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Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2022-3934

2. Registrant Information.

Registrant Reference Number: NUA

Registrant Name (Full Legal Name no abbreviations): Nufarm Agriculture Inc.

Address: 5101, 333 96th Ave NE

City: Calgary

Prov / State: AB

Country: Canada

Postal Code: T3K 0S3

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

Human

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

Unknown

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.

PMRA Registration No. 32111      PMRA Submission No.       EPA Registration No.

Product Name: BlackHawk Herbicide

• Active Ingredient(s)
  • 2,4-D (PRESENT AS LOW VOLATILE ESTERS)
  • PYRAFLUFEN-ETHYL

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.

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
  • Symptom - Numbness

• General
  • Symptom - Sweating
  • Symptom - Chills
  • Symptom - Swelling
  • Specify - Swollen Lymph Nodes

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?

Unknown

6. b) For how long?

7. Exposure scenario

Occupational

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

Pesticide Spill

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

Long pants

10. Route(s) of exposure.

Skin

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.)

A secondhand report of a spill of BlackHawk concentrate on an applicator's pant leg and prolonged exposure with insufficient ppe as directed by the label (according to the report) allegedly resulted in poisoning symptoms. The incident allegedly occurred at some point in 2021, a Nufarm representative was informed not by the data subject, but an individual who was told of the incident.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.