Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-5457

2. Registrant Information.

Registrant Reference Number: 1-34976894

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.

18-SEP-13

5. Location of incident.

Country: CANADA

Prov / State: MANITOBA

6. Date incident was first observed.

18-SEP-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)

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PMRA Registration No. 26396      PMRA Submission No.       EPA Registration No.

Product Name: Reglone Liquid Herbicide/Desiccant

• Active Ingredient(s)
  • DIQUAT

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7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

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

• Gastrointestinal System
  • Symptom - Stomach pain

• Respiratory System
  • Symptom - Nose bleed

4. How long did the symptoms last?

>30 min <=2 hrs / >30 min <=2 h

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

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.

Skin

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.)

1-34976894 - The reporter indicated that while at work he was exposed to an herbicide containing the active ingredient diquat. The reporter an adult male stated that while transferring the diluted product from one tank to another tank the diluted product splashed on his face and a small amount got into his eyes. The patient washed after the exposure but he did experience transient stomach pain and a brief nose bleed. On follow-up call, one day later, the reporter indicated that his symptoms resolved within two hours. No medical intervention was needed. No further information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.