Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-2802

2. Registrant Information.

Registrant Reference Number: PROSAR Case #: 1-30567878

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

Domestic Animal

4. Date registrant was first informed of the incident.

20-JUN-12

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

Unknown

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. 28642      PMRA Submission No.       EPA Registration No.

Product Name: Axial 100EC Herbicide

• Active Ingredient(s)
  • PINOXADEN

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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: unspecified

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: Female

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Coughing

• Eye
  • Symptom - Irritated eye
  • Symptom - Itchy eye

4. How long did the symptoms last?

>3 days <=1 wk / >3 jours <=1 sem

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

No

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Non-occupational

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

Drift from the application site

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

None

10. Route(s) of exposure.

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

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.)

1-30567878- The reporter indicated potential exposure of herself, her spouse and her pets to an herbicide containing the active ingredient pinoxaden. The reporter stated she and her husband live in a rural setting and were away from their home the other night. Upon returning home they encountered an aroma as they approached their home as far as one quarter mile from the home. The caller described the aroma was encountered on their property and in their home as well. She explained their home sits adjacent to agricultural property and that it was apparent the owner of that property had applied something earlier that day. The reporter stated she (Subform II, #1) had experienced ocular irritation, itch, and cough. Her husband (Subform II, #2) had experienced ocular irritation, respiratory irritation, and cough. Her four dogs (Subform III, #1) had demonstrated cough and signs consistent with ocular irritation and ocular itch. The reporter stated she addressed the application with her neighbor but was not provided assistance. The reporter stated she believed two products were applied, the registrants product and a non-registrant product she provided as Infinity (registrant Bayer). The caller stated she had contacted Bayer directly regarding their product and was awaiting a response. The reporter was advised with regards to the registrants product the exposure described would not be expected to elicit harm but in so far as the aromas may be found disagreeable to sensitive individuals or irritating to the respiratory tract. She was advised to assure adequate ventilation and access to fresh air. It was recommended she seek medical assistance/veterinary assistance as needed to alleviate any discomfort they may have. On follow up the reporter stated her symptoms had resolved within 3-4 days of her initial contact. She did not provide information about her husband or the animals. No further information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

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

• Respiratory System
  • Symptom - Coughing
  • Symptom - Respiratory irritation

• Eye
  • Symptom - Irritated eye

4. How long did the symptoms last?

Unknown / Inconnu

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

No

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Non-occupational

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

Drift from the application site

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

None

10. Route(s) of exposure.

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

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.)

1-30567878- The reporter indicated potential exposure of herself, her spouse and her pets to an herbicide containing the active ingredient pinoxaden. The reporter stated she and her husband live in a rural setting and were away from their home the other night. Upon returning home they encountered an aroma as they approached their home as far as one quarter mile from the home. The caller described the aroma was encountered on their property and in their home as well. She explained their home sits adjacent to agricultural property and that it was apparent the owner of that property had applied something earlier that day. The reporter stated she (Subform II, #1) had experienced ocular irritation, itch, and cough. Her husband (Subform II, #2) had experienced ocular irritation, respiratory irritation, and cough. Her four dogs (Subform III, #1) had demonstrated cough and signs consistent with ocular irritation and ocular itch. The reporter stated she addressed the application with her neighbor but was not provided assistance. The reporter stated she believed two products were applied, the registrants product and a non-registrant product she provided as Infinity (registrant Bayer). The caller stated she had contacted Bayer directly regarding their product and was awaiting a response. The reporter was advised with regards to the registrants product the exposure described would not be expected to elicit harm but in so far as the aromas may be found disagreeable to sensitive individuals or irritating to the respiratory tract. She was advised to assure adequate ventilation and access to fresh air. It was recommended she seek medical assistance/veterinary assistance as needed to alleviate any discomfort they may have. On follow up the reporter stated her symptoms had resolved within 3-4 days of her initial contact. She did not provide information about her husband or the animals. No further information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Unknown

4. Number of animals affected

4

5. Sex

Unknown

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Respiratory

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

• Respiratory System
  • Symptom - Coughing

• Eye
  • Symptom - Itchy eye
  • Symptom - Irritated eye

12. How long did the symptoms last?

Unknown / Inconnu

13. Was medical treatment provided? Provide details in question 17.

No

14. a) Was the animal hospitalized?

No

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Unknown/Inconnu

16. How was the animal exposed?

Spray drift / Dérive de pulvérisation

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

1-30567878- The reporter indicated potential exposure of herself, her spouse and her pets to an herbicide containing the active ingredient pinoxaden. The reporter stated she and her husband live in a rural setting and were away from their home the other night. Upon returning home they encountered an aroma as they approached their home as far as one quarter mile from the home. The caller described the aroma was encountered on their property and in their home as well. She explained their home sits adjacent to agricultural property and that it was apparent the owner of that property had applied something earlier that day. The reporter stated she (Subform II, #1) had experienced ocular irritation, itch, and cough. Her husband (Subform II, #2) had experienced ocular irritation, respiratory irritation, and cough. Her four dogs (Subform III, #1) had demonstrated cough and signs consistent with ocular irritation and ocular itch. The reporter stated she addressed the application with her neighbor but was not provided assistance. The reporter stated she believed two products were applied, the registrants product and a non-registrant product she provided as Infinity (registrant Bayer). The caller stated she had contacted Bayer directly regarding their product and was awaiting a response. The reporter was advised with regards to the registrants product the exposure described would not be expected to elicit harm but in so far as the aromas may be found disagreeable to sensitive individuals or irritating to the respiratory tract. She was advised to assure adequate ventilation and access to fresh air. It was recommended she seek medical assistance/veterinary assistance as needed to alleviate any discomfort they may have. On follow up the reporter stated her symptoms had resolved within 3-4 days of her initial contact. She did not provide information about her husband or the animals. 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

Minor

19. Provide supplemental information here