 5/23/2018 The pathologists' office summarizes that there were five victims in a trailer potentially exposed to the product. The product container was found in the laundry room of the trailer house, and was sealed with a plastic screw top. Responding emergency medical services noted a noxious smell outside and inside the trailer. The first victim is deceased, and an autopsy will be performed today. Two other victims are in the intensive care unit of a local hospital. The other two victims were noted to have disorientation and emesis, but were released from the hospital.

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. The product use history is extremely vague and lacks any description of a known or defined point of direct exposure to this product. Without more information it would be very difficult to determine a relationship between any possible exposure to the product and the events reported.