Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-4239

2. Registrant Information.

Registrant Reference Number: PROSAR case number: 1-38262678

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.

27-AUG-14

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

22-AUG-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. 28072      PMRA Submission No.       EPA Registration No.

Product Name: Touchdown Total Herbicide

• Active Ingredient(s)
  • GLYPHOSATE (PRESENT AS POTASSIUM SALT)

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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: Res. - Out Home / Rés - à l'ext.maison

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: Female

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

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Red skin
  • Symptom - Irritated skin

• General
  • Symptom - Swelling

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)

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.

<=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.)

1-38262678 - The reporter indicated that she was exposed to an herbicide containing the active ingredient glyphosate. Five days prior to her initial call, while applying the diluted product, the reporter had accidental skin contact with the product and almost immediately following this contact she developed, swollen, red and irritated skin that she rinsed with soapy water. Three days after the exposure she went to her doctor who recommended that she keep the foot elevated and that she call the registrant for further product information. The reporter was advised that dermal contact may cause transient skin irritation and to apply hydrocortisone cream to the affected area. Treatment from a dermatologist was recommended if symptoms did not improve. The reporter could not be reached on follow-up. No further information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.