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Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-3572

2. Registrant Information.

Registrant Reference Number: PROSAR Case#:1-33957467

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.

11-JUN-13

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

07-JUN-13

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)

PMRA Registration No. 30431 PMRA Submission No. EPA Registration No.

Product Name: Axial Bia

Active Ingredient(s)
- PINOXADEN

PMRA Registration No. 19346 PMRA Submission No. EPA Registration No.

Product Name: Tilt 250E Fungicide

Active Ingredient(s)
- PROPICONAZOLE

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.

Other

2. Demographic information of data subject

Sex: Female

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

3. List all symptoms, using the selections below.

System

Skin
- Symptom - Blister

Nervous and Muscular Systems
- Symptom - Headache
- Symptom - Dizziness

Gastrointestinal System
- Symptom - Nausea

4. How long did the symptoms last?

Unknown / Inconnu

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

Yes

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

7. Exposure scenario

Non-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.

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.)

1-33957467 - The reporter, a peace officer with the organization "name" indicated that an adult female was exposed to a registrant fungicide and a registrant herbicide containing the active ingredients propiconazole and pinoxaden respectively. The patient was also exposed to a non-registrant product with unknown active ingredients. The reporter indicated that four days prior to initial contact with the registrant he received a call from the patient who indicated that while driving by an application area she accidentally inhaled some drift. The reporter indicated that the patient complained of headache, dizziness, nausea and a blistering mouth after her exposure. Per the reporter the patient did go to her doctor who ran blood work but the results of this blood work are unknown. The reporter did not know if the doctor provided any treatment to the patient. Per the reporter, on the day of initial contact, he had spoken with the patient and she indicated that she was feeling better. No further information is available.

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Incident Report

Subform I: General Information

1. Report Type.

2. Registrant Information.

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

4. Date registrant was first informed of the incident.

5. Location of incident.

6. Date incident was first observed.

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.

7. b) Type of formulation.

Application Information

8. Product was applied?

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?

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

2. Demographic information of data subject

3. List all symptoms, using the selections below.

4. How long did the symptoms last?

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

6. a) Was the person hospitalized?

6. b) For how long?

7. Exposure scenario

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

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

10. Route(s) of exposure.

11. What was the length of exposure?

12. Time between exposure and onset of symptoms.

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.)

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.