Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2017-2845

2. Registrant Information.

Registrant Reference Number: ProPharma Group case #: 1-48211258

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.

14-MAY-17

5. Location of incident.

Country: CANADA

Prov / State: MANITOBA

6. Date incident was first observed.

13-MAY-17

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. 26153      PMRA Submission No.       EPA Registration No.

Product Name: QUADRIS FLOWABLE FUNGICIDE

• Active Ingredient(s)
  • AZOXYSTROBIN

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PMRA Registration No. 31981      PMRA Submission No.       EPA Registration No.

Product Name: APROVIA FUNGICIDE

• Active Ingredient(s)
  • BENZOVINDIFLUPYR

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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 - Respiratory irritation

• Nervous and Muscular Systems
  • Symptom - Dizziness
  • Symptom - Headache

• Respiratory System
  • Symptom - Nose bleed

• Gastrointestinal System
  • Symptom - Difficulty swallowing

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?

Yes

6. b) For how long?

1

Day(s) / Jour(s)

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.

Respiratory

11. What was the length of exposure?

<=15 min / <=15 min

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.)

1-48211258 - The reporter, a nurse, indicates an exposure to two pesticides containing the active ingredients azoxystrobin and benzovindiflupyr. An unknown number of days before the day of initial contact with the registrant, the reporter indicated the patient was preparing the two separate products in two separate containers with no more than 15 minutes of contact time with the fumes. There was no aerosolized particles or physical contact with either of the products. The evening before the day of initial contact with the registrant, the patient presented to the emergency room with respiratory irritation, difficulty swallowing, dizziness, headache and a bloody nose. At the time of initial contact, the patients symptoms were mild. The reporter was advised that the symptoms would not be expected from the described exposure. On follow-up one day later, the reporter indicated the patient had been discharged and no update was available. On follow-up with the patient five days after the day of initial contact, he indicated only some mild respiratory irritation remained. No additional information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.