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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-5186
2. Registrant Information.
Registrant Reference Number: PROSAR case #: 1-41702977
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.
26-AUG-15
5. Location of incident.
Country: CANADA
Prov / State: ALBERTA
6. Date incident was first observed.
25-AUG-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: Gramaxone
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: 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.
Data Subject
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 - Itchy skin
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
Unknown
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.
>30 min <=2 hrs / >30 min <=2 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.)
1-41702977 - The reporter indicated that she had been exposed to an herbicide containing the active ingredient paraquat. The reporter applied the diluted product (Per the reporter the product was diluted according to directions.) one day prior to initial contact with the registrant. The reporter was wearing full personnel protective equipment during application but about one hour after she finished applying the product she developed a rash on her neck. On the morning of initial contact the rash had spread from her neck to her face. She went to her doctor who treated her for both an allergic reaction and skin irritation and started her on Flamazine cream, bactroban and Reactine. The reporter could not be reached on routine follow-up attempts. No additional information is available.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.