Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2009-3385

2. Registrant Information.

Registrant Reference Number: Prosar 1-19721416

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

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.

01-SEP-09

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

31-AUG-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. 4709      PMRA Submission No.       EPA Registration No.

Product Name: Malathion 500 E

• Active Ingredient(s)
  • MALATHION

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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 to an herb garden on 08/30/2009.

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.

Medical Professional

2. Demographic information of data subject

Sex: Female

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Headache

• Eye
  • Symptom - Watery eye

• Cardiovascular System
  • Symptom - Chest tightness

• Gastrointestinal System
  • Symptom - Mouth Irritation
  • Specify - "Mouth feels scratchy"

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

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)

Contact with treated area

What was the activity? working in a treated garden

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

Unknown

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

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.)

1-19721416: A reporter (a nurse) called on 09/01/2009 to report the exposure of a female patient to an insecticide containing the active ingredient Malathion. According to the reporter, an herb garden was sprayed with the product on 08/30/2009. On 08/31/2009, the patient was working in the garden and could smell the product. Later in the day, the patient developed a headache, watery eyes, and chest tightness. At the time of the report, the only persistent signs were watery eyes and a mouth that felt scratchy. The reporter was advised that the the active ingredient is an organophosphate and is typically diluted prior to application. If the wet diluted product is inhaled it may result in ocular and upper respiratory tract irritation. Typically, these signs resolve with removal from the source. If the product was sprayed in a poorly ventilated area and the odor lingered, it is possible for some respiratory tract irritation to occur. Exposure to the dry product is not expected to result in adverse effects. The common signs of organophosphate toxicity were reviewed. A recommendation was made to rule out other causes for the signs as the time line and signs present are not totally consistent with product exposure. A follow up attempt was unsuccessful. No further information was obtained.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.