Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2007-5673

2. Registrant Information.

Registrant Reference Number: PROSAR Case 1-14963934

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.

03-JUN-07

5. Location of incident.

Country: CANADA

Prov / State: NOVA SCOTIA

6. Date incident was first observed.

01-JUN-07

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. 21209      PMRA Submission No.       EPA Registration No.

Product Name: Venture L Postemergence Herbicide

• Active Ingredient(s)
  • FLUAZIFOP-P-BUTYL

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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.

Other

2. Demographic information of data subject

Sex: Male

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Dizziness
  • Symptom - Headache

• Eye
  • Symptom - Swollen eye

• General
  • Symptom - Edema

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

Occupational

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 <=2 hrs / >30 min <=2 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.)

Caller stated that approx. one hour ago an adult male worker accidentally splashed "Venture L Postemergence Herbicide (Canada)" on his eyes. He developed eye swelling and was taking to a local hospital for exam and treatment. Unknown if decontamination was provided, no more information available. Follow-up contact: Caller said that he does not know how the patient is currently because he has not talked to him. He states he was brought to local hospital on Friday, 6/1 and they did some testing and gave him some drugs. He had developed a HA and facial swelling and was slightly dizzy. No further information available.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.