Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-4242

2. Registrant Information.

Registrant Reference Number: PROSAR case number: 1-38167485

Registrant Name (Full Legal Name no abbreviations): Syngenta 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.

19-AUG-14

5. Location of incident.

Country: CANADA

Prov / State: SASKATCHEWAN

6. Date incident was first observed.

19-AUG-14

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. 11809      PMRA Submission No.       EPA Registration No.

Product Name: Agral 90 Non-Ionic Liquid Wetting/Spreading Agent

• Active Ingredient(s)
  • NONYLPHENOXYPOLYETHOXYETHANOL

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7. b) Type of formulation.

Application Information

8. Product was applied?

Unknown

9. Application Rate.

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

• Eye
  • Symptom - Red eye
  • Symptom - Pain

4. How long did the symptoms last?

Unknown / Inconnu

5. Was medical treatment provided? Provide details in question 13.

No

6. a) Was the person hospitalized?

No

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.

Eye

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

<=30 min / <=30 min

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.)

1-38167485 - The reporter indicated that he was exposed to a spreading agent containing the active ingredient nonyl-phenoxy-polyethoxy-ethanol. The reporter stated that just prior to his initial call he was adding the product to a container and some of the concentrated product splashed into his eye. He immediately rinsed his eye for a period of 10 minutes but at the time of the initial call his eye was turning red and it was sore. The reporter was advised that the product may cause transient ocular irritation. Medical care was recommended if symptoms became severe or persistent. On follow-up call, one day later, the reporter stated that he rinsed his eye as recommended and the eye is now feeling better.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.