Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-4613

2. Registrant Information.

Registrant Reference Number: PROSAR Case #: 1-31408661

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.

03-SEP-12

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

03-SEP-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. 28072      PMRA Submission No.       EPA Registration No.

Product Name: Touchdown Total Herbicide

• Active Ingredient(s)
  • GLYPHOSATE (PRESENT AS POTASSIUM SALT)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No.

Product Name: Non registrant product

• Active Ingredient(s)

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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 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?

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.

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.)

1-31408661 - The reporter indicated that he was exposed to an herbicide containing the active ingredient glyphosphate and another non-registrant product with unknown active ingredients. The reporter indicated that five minutes prior to his initial call he was applying the product to a field and one of the valves on his tractor blew and the registrant product which was mixed with an unknown amount of non-registrant product went into his eye. The reporter rinsed his eyes for a few minutes but at the time of the call his eye was still irritated. Caller was advised that the registrant product may irritate the eye but is not a corrosive. After a 15-20 minute rinse of the eye symptoms will typically resolve within 6 hours without further treatment. If ocular irritation persists beyond 6 hours reporter was advised to seek medical attention. No further information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.