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Global Adverse Effects Reporting Form

Use this form to report to Dow AgroSciences any alleged or actual product complaint, incident, issue or concern involving exposure or injury to humans, animals or the environment related to the use of a Dow AgroSciences product in countries where it conducts business. The form must be completed within 72 hours of the employee or DAS agent being made aware of such information or incident. Exception: An incident or information involving a human death allegation must be reported immediately!

If you receive additional information or incident details after submitting the initial form, please complete a separate Global Adverse Effects Reporting Form and forward within 72 hours of receipt of the new information.

Instructions:

  1. This form must be submitted in English.
  2. You do not need to submit this form unless you have, at a minimum:
    (a) information about the location where the incident occurred,
    (b) the name of the pesticide(s) or product(s) involved, and
    (c) the name and phone number of the person to contact regarding the incident.
  3. Fill out the forms as completely as possible.

Questions:
Global Adverse Effects Administrator
Global Product Stewardship Department
Telephone: 1-317-337-4577

Mail:
Dow AgroSciences
9330 Zionsville Road
Indianapolis, IN 46268 USA
Attn: Global Adverse Effects Administrator

Fax:
1-317-337-4880

Global Adverse Effects Reporting Form
Section 1. Administrative Data  
Your Name‡ 
Date you Became Aware of
Incident (mm/dd/yyyy)‡		 
Reporter Name‡ 
Reporter Address‡ 
Reporter Phone Number‡ 
Contact Name
(if different than Reporter)		 
Contact Address 
Contact Phone Number 
Section 2. Product(s) Involved
  
Product 1 Name‡ 
Active Ingredient(s)‡ 
EPA Registration #
(for U.S. products only)		 
Was Product Involved
in a Concentrated
or a Diluted Form?		 
Product 2 Name 
Active Ingredient(s) 
EPA Registration #
(for U.S. products only)		 
Was Product Involved
in a Concentrated or
a Diluted Form?		 
Product 3 Name 
Active Ingredient(s) 
EPA Registration #
(for U.S. products only)		 
Was Product Involved
in a Concentrated or
a Diluted Form?		 
Section 3. Incident Information  
Type of Incident?
(check all that apply)		 
Human
Domestic Animal
Crop Injury
Property Damage
Fish/Wildlife
Water Contamination
Brief Description
of Alleged Incident:		 
Date of Exposure
or Adverse Effect
(mm/dd/yyyy)		 
Species Affected
(e.g., human, canine, feline,
bovine, soybean, corn, rice,
bluegill, deer, etc.)		 
If Human or Animal,
How Many of Each
Species is Involved?		 
If Humans, are they:
(check all that apply)		 
Adult(s)
Child(ren)
Gender (choose one) 
Ages 
Specify Symptoms
Experienced:		 
Was Medical Care Sought? 
Treating Physician/
Veterinarian Information
(name, city, state, country, phone)		 
Time Between Exposure
and Onset of Symptoms?		 
Laboratory Test Results
or Medical Diagnosis:
(forward copy to AERC if available)		 
How did Incident Occur:
(e.g., contact with treated surface,
intentional ingestion, accidental
ingestion, from prior year's
application, spill, drift, inhalation)		 
Application Was Made by: 
If Other, Please Specify: 
Was there Evidence of
Intentional Product Misuse?		 
Were Label
Directions Followed?		 
Was Protective
Clothing Worn?		 
If Plant or Crop Injury
Involved, How Many Acres
were Treated?		 
How Many Acres were
Allegedly Affected?		 
What was the
Application Rate?		 
Were Tank Mix Partner(s)
Involved? (choose one)		 
List the DAS Tank
Mix Partner(s) Involved:		 
List the Non-DAS Tank Mix
Partner(s) Involved:		 
What was the Tank Mix
Partner Application Rate?		 
Was the Plant or Crop Injury
due to Prior Year's Chemical
Application (carryover)?		 
Other Comments 
‡Required Field