Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-3677

2. Registrant Information.

Registrant Reference Number: PROSAR case #: 1-41439968

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.

31-JUL-15

5. Location of incident.

Country: UNITED STATES

Prov / State: NORTH CAROLINA

6. Date incident was first observed.

09-JUN-15

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. Unknown

Product Name: Unknown

• Active Ingredient(s)
  • PARAQUAT
    • Unknown

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7. b) Type of formulation.

Liquid

Application Information

8. Product was applied?

No

9. Application Rate.

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

Site: Unknown / Inconnu

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.

Medical Professional

2. Demographic information of data subject

Sex: Male

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Shortness of breath
  • Symptom - Pneumonia
  • Specify - "community acquired pneumonia"

• Renal System
  • Symptom - Creatinine increased

• Blood
  • Symptom - Hypernatremia

• Renal System
  • Symptom - Other
  • Specify - GFR - 23

• Respiratory System
  • Symptom - Acute respiratory distress syndrome

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?

Yes

6. b) For how long?

Unknown

7. Exposure scenario

Unknown

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

Poisoning from ingestion of the pesticide

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.

Oral

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.)

1-41439968 - The reporter, a doctor, indicated that a patient may have been exposed to an herbicide containing the active ingredient paraquat. The reporter was not able to provide an EPA registration number for the product. He indicated that the name of the product was Three times dead. This name does not match any of the registrant products but the name is not a match for any other companys products either. Per the reporter the patients estranged girlfriend may have added this product to some V8 juice that the patient drank 52 days prior to initial contact with the registrant. The patient also chronically takes methamphetamines. The patient was initially treated at another hospital. Forty-one days after the exposure the patient presented to the callers hospital because of shortness of breath. The patient was diagnosed with community acquired pneumonia. The reporter believes this pneumonia was acquired at another hospital. The patient was put on antibiotics but the patient s symptoms worsened over the next four days and he was finally intubated. The patient was initially on IV fluids but he became hypernatremic so, the fluids were discontinued and he was just being given water through tube feedings. Initial blood work showed an elevation in creatinine (2.9) with a glomerular filtration rate of 23 but at the time of the call creatinine was down to 1.2. The reporter was advised that the delayed onset of the patients symptoms is not consistent with ingestion of the product. On follow-up call, three days later, the reporter indicated that the patient is still being treated for community pneumonia and ARDS and he is doing about the same. The reporter further stated that there was no evidence of pulmonary fibrosis and he did not believe symptoms were due to exposure to paraquat. No additional information is available.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.