Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2009-4207

2. Registrant Information.

Registrant Reference Number: UAP 2009-14

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.

02-OCT-09

5. Location of incident.

Country: CANADA

Prov / State: NEW BRUNSWICK

6. Date incident was first observed.

02-OCT-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)

---

PMRA Registration No. 27884      PMRA Submission No.       EPA Registration No.

Product Name: Par III Turf Herbicide CANADA

• 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-ISOMER PRESENT AS DIMETHYLAMINE SALT

---

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).

Weedman applied PAR III to neighbour's lawn 2October2009

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

• Gastrointestinal System
  • Symptom - Stomachache

• Nervous and Muscular Systems
  • Symptom - Headache

4. How long did the symptoms last?

>30 min <=2 hrs / >30 min <=2 h

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)

Drift from the application site

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

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.)

Call received 2October2009; possible exposure to PAR III containing the active ingredients 2,4 D, Mecoprop-p, and Dicamba. According to the reporter, Weedman sprayed her neigbour's lawn today, caller and her daughter felt immediate symptoms upon arrival at home when they could smell product as Weedman was packing up. Caller first called Weedman to obtain name of product applied. Weedman provided UAP contact information. Caller feeling a headache and cramping/stomach ache; daughter feeling headache.

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: >1 <=6 yrs / > 1 < = 6 ans

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Headache

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)

Drift from the application site

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

10. Route(s) of exposure.

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.)

Call received 2October2009; possible exposure to PAR III containing the active ingredients 2,4 D, Mecoprop-p, and Dicamba. According to the reporter, Weedman sprayed her neigbour's lawn today, caller and her daughter felt immediate symptoms upon arrival at home when they could smell product as Weedman was packing up. Caller first called Weedman to obtain name of product applied. Weedman provided UAP contact information. Caller feeling a headache and cramping/stomach ache; daughter feeling headache.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.