Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-2801

2. Registrant Information.

Registrant Reference Number: PROSAR Case #: 1-30492041

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.

14-JUN-12

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

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

Product Name: Ratak (non-specific)

• Active Ingredient(s)
  • BRODIFACOUM

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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: Other / Autre

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: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• General
  • Symptom - Flu-like symptoms

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?

Unknown

6. b) For how long?

7. Exposure scenario

Occupational

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

Application

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.

Unknown

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>8 hrs <=24 hrs / > 8 h < = 24 h

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.)

1-30492041-The reporter indicated a coworker had been exposed to a rodenticide containing the active ingredient brodifacoum. The caller, a manager at a retail store, had reported a coworker had handled the product the day prior to the initial report. He did not provide label information that may definitively identify the product such as full name or registration numbers. He did not clarify the body surface exposed but it was inferred to be dermal exposure of the hands. The caller did not clarify the duration of the exposure or any decontamination that may have followed the exposure. The reporter indicated his coworker was experiencing flu-like symptoms the day of the report. The reporter was referred to the medical service for the registrant for assessment of the exposure. The reporter did not follow up with the medical service. The reporter was not reached for follow up. Dermal exposure of this product would not be anticipated to elicit flu-like symptoms. The time line indicated is inconsistent with the toxicity profile of the active ingredient. No further information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.