Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2016-5456
2. Registrant Information.
Registrant Reference Number: ProPharma Group case #: 1-45137522
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.
05-AUG-16
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
05-AUG-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)
PMRA Registration No. 27428
PMRA Submission No.
EPA Registration No.
Product Name: Demand CS Insecticide
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: >1 <=6 yrs / > 1 < = 6 ans
3. List all symptoms, using the selections below.
System
4. How long did the symptoms last?
Unknown / Inconnu
5. Was medical treatment provided? Provide details in question 13.
Unknown
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 9
Hour(s) / Heure(s)
What was the activity? Re-entry into living area after application.
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.
Unknown
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.)
1-45137522 - The reporter indicated that her child may have been exposed to a pesticide with the active ingredient Lambda-cyhalothrin. Two days before initial contact with the registrant, the reporter indicated her home interior had been sprayed with the diluted product, and the registrant and her daughter did not re-enter the home until 9 hours after application. On the morning of the day of initial contact with the registrant, the reporter indicated her 3.5-year-old daughter had developed diarrhea and a low-grade fever. The reporter was advised that re-entry into the home after the product is dry is not expected to cause any side effects, and her daughters specific side effects would be unusual for an exposure to the product. The reporter was advised if the symptoms persisted medical attention should be sought. No additional information is available.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.