Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2009-4283

2. Registrant Information.

Registrant Reference Number: Prosar 1-19653311

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.

27-AUG-09

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

27-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. 8661      PMRA Submission No.       EPA Registration No.

Product Name: Gramoxone

• Active Ingredient(s)
  • PARAQUAT

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7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

180

Other Units: mls product in 3.5 gallons water

10. Site pesticide was applied to (select all that apply).

Site: Unknown / Inconnu

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

180 mls product was mixed in a backpack sprayer with 3.5 gallons water

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: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Rash

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

Unknown

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?

Unknown / Inconnu

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.)

1-19653311: A reporter called on 08/27/2008 to report his exposure to an herbicide containing the active ingredient Paraquat. According to the reporter, he had mixed 180 mls of product with 3.5 gallons of water in a back sprayer. The sprayer leaked product onto his back just prior to the call. He developed a rash on his back 5 minutes prior to the report. The reporter was advised that a rash is not an expected result of dermal contact with diluted product. The diluted product may be an irritant to the skin. A recommendation was made to rinse the affected area for 20 minutes to remove any product residue. A recommendation was also made to use an over-the-counter hydrocortisone product to help relieve the signs. The reporter was advised to consult a health professional if his signs spread to other parts of the body, worsen in severity, or do not resolve within 72 hours. An attempt at follow up was unsuccessful. No further information was obtained.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.