Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-1746

2. Registrant Information.

Registrant Reference Number: Case 5435847 Rocky Mountain Poison and Drug Center

Registrant Name (Full Legal Name no abbreviations): Agrium Advanced Technologies

Address: 10 Craig St.

City: Brantford

Prov / State: ON

Country: CANADA

Postal Code: N3R 7J1

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

Human

4. Date registrant was first informed of the incident.

30-APR-15

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

09-APR-15

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. 19480      PMRA Submission No.       EPA Registration No.

Product Name: PRO BORADUST INSECTICIDE DUST

• Active Ingredient(s)
  • BORACIC ACID (BORIC ACID)

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PMRA Registration No. 24190      PMRA Submission No.       EPA Registration No.

Product Name: PRO BUG-X RESIDUAL INSECT SPRAY

• Active Ingredient(s)
  • PROPOXUR

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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: Female

Age: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

• Eye
  • Symptom - Other
  • Specify - unknown vision changes

• Gastrointestinal System
  • Symptom - Nausea
  • Symptom - Vomiting

• Respiratory System
  • Symptom - Shortness of breath

• 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.

Unknown

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.

Unknown

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>2 mos <=6 mos / > 2 mois < = 6 mois

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.)

Patient 1 Exposure Information Exposure Site: Residence Reason Detail: Contaminated Environment UEUnintentional Environmental Occupational: No Acuity: Chronic Product Name: Boradust Time Of Exposure: Months ago Route: Unknown Duration: Unknown Patient 1 Clinical Effects Effects Present: Miscellaneous Other Unknown vision changes Relatedness: Not related Onset: Unknown Effects Present: Gastrointestinal Nausea Relatedness: Not related Onset: Unknown Effects Present: Gastrointestinal Vomiting Relatedness: Not related Onset: Unknown Effects Present: Respiratory Short of breath Relatedness: Not related Onset: Unknown Effects Present: Neurological Dizzyvertigo near syncope Relatedness: Not related Onset: Unknown Patient 1 Management Information Type: OnSiteNonHCF Result: Caller encouraged to call with any questions, concerns or additional symptoms SubType: Residence Patient 1 Therapy Information Patient 1 Outcome Medical Outcome: Unrelated Effect Effect Duration: Industry Outcome: Moderate Industry Duration: Unknown Causation: Not Related EPA Code: HC

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

There are detailed notes taken from (name) CENTRE shown on the enclosed report, there are too many words to fit in this box.