Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-4489

2. Registrant Information.

Registrant Reference Number: PROSAR Case 1-27245676

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.

30-AUG-11

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

30-AUG-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. 26396      PMRA Submission No.       EPA Registration No.

Product Name: Reglone Liquid Herbicide Desiccant

• Active Ingredient(s)
  • DIQUAT

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PMRA Registration No. 11809      PMRA Submission No.       EPA Registration No.

Product Name: Agral 90 Non-Ionic Liquid Wetting Spreading Agent

• Active Ingredient(s)
  • NONYLPHENOXYPOLYETHOXYETHANOL

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7. b) Type of formulation.

Application Information

8. Product was applied?

Unknown

9. Application Rate.

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

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

• Eye
  • Symptom - Irritated eye

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)

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

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.)

1-27308776-The reporter indicated exposure to an herbicide containing the active ingredient diquat dibromide and a surfactant product containing the active ingredient Nonylphenoxy polyethoxy ethanol. The reporter indicated an adult male companion (relationship not clarified) had splashed the two products in either one or both eyes immediately prior to the report while mixing these products. He was reported to have rinsed his eyes for approximately five minutes and had gone to the hospital due to persistent irritation. The caller was advised of proper decontamination and the threshold at which medical advice should be sought. She was advised no harm beyond the irritation described would be expected, but that decontamination should be thorough. On follow up one day later the reporter was able to verify the patient was 'fine'. She indicated he had gone to the hospital but was unable to convey what treatment or diagnostics were done. No further follow up was obtained. No further information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

No indication that patient was wearing goggles or face shield even though label directions state to do so.