Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-6095

2. Registrant Information.

Registrant Reference Number: PROSAR Case # 1-27687224

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.

Domestic Animal

4. Date registrant was first informed of the incident.

13-OCT-11

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

13-OCT-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.       PMRA Submission No.       EPA Registration No. Unknown

Product Name: Reglone (non-specific)

• Active Ingredient(s)
  • DIQUAT

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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: unknown

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 III: Domestic Animal Incident Report

1. Source of Report

Medical Professional

2. Type of animal affected

Dog / Chien

3. Breed

Mixed breed dog

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

7

7. Weight (provide a range if necessary )

134

lbs

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

• Gastrointestinal System
  • Symptom - Diarrhea
  • Symptom - Anorexia

• Nervous and Muscular Systems
  • Symptom - Difficulty getting up
  • Symptom - Muscle weakness

• General
  • Symptom - Death

12. How long did the symptoms last?

Persisted until death

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

Euthanised / Euthanasie

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

1-27677023- The reporter, a veterinarian, indicated an animal had presented to him which may have been exposed to an herbicide containing the active ingredient diquat. The reporter indicates a seven year one hundred thirty four pound male mixed breed dog had presented with the signs of diarrhea, anorexia, and the animal was unable rise or use its hind legs. The reporter indicated two days prior to his report the animal had run through a field (unspecified crop) that had either been sprayed with the indicated product or an unspecified Round up product. The caller was unsure which product had been used, the specific formulation of either product or he re-entry interval though he was able to say the animal had run into the field just as spraying had been completed. The veterinarian was advised of the toxicity profile of the diquat product, appropriate diagnostics and standards of care following exposure. He was advised the signs seen would be largely inconsistent with the exposure described. He was advised to seek advice from the registrant of the Round up product directly regarding expectations following a similar exposure. On follow up five days later the veterinarian stated the animal had been euthanized. He stated the signs were related to a back injury rather than any herbicide exposure. No further information is available.

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To be determined by Registrant

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

Death

19. Provide supplemental information here

As noted by physician, was due to back injury, not pesticide exposure.