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Incident Report

Subform I: General Information

1. Report Type.

Update the report

Incident Report Number: 2022-3380

2. Registrant Information.

Registrant Reference Number: 2022-11

Registrant Name (Full Legal Name no abbreviations): BASF Canada Inc.

Address: 5025 Creekbank Road, Building A, 2nd Floor

City: Mississauga

Prov / State: Ontario

Country: Canada

Postal Code: L4W 0B6

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

Human

Domestic Animal

4. Date registrant was first informed of the incident.

25-MAY-22

5. Location of incident.

Country: UNITED STATES

Prov / State: ALABAMA

6. Date incident was first observed.

23-MAY-22

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)

PMRA Registration No. PMRA Submission No. EPA Registration No. 7969-448

Product Name: LIBERTY 280 SL HERBICIDE

Active Ingredient(s)
- GLUFOSINATE AMMONIUM
  - Guarantee/concentration 24.5 %

7. b) Type of formulation.

Liquid

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: Cotton

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

A neighbouring farm sprayed this product on their cotton field on May 16, 2022 in windy conditions.

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: Unknown

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

Respiratory System
- Symptom - Pneumonia

General
- Symptom - Death

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.

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.)

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Bird - Poultry / Oiseau - Volaille

3. Breed

Blue Face Hatch Bauman

4. Number of animals affected

5. Sex

Male

6. Age (provide a range if necessary )

7. Weight (provide a range if necessary )

lbs

8. Route(s) of exposure

Unknown

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>3 days <=1 wk / >3 jours <=1 sem

11. List all symptoms

System

General
- Symptom - Death

12. How long did the symptoms last?

Unknown / Inconnu

13. Was medical treatment provided? Provide details in question 17.

14. a) Was the animal hospitalized?

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Died

16. How was the animal exposed?

Spray drift / Dérive de pulvérisation

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

The Animal's owner said the chicken was not showing any abnormal behavior prior to finding him passed away.

To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Death

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Incident Report

Subform I: General Information

1. Report Type.

2. Registrant Information.

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

4. Date registrant was first informed of the incident.

5. Location of incident.

6. Date incident was first observed.

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.

7. b) Type of formulation.

Application Information

8. Product was applied?

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?

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

2. Demographic information of data subject

3. List all symptoms, using the selections below.

4. How long did the symptoms last?

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

6. a) Was the person hospitalized?

6. b) For how long?

7. Exposure scenario

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)

10. Route(s) of exposure.

11. What was the length of exposure?

12. Time between exposure and onset of symptoms.

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.)

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.

Subform III: Domestic Animal Incident Report

1. Source of Report

2. Type of animal affected

3. Breed

4. Number of animals affected

5. Sex

6. Age (provide a range if necessary )

7. Weight (provide a range if necessary )

8. Route(s) of exposure

9. What was the length of exposure?

10. Time between exposure and onset of symptoms

11. List all symptoms

12. How long did the symptoms last?

13. Was medical treatment provided? Provide details in question 17.

14. a) Was the animal hospitalized?

14. b) How long was the animal hospitalized?

15. Outcome of the incident

16. How was the animal exposed?

17. Provide any additional details about the incident

To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

19. Provide supplemental information here