Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-0231

2. Registrant Information.

Registrant Reference Number: PROSAR case #: 1-35722602

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.

10-DEC-13

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

10-DEC-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. 21084      PMRA Submission No.       EPA Registration No.

Product Name: Weatherblok XT Bait Ratak + Rodenticide

• Active Ingredient(s)
  • BRODIFACOUM

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7. b) Type of formulation.

Application Information

8. Product was applied?

Unknown

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

• Skin
  • Symptom - Rash

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?

No

6. b) For how long?

7. Exposure scenario

Non-occupational

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

Other

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

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.)

1-35722602 - The reporter indicated that he was exposed to a rodenticide containing the active ingredient brodifacoum. One day prior to initial contact with the registrant the reporter touched the bait block and the following day the reporter woke up with a rash on most of his body. The reporter was advised that there are numerous possible causes for a rash including a possible sensitivity to this product. Medical treatment was recommended to help determine a cause for the rash and appropriate treatment. On follow-up call, two days later, the reporter stated that he went to the doctor who thought the symptoms were an allergic reaction to a medication that the reporter was taking. The medication was discontinued and the rash was fading. No further information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.