Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-4952

2. Registrant Information.

Registrant Reference Number: PROSAR case number: 1-38553407

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.

24-SEP-14

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

24-SEP-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. Unknown

Product Name: Unidentified product

• Active Ingredient(s)
  • CHLOROTHALONIL

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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.

Medical Professional

2. Demographic information of data subject

Sex: Male

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

3. List all symptoms, using the selections below.

System

• Eye
  • Symptom - Irritated eye
  • Symptom - Red eye

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

Unknown

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

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.

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.)

1-38553407 - The reporter, a nurse, indicated that a patient was exposed to a fungicide containing the active ingredient chlorothalonil and/or to a non-registrant herbicide containing the active ingredient 2,4-D. The reporter indicated about one hour prior to initial contact with the registrant an adult male got either the diluted chlorothalonil and/or the diluted 2,4-D in his eye. The reporter was not able to provide a PCP registration number, a bar code number, nor the full name of the products involved. Per the reporter the patient rinsed his eye for 15-20 minutes after the exposure but his eye was still irritated and red. On follow-up the reporter was unable to provide additional information on how the patient was doing. No further information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

Because the PCP number and product name are unknown, there is a possibility that this is a generic product, not registered to Syngenta Canada Inc.