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Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2017-1871

2. Registrant Information.

Registrant Reference Number: ProPharma Group case #: 1-47469230

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.

5. Location of incident.

Country: UNITED STATES

Prov / State: NORTH CAROLINA

6. Date incident was first observed.

Unknown

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.

PMRA Registration No.       PMRA Submission No.       EPA Registration No. 100-1324

Product Name: QUILT XCEL

• Active Ingredient(s)
  • AZOXYSTROBIN
    • Guarantee/concentration 13.5 %
  • PROPICONAZOLE
    • Guarantee/concentration 11.7 %

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: Agricultural-Outdoor/Agricole-extérieur

Préciser le type: Unknown

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: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• General
  • Symptom - Other
  • Specify - Hydrocephalus

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)

Drift from the application site

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.

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.)

1-47469230 - The reporter, a scientist, indicates an exposure to a pesticide containing the active ingredients azoxystrobin and propiconazole. Approximately three weeks before the day of initial contact with the registrant, the reporter indicated they were approached by a person who indicated her granddaughter of unknown age was exposed to the product at an unknown time within the last two years. The child was diagnosed with hydrocephalus after an aerial application of the product occurred in a field adjacent to the childs home. No follow-up was attempted. No additional information is available.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.