Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2009-2553

2. Registrant Information.

Registrant Reference Number: Prosar 1-19116458

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.

09-JUL-09

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

09-JUL-09

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 Herbicide

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

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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).

The product was applied on 07/09/2009.

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

• General
  • Symptom - Taste altered
  • Specify - Salty taste in mouth

4. How long did the symptoms last?

<=30 min / <=30 min

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

Non-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.

Skin

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.)

1-19116458: A reporter called on 07/09/2009 to report his exposure to an herbicide containing the active ingredient fluazifop-P-butyl. According to the reporter, he was using the product when the hose broke and sprayed him with diluted product. He developed a salty taste in his mouth that resolved when he brushed his teeth. He showered for 30 minutes and was asymptomatic at the time of the report. There was no ocular or oral exposure. The reporter was advised that the diluted product may result in skin irritation which should subside with irrigation. No other signs would be expected at this point following decontamination. No further information was obtained.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.