Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-2415

2. Registrant Information.

Registrant Reference Number: Case 5454416 Rocky Mountain Poison and Drug Center

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

Address: 10 Craig St

City: BRANTFORD

Prov / State: ONTARIO

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.

10-JUN-15

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

18-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. 16282      PMRA Submission No.       EPA Registration No.

Product Name: Pro Aerosol Insecticide

• Active Ingredient(s)
  • PIPERONYL BUTOXIDE
  • PYRETHRINS

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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

• Respiratory System
  • Symptom - Shortness of breath

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

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.

Respiratory

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.)

Exposure InformationExposure Site: ResidenceReason Detail: Handlingtransfermixing UGUnintentionalGeneralOccupational: NoAcuity: AcuteProduct Name: Pro Aerosol InsecticideTime Of Exposure: 2.00 Days ago Route: InhalationnasalExposure Duration: Brief Inhaled: MistPatient 1 Clinical EffectsEffects Present: Respiratory Shortof breath Relatedness: RelatedOnset: 2.00 Days agoPatient 1 Management InformationType: OnSiteNonHCFResult: Caller encouraged to call with anyquestions, concerns or additionalsymptomsSubType:ResidencePatient 1 Therapy InformationTherapy Type: Fresh air Recommendation: PerformedPatient 1 OutcomeMedical Outcome: Minor Effect Duration: 24 hours, = 3 daysIndustry Outcome: Minor Industry Duration: 24 hours, = 3 daysCausation: Related EPA Code: HD

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

05/18/15 18:37S.Caller states he was spraying some Pro Aerosol Insecticide 2 days ago and he breathed some of the mist. C/O shortness ofbreath that is resolved.GHNKDANo medsCaller: Calvin youngPatient Name:(name) Age: Years Gender:MaleO.Shortness of breathSymptoms: Short of breathA.Acute adult inhalation, symptomatic.Exposure: Pro Aerosol InsecticideR.Reviewed with caller potential for nasal, respiratory irritation. If develops persistent cough or fever will need medicalevaluation. Caller to call if further concerns or questions. CC/TETherapies: Fresh air(Performed)