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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-2965
2. Registrant Information.
Registrant Reference Number: PROSAR case #: 1-40979553
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.
19-JUN-155. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
19-JUN-15Product 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. 30862 PMRA Submission No. EPA Registration No.
Product Name: Altriset Termiticide
- Active Ingredient(s)
- CHLORANTRANILIPROLE
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: Res. - In Home / Rés. - à l'int. maison
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: Female
Age: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Skin
- Symptom - Rash
- Symptom - Hives
- Eye
- Symptom - Swollen eye
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
Non-occupational
8. How did exposure occur? (Select all that apply)
Contact with treated area
Amount of time between application and contact 1
Day(s) / Jour(s)
What was the activity? sleeping and daily activities in her home
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?
Unknown / Inconnu
12. Time between exposure and onset of symptoms.
>8 hrs <=24 hrs / > 8 h < = 24 h
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.)
1-40979553 - The reporter, a pest control operator, indicated that a customer was exposed to an insecticide containing the active ingredient chlorantranilprole. The reporter stated that her company applied the product in the customers home one day prior to initial contact with the registrant. Per the reporter her company strictly follows the label directions and they do not allow the customer to enter the home during spraying but the reporter is unsure how soon after the spraying was complete the customer went back in the home. The customer called the reporter on the morning of initial contact and indicated that she woke up with a rash, hives and swollen eyes. The customer believed her symptoms were from exposure to product vapors, no dermal contact was noted. The reporter was advised that there are numerous possible causes for an allergic reaction and medical attention was recommended due to the severity of the described symptoms. On follow-up call, six days later, the patient's spouse indicated that his wife had started a new medication and the doctor thought her reaction was due to use of this medication. No additional information is available.
To be determined by Registrant
14. Severity classification.
Minor
