Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-1356

2. Registrant Information.

Registrant Reference Number: PROSAR case: 1-36382521

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.

06-MAR-14

5. Location of incident.

Country: UNITED STATES

Prov / State: MISSISSIPPI

6. Date incident was first observed.

27-FEB-14

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. 100-1074

Product Name: Gramaxone Max

• Active Ingredient(s)
  • PARAQUAT
    • Guarantee/concentration 43.8 %

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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: 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: Male

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

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Bleeding
  • Symptom - Pain
  • Symptom - Burns (2nd or 3rd degree)
  • Symptom - Other
  • Specify - Bumps on the affected skin
  • Symptom - Red skin

• General
  • Symptom - Lightheadedness

• Nervous and Muscular Systems
  • Symptom - Dizziness

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?

Yes

6. b) For how long?

6

Day(s) / Jour(s)

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

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.)

1-36382521 - The reporter, a friend of the patient indicated that a (age) year old male was exposed to an herbicide containing the active ingredient Paraquat. The reporter stated that one week prior to initial contact with the registrant his friend had been wearing a backpack that contained the registrant product mixed with some water. The caller did not know how much water had been added to the product. The back pack leaked causing the patients pants to become wet. The patient was not initially aware of the leak and he continued wearing his contaminated clothing for an unknown amount of time. After the exposure the patients scrotal area had bumps, was red and bleeding. Per the reporter the patient went to the local doctor where an unknown topical cream for the affected area and an unknown oral medication were prescribed. At the time of the initial call the reporter indicated that he had just spoken with the patient who was complaining of severe pain in his scrotum which was making it difficult for him to walk. The patient had also indicated that he felt light headed and dizzy. The reporter was advised of the risk for systemic toxicity after dermal exposure to thin skinned areas and immediate medical attention was recommended. On follow-up call, two days later, the reporter indicated that the patient had gone to the ER, blood work was normal but the patient was in the burn unit of an unknown hospital in(city, state) and was scheduled to receive a scrotal skin graft the following day. On follow-up call, seven days later, the reporter indicated that his friend did go to surgery where the area was debrided and sutured. A skin graft was not needed. The patient came home from the hospital six days after the initial call and per the reporter the patient is doing well now. No further information is available.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.