Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-4930

2. Registrant Information.

Registrant Reference Number: unknown

Registrant Name (Full Legal Name no abbreviations): Winfield Solutions LLC

Address: 1080 County Rd F West

City: Shoreview

Prov / State: MN

Country: USA

Postal Code: 55126

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

Human

4. Date registrant was first informed of the incident.

21-SEP-10

5. Location of incident.

Country: CANADA

Prov / State: MANITOBA

6. Date incident was first observed.

Unknown

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. 29100      PMRA Submission No.       EPA Registration No.

Product Name: CONFINE Fungicide

• Active Ingredient(s)
  • MONO- AND DI-POTASSIUM SALT OF PHOSPHOROUS ACID

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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: Agricultural-Outdoor/Agricole-extérieur

Préciser le type: Potatoes

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

The producer was applying CONFINE post harvest to the potato crop, when the hoses coming from the pump burst. Product was in a diluted ready to use state and the producer had the diluted spray solution spray into their eyes and mouth

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: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Eye
  • Symptom - Irritated eye

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

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?

No

6. b) For how long?

7. Exposure scenario

Occupational

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

Pesticide Spill

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.

Eye

Oral

11. What was the length of exposure?

<=15 min / <=15 min

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.)

The producer contacted the (province) Poison Control Centre and was told to rinse mouth and eyes with copious amounts of water. The producer did and symptoms went away

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

Followed up with producer, no further symptoms or concerns