Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2018-2336

2. Registrant Information.

Registrant Reference Number: SC2220457

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.

20-APR-18

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

20-APR-18

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.       PMRA Submission No.       EPA Registration No. 62719-410

Product Name: Rally 40W Fungicide in WSP

• Active Ingredient(s)
  • MYCLOBUTANIL

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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: Agricultural-Indoor / Agricole-intérieur

Préciser le type: Greenhouse

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.

Data Subject

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 - Palpitations

• Nervous and Muscular Systems
  • Symptom - Dizziness
  • Symptom - Memory loss

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

Unknown

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

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

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?

>1 mo <= 6 mos / > 1 mois < = 6 mois

12. Time between exposure and onset of symptoms.

>1 wk <=1 mo / > 1 sem < = 1 mois

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.)

4/20/2018 Caller applied product on plants in a greenhouse warehouse where plants were affected with white mold. The rooms were closed and had air conditioning. Caller was in the room for 4 hours at a time on two occasions in a two week period. He started having issues 2 weeks after the initial spray. He feels his memory is not very good, lightheaded, dizziness, loss of concentration, and feels palpitations in his heart area. He has been to 2 or 3 hospitals and has had lab tests, blood glucose levels, lung tests, and an abdominal ultrasound yesterday. An electrocardiogram was performed 2 days ago, and caller was told he had something like an extra heart beat but not to worry. Caller was vague about dates and times, but does recall that blood glucose and ultrasound results were normal. He has another appointment with a hospital in 3 days. 5/7/2018 Caller's dizziness is still present constantly, and palpitations are present on and off.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.

Any relationship between the use of this product and the development of the complications reported in this case is highly unlikely and lacks biological plausibility. Secondly, the product use history is extremely vague and lacks any description of a known or defined point of direct exposure to this product. Even had casual or incidental contact with this product occurred, such illness would be unexpected and is not consistent with the toxicological profile of this product. 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.