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:

This form must be submitted in English.

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.

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^‡

Your Email^‡

Date you Became Aware of
Incident (mm/dd/yyyy)^‡

Reporter/Contact Name^‡

Reporter/Contact Address^‡

Reporter/Contact Phone Number^‡

Section 2. Product(s) Involved

Product 1 Name^‡

Product 2 Name

Product 3 Name

Section 3. Incident Information

Date of Exposure
or Adverse Effect
(mm/dd/yyyy)

Type of Incident?
(check all that apply)

	Human (specify adult/child gender, number involved, age below)
	Domestic Animal (specify species and number involved below)
	Property Damage and/or Crop/Plant Injury (specify acres, dollar amount, number of objects affected below)
	Water Contamination
	Fish/Wildlife

Brief Description
of Alleged Incident,
How Incident Occured,
Application Method:

Description of Use;
Was there Evidence of
Intentional Product Misuse;
Was Protective Equipment Worn;
Were Label Description Followed:

Specify Symptoms Experienced,
Lab Results,
Time Between Exposure
and Onset:

Was Medical Care Sought?

Treating Physician/
Veterinarian Information
(name, city, state, country, phone)

If Other, Please Specify:

Other Comments

^‡Required Field

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