Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-2054

2. Registrant Information.

Registrant Reference Number: 4886193

Registrant Name (Full Legal Name no abbreviations): Agrium Advanced Technologies RP Inc

Address: 10 Craig St

City: Brantford

Prov / State: ON

Country: Canada

Postal Code: N3R 7J1

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

Domestic Animal

4. Date registrant was first informed of the incident.

21-MAY-12

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

27-NOV-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. 19480      PMRA Submission No.       EPA Registration No.

Product Name: PRO Boradust Insecticide Dust

• Active Ingredient(s)
  • BORACIC ACID (BORIC ACID)

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7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

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 III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Cat / Chat

3. Breed

domestic

4. Number of animals affected

1

5. Sex

Unknown

6. Age (provide a range if necessary )

5

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Respiratory

9. What was the length of exposure?

>1 wk <=1 mo / > 1 sem < = 1 mois

10. Time between exposure and onset of symptoms

>1 wk <=1 mo / > 1 sem < = 1 mois

11. List all symptoms

System

• Cardiovascular System
  • Symptom - Heart murmur
  • Symptom - Other
  • Specify - Cardiomypoathy

• General
  • Symptom - Polydipsia
  • Specify - thirst

• Respiratory System
  • Symptom - Tachypnea
  • Symptom - Difficulty Breathing

• General
  • Symptom - Death

• Respiratory System
  • Symptom - Dyspnea

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

Died

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

Product applied by professional exterminator on Nov 7, 2011. Exterminator came back to re-apply Nov 21, 2011. Cat was not in apartment at time of application. Expressed symptoms within 20 days of exposure. Cat developed heart murmur and had an x-ray that showed hypertrophic cardiomyopathy, died Feb 21, 2011.

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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