Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-2394

2. Registrant Information.

Registrant Reference Number: 15052901

Registrant Name (Full Legal Name no abbreviations): Nufarm Agriculture Inc.

Address: 5507 1st Street SE

City: Calgary

Prov / State: Alberta

Country: Canada

Postal Code: T2H 1H9

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

Human

4. Date registrant was first informed of the incident.

29-MAY-15

5. Location of incident.

Country: CANADA

Prov / State: SASKATCHEWAN

6. Date incident was first observed.

29-MAY-15

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. 25341      PMRA Submission No.       EPA Registration No.

Product Name: Nufarm Koril 235 Liquid Herbicide

• Active Ingredient(s)
  • BROMOXYNIL

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7. b) Type of formulation.

Application Information

8. Product was applied?

No

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 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: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Sore throat

• Gastrointestinal System
  • Symptom - Stomach cramps

• Ear
  • Symptom - Earache

• Gastrointestinal System
  • Symptom - Tingling in mouth
  • Symptom - Nausea

4. How long did the symptoms last?

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

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

Unknown

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Occupational

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

Other

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.

Skin

Oral

Respiratory

11. What was the length of exposure?

<=15 min / <=15 min

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.)

Caller stated he is a chemical handler on a farm. He was accidentally sprayed in the face this evening with the concentrated product. The product got in his eyes and mouth and on his skin. He rinsed his skin. Symptoms lasted for less than 24 hours.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.