Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-3658

2. Registrant Information.

Registrant Reference Number: PROSAR Case # 1-26974243

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.

28-JUL-11

5. Location of incident.

Country: CANADA

Prov / State: MANITOBA

6. Date incident was first observed.

25-JUN-11

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. 28028      PMRA Submission No.       EPA Registration No.

Product Name: Target Liquid Systemic Herbicide

• Active Ingredient(s)
  • DICAMBA (PRESENT AS ACID, AMINE SALT, ESTER, OR SODIUM SALT)
  • MCPA (PRESENT AS AMINE SALTS: DIETHANOLAMINE, DIMETHYLAMINE, OR MIXED AMINES)
  • MECOPROP-P (PRESENT AS DIGLYCOLAMINE SALT)

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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: Unknown / Inconnu

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

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

• Skin
  • Symptom - Tingling skin
  • Symptom - Irritated skin
  • Symptom - Burns (superficial)

4. How long did the symptoms last?

Unknown / Inconnu

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

Yes

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.

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.)

1-26974243- The reporter called to indicate exposure to an herbicide that contained the active ingredients MCPA, Mecoprop-p, and dicamba. The reporter indicated he was applying the product via a 'pull behind sprayer' thirty three days prior to his initial contact with the registrant. He did not describe the concentration of the product used nor did he describe the capacity in which he used the product. He described during the course of the application a spray nozzle either had broken or it malfunctioned. He looked behind him and was sprayed with the product along the left side of his face. He stated he immediately removed contaminated clothing and showered. The reporter indicated since the exposure he has noted an ongoing tingling sensation and irritation on the surface of his face. The reporter stated he had seen a doctor twenty days following the exposure and was told he had a 'mild burn' and it was recommended he use OTC Aloe Vera lotion and Vaseline to alleviate the discomfort. The caller was advised burns would not be expected following dermal contact with the product. He was, further, advised the duration of the signs seen would be unexpected to be related to the exposure described. It was recommended he follow up further with his doctor to determine the cause of his symptoms and the appropriate care. On follow up one week after his initial contact the reporter indicated the symptoms described were 'almost gone'. He did not indicate he had returned to the doctor. No further information is available.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.