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Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-3657

2. Registrant Information.

Registrant Reference Number: PROSAR Case # 1-27070768

Registrant Name (Full Legal Name no abbreviations): Syngenta Crop Protection Canada, Inc.

Address: 140 Research Lane, Research Park

City: Guelph

Prov / State: Ontario

Country: Canada

Postal Code: N1G4Z3

3. Select the appropriate subform(s) for the incident.

Human

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

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.

PMRA Registration No.       PMRA Submission No.       EPA Registration No. Unknown

Product Name: Touchdown Herbicide (non specific)

• Active Ingredient(s)
  • GLYPHOSATE

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: Unknown / Inconnu

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 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

• Respiratory System
  • Symptom - Respiratory irritation
  • Symptom - Irritated throat

• Nervous and Muscular Systems
  • Symptom - Muscle pain

• General
  • Symptom - Other
  • Specify - "a cold"

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?

Unknown

6. b) For how long?

7. Exposure scenario

Unknown

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

Application

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.

>8 hrs <=24 hrs / > 8 h < = 24 h

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.)

1-27070768- The reporter called to indicate exposure to an herbicide containing the active ingredient glyphosate. The caller indicated he had been applying the product diluted at a ratio of 1:10 six days prior to his initial contact with the registrant. The reporter did not clarify in what capacity he was applying this product, the duration of application, or any personal protective equipment that may have been use during application. The reporter indicated he was not aware of any discreet exposure incident. He indicated in the time frame between application and contact with the registrant he had noted the symptoms of respiratory irritation, throat irritation and back ache. The caller was unsure if his symptoms were consistent with undetected exposure or a respiratory infection. The reporter was advised to seek medical attention to assist in determining the cause of his symptoms and appropriate treatment as the symptoms described, time line and, duration of symptoms were inconsistent with the toxicity profile of the product and active ingredient. On follow up the reporter indicated he had been to a physician, had 'some tests', and it was determined he had a 'cold'. He indicated he was provided medication (non specific) and was at the time of follow-up resolved. No further information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.