Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-3945

2. Registrant Information.

Registrant Reference Number: 2011-29

Registrant Name (Full Legal Name no abbreviations): BASF Canada

Address: 100 Milverton, 5th floor

City: Mississauga

Prov / State: ON

Country: Canada

Postal Code: L5R4H1

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

Human

Domestic Animal

Environment

4. Date registrant was first informed of the incident.

12-AUG-11

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

05-JUL-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. 24407      PMRA Submission No.       EPA Registration No.

Product Name: Conquest

• Active Ingredient(s)
  • IMAZETHAPYR

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PMRA Registration No. 24835      PMRA Submission No.       EPA Registration No.

Product Name: POAST Ultra

• Active Ingredient(s)
  • SETHOXYDIM

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PMRA Registration No. 24702      PMRA Submission No.       EPA Registration No.

Product Name: MERGE

• Active Ingredient(s)
  • AROMATICS
  • SURFACTANT BLEND

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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: beans

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

May 24 Touchdown at 1L/A,Conquest at 1 jug/20A preplant;July 1 Poast Ultra at 0.13L/A, Classic at 14g/A,in addition Merge was used at 400ml/A. Sprayed in late afternoon and wind speed less than 15km/hr;Sprayer used had Aim Command system for drift reduction. Experimental Syngenta pre-plant fungicide treatment, treated seed planted in a band about 160 ft wide in centre of longest part of field.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Yes

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

• Gastrointestinal System
  • Symptom - Diarrhea

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?

No

6. b) For how long?

7. Exposure scenario

Non-occupational

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

Contact with treated area

What was the activity? walking by field

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

10. Route(s) of exposure.

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.)

Reporter walks by field with dog and cat; cat developed flu like symptoms, reporter had diarhea.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

Unclear what level of exposure; symptoms not consistent with the registered products and expected exposure. Experimental fungicide on treated seed planted in the ground.

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Cat / Chat

3. Breed

Unknown

4. Number of animals affected

1

5. Sex

Unknown

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Unknown

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

• General
  • Symptom - Flu-like symptoms

• Gastrointestinal System
  • Symptom - Diarrhea

12. How long did the symptoms last?

Unknown / Inconnu

13. Was medical treatment provided? Provide details in question 17.

Yes

14. a) Was the animal hospitalized?

Unknown

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Unknown/Inconnu

16. How was the animal exposed?

Contact treat.area/Contact surf. traitée

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

The cat was taken to vet who diagnosed flu.

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To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Minor

19. Provide supplemental information here

Unclear level of exposure, symptoms inconsistent with what is known of registered product known toxicity.

Subform IV: Environment (includes plants insects and wildlife)

1. Type of organism affected

Trees or shrubs / Arbre ou arbuste

2. Common name(s)

Spruce and deciduous trees

3. Scientific name(s)

Unknown

4. Number of organisms affected

2

5. Description of site where incident was observed

Fresh water

Terrestrial

Agricultural

Salt Water

6. Check all symptoms that apply

Visible injury ( eg. chlorosis, necrosis, bleaching)

7. Describe symptoms and outcome (died, recovered, etc.).

MoE inspector reported some spruce trees had some tips that had turned white, other tips were rust in colour. Both tip discolourations were present all around the tree ( not just the side of the trees facing fields). Also observed 2 deciduous trees on which some of the leaves were black, other leaves were missing parts and other leaves had spots like droplets. Trees located 4-6 ft from soy; no damage to plants seen in the lawn even a few inches from soy.

8. a) Was the incident a result of (select all that apply)

N/A

Unknown

8. b) i) How many times has the product been applied this year?

8. b) ii) What was the date of the last application?

9. Did it rain

9. a) During application?

Unknown

9. b) Up to 3 days after application?

Unknown

10. a) Was there a buffer zone?

Unknown

10. b) What type?

10. c) What was the size of the buffer zone?

11. a) Were environmental samples collected and analysed?

Unknown

To be determined by Registrant

12. Severity classification (if there is more than one possible classification, select the most severe)

Minor

13. Please provide supplemental information here

Unclear exposure and relationship, if any, to symptoms observed.