Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-2798

2. Registrant Information.

Registrant Reference Number: PROSAR Case #: 1-30426599

Registrant Name (Full Legal Name no abbreviations): Syngenta 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.

07-JUN-12

5. Location of incident.

Country: CANADA

Prov / State: SASKATCHEWAN

6. Date incident was first observed.

07-JUN-12

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. 29450      PMRA Submission No.       EPA Registration No.

Product Name: PULSAR Herbicide

• Active Ingredient(s)
  • DICAMBA (PRESENT AS ACID, AMINE SALT, ESTER, OR SODIUM SALT)
  • FLUROXYPYR 1-METHYLHEPTYL ESTER

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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?

<=30 min / <=30 min

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

Unknown

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)

Other

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.)

1-30426599- The reporter indicated an exposure to an herbicide containing the active ingredients dicamba and fluroxypyr. The reporter indicated he had splashed the product in his eye and on some of the skin on his face within 20 minutes of his initial contact with the registrant. He had rinsed his face and eye with water. He reported initial ocular irritation that persisted for five minutes and then resolved. The reporter was advised of proper decontamination technique, over the counter treatment at home and the threshold at which to see the doctor. The reporter was not reached for follow up. No further information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.