Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2019-2251

2. Registrant Information.

Registrant Reference Number: ProPharma Group case #: 1-56515590

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.

09-MAY-19

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

09-MAY-19

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: Moddus

• Active Ingredient(s)
  • TRINEXAPAC-ETHYL

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7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

10. Site pesticide was applied to (select all that apply).

Site: Agricultural-Outdoor/Agricole-extérieur

Préciser le type: winter wheat

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

1-56515590 - The reporter indicated that the grower applied 28% nitrogen to the winter wheat crop prior to applying the Moddus.

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

• Nervous and Muscular Systems
  • Symptom - Headache

• Gastrointestinal System
  • Symptom - Sore throat

• General
  • Symptom - Malaise

4. How long did the symptoms last?

>8 hrs <=24 hrs / > 8 h < = 24 h

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

Non-occupational

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

Contact with treated area

What was the activity? Running by treated field

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

Unknown

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.)

1-56515590 - The reporter, a sales representative, indicates an exposure to a pesticide containing the active ingredient trinexapac-ethyl. On the day of initial contact with the registrant, the reporter indicated the patient had gone for a run by a field where the product had been applied and soon afterwards developed a headache, sore throat and malaise. The patient was advised the symptoms were not expected from the described exposure, but to seek medical attention should the symptoms persist. On follow-up call later in the day on the day of initial contact the patient was not available. Three days after the day of initial contact, the patient contacted the reporter to say his symptoms had resolved the next morning after the day of exposure.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.