Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2022-6338

2. Registrant Information.

Registrant Reference Number: 2022072502

Registrant Name (Full Legal Name no abbreviations): UPL AgrosolutionsCanada, Inc.

Address: 630 Freedom Business Center, Suite 402

City: King of Prussia

Prov / State: Pennsylvania

Country: United States

Postal Code: 19406

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

Human

4. Date registrant was first informed of the incident.

01-NOV-22

5. Location of incident.

Country: CANADA

Prov / State: MANITOBA

6. Date incident was first observed.

25-JUL-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)

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PMRA Registration No. 28217      PMRA Submission No.       EPA Registration No.

Product Name: Manzate ProStick

• Active Ingredient(s)
  • MANCOZEB

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7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

22

Other Units: acres per 20kg bag

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

Site: Agricultural-Outdoor/Agricole-extérieur

Préciser le type: potatoes

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.

Data Subject

2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Rash

4. How long did the symptoms last?

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

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

Yes

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Occupational

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

Application

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.

Skin

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>24 hrs <=3 days / >24 h <=3 jours

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.)

Mixer loader person broke out in a skin rash after being exposed to Manzate Prostick while mixer and loading the product. Went to doctor.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

Symptoms resolved after 1 week