Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-1049

2. Registrant Information.

Registrant Reference Number: 14022701

Registrant Name (Full Legal Name no abbreviations): Nufarm Agriculture Inc.

Address: 5507 1st Street SE

City: Calgary

Prov / State: Alberta

Country: Canada

Postal Code: T2H 1H9

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

Human

4. Date registrant was first informed of the incident.

27-FEB-14

5. Location of incident.

Country: UNITED STATES

Prov / State: MINNESOTA

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.       PMRA Submission No.       EPA Registration No. 62719-1-264

Product Name: Formula 40

• Active Ingredient(s)
  • 2,4-D (PRESENT AS AMINE SALTS : DIMETHYLAMINE SALT, DIETHANOLAMINE SALT, OR OTHER AMINE SALTS)
    • Guarantee/concentration 36.5 %

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7. b) Type of formulation.

Liquid

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

10. Site pesticide was applied to (select all that apply).

Site: Other / Autre

Préciser le type: Rail-yard

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

Starting in 1993, the company would spray some areas for weeds with this product. Caller is not sure about the dilution.

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

• General
  • Symptom - Cancer
  • Specify - Prostate Cancer

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

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)

Unknown

10. Route(s) of exposure.

Skin

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.)

Caller states that many times when he was not aware that they were spraying for weeds and he would feel a mist on his arms. There was no shower, so he would just wipe it off onto his clothes. Caller was diagnosed with prostate cancer in 2006. He goes for a blood test twice a year and has been fine since.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.