Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2016-5415

2. Registrant Information.

Registrant Reference Number: ProPharma Group case #: 1-45308691

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.

20-AUG-16

5. Location of incident.

Country: CANADA

Prov / State: NOVA SCOTIA

6. Date incident was first observed.

30-JUL-16

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. 29341      PMRA Submission No.       EPA Registration No.

Product Name: HALEX GT HERBICIDE

• Active Ingredient(s)
  • GLYPHOSATE (PRESENT AS POTASSIUM SALT)
  • MESOTRIONE
  • S-METOLACHLOR AND R-ENANTIOMER

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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.

Data Subject

2. Demographic information of data subject

Sex: Male

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

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Paresthesia

4. How long did the symptoms last?

>1 wk <=1 mo / > 1 sem < = 1 mois

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)

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.

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

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.)

1-45308691 - The reporter indicates an exposure to an herbicide containing the active ingredients mesotrione, glyphosate (present as potassium salt), and S-metolachlor and R-enantiomer. Approximately one month before initial contact with the registrant, the reporter indicated he was using the diluted product and may have gotten some of it on his hands, one of which had a cut. The reporter washed his hands soon after the exposure. For a three-week period right before initial contact with the registrant, the reporter indicated he had a constant burning and tingling sensation all over his body. He sought medical evaluation at an unknown time, but no diagnosis was given. The reporter was advised that the product may cause skin irritation which should resolve quickly after irrigation. The reporters symptoms would not be expected and he was encouraged to continue to work with his doctors. No additional information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.