Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2008-0423

2. Registrant Information.

Registrant Reference Number: PROSAR Case 1-15102214

Registrant Name (Full Legal Name no abbreviations): United Agri Products Canada, Ltd

Address: 789 Donnybrook Drive

City: Dorchester

Prov / State: Ontario

Country: Canada

Postal Code: N0L1G5

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

Human

4. Date registrant was first informed of the incident.

12-JUL-07

5. Location of incident.

Country: CANADA

Prov / State: MANITOBA

6. Date incident was first observed.

09-JUL-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. 27884      PMRA Submission No.       EPA Registration No.

Product Name: PAR III TURF HERBICIDE

• Active Ingredient(s)
  • 2,4-D (PRESENT AS AMINE SALTS : DIMETHYLAMINE SALT, DIETHANOLAMINE SALT, OR OTHER AMINE SALTS)
  • DICAMBA (PRESENT AS ACID, AMINE SALT, ESTER, OR SODIUM SALT)
  • MECOPROP-P (PRESENT AS DIMETHYLAMINE SALT)

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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: Res. - Out Home / Rés - à l'ext.maison

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

Residence located 60 yards away from patients location

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: Female

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

3. List all symptoms, using the selections below.

System

• General
  • Symptom - Metallic taste in the mouth

• Gastrointestinal System
  • Symptom - Nausea
  • Symptom - Stomach pain

• Liver
  • Symptom - Pain
  • Specify - pain

• General
  • Symptom - Metallic taste in the mouth
  • Specify - metallic taste in nose

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?

Unknown

6. b) For how long?

7. Exposure scenario

Non-occupational

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

Drift from the application site

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.

Respiratory

11. What was the length of exposure?

>15 min <=2 hrs / >15 min <=2 h

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 reports inhaling product after application to a nearby house (about 60 yards away) 3 days ago (7-9-07), and now reports that following persistent symptoms: Headache, nausea, metallic taste in mouth/nose, stomach pain, liver pain Assessment: Product not expected to cause reported symptoms of reported severity/duration given distance from product during time of application. Suggest physician evaluation for you and your friend, given severity and duration of symptoms.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Female

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

3. List all symptoms, using the selections below.

System

• General
  • Symptom - Metallic taste in the mouth

• Gastrointestinal System
  • Symptom - Nausea

• Liver
  • Symptom - Pain
  • Specify - pain

• Gastrointestinal System
  • Symptom - Stomach pain

• General
  • Symptom - Metallic taste in the mouth
  • Specify - Metallic taste in nose

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?

Unknown

6. b) For how long?

7. Exposure scenario

Non-occupational

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

Drift from the application site

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.

Respiratory

11. What was the length of exposure?

>15 min <=2 hrs / >15 min <=2 h

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 reports inhaling product after application to a nearby house (about 60 yards away) 3 days ago (7-9-07), and now reports that following persistent symptoms: Headache, nausea, metallic taste in mouth/nose, stomach pain, liver pain Assessment: Product not expected to cause reported symptoms of reported severity/duration given distance from product during time of application. Suggest physician evaluation for you and your friend, given severity and duration of symptoms.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.