Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-2362

2. Registrant Information.

Registrant Reference Number: PROSAR case #: 1-40576016

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.

13-MAY-15

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

13-MAY-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. 27363      PMRA Submission No.       EPA Registration No.

Product Name: Dual Magnum

• Active Ingredient(s)
  • S-METOLACHLOR AND R-ENANTIOMER

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PMRA Registration No. 27362      PMRA Submission No.       EPA Registration No.

Product Name: Sencor DF (A COMPONENT OF THE BOUNDARY HERBICIDE TANK-MIX)

• Active Ingredient(s)
  • METRIBUZIN

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7. b) Type of formulation.

Application Information

8. Product was applied?

No

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.

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

• Eye
  • Symptom - Irritated eye

4. How long did the symptoms last?

<=30 min / <=30 min

5. Was medical treatment provided? Provide details in question 13.

No

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Occupational

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

Other

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?

<=15 min / <=15 min

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.)

1-40576016 - The reporter indicated that his co-worker was exposed to an herbicide mixture containing the active ingredient s-metolachlor and metribuzin. The reporter indicated that about 15 minutes prior to initial contact with the registrant his co-worker accidentally splashed some of the concentrated product into his eye. It stung right after the exposure but then started feeling better as the patient was rinsing the eye with water. On follow-up call, one day later, the reporter indicated that the ocular irritation lasted for about 30 minutes and then resolved. No medical attention was needed. No additional information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.