Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2020-4144
2. Registrant Information.
Registrant Reference Number: SC2746479
Registrant Name (Full Legal Name no abbreviations): Dow AgroSciences Canada Inc.
Address: Suite 2400, 215 - 2nd Street S.W.
City: Calgary
Prov / State: Alberta
Country: Canada
Postal Code: T2P 1M4
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
21-AUG-20
5. Location of incident.
Country: UNITED STATES
Prov / State: UNKNOWN
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. 62719-260-5905
Product Name: Crossbow Herbicide
- Active Ingredient(s)
- 2,4-D (PRESENT AS AMINE SALTS : DIMETHYLAMINE SALT, DIETHANOLAMINE SALT, OR OTHER AMINE SALTS)
- Guarantee/concentration 34.4 %
- TRICLOPYR
- Guarantee/concentration 16.5 %
7. b) Type of formulation.
Liquid
Application Information
8. Product was applied?
Unknown
9. Application Rate.
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).
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
Unknown
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
Unknown
4. Number of animals affected
1
5. Sex
Unknown
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- General
- Symptom - Cancer
- Symptom - Death
12. How long did the symptoms last?
Unknown / Inconnu
13. Was medical treatment provided? Provide details in question 17.
Unknown
14. a) Was the animal hospitalized?
Unknown
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Died
16. How was the animal exposed?
Other / Autre
specify unknown
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
The caller alleges that their neighbor had sprayed the product last week and "the odor" entered the caller真真真s home. The caller also indicated that her dog died of cancer.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Cat / Chat
3. Breed
Unknown
4. Number of animals affected
1
5. Sex
Unknown
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- Renal System
- Symptom - Other
- Specify - Kidney Disease
12. How long did the symptoms last?
Unknown / Inconnu
13. Was medical treatment provided? Provide details in question 17.
Unknown
14. a) Was the animal hospitalized?
Unknown
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Died
16. How was the animal exposed?
Other / Autre
specify unknown
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
The caller alleges that their neighbor had sprayed the product last week and 真真真the odor真真真 entered the caller真真真s home. The caller further alleges that her cat suddenly died of kidney disease.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here