Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2017-5126
2. Registrant Information.
Registrant Reference Number: ProPharma Group case #: 1-49196501
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.
02-AUG-17
5. Location of incident.
Country: UNITED STATES
Prov / State: CALIFORNIA
6. Date incident was first observed.
02-AUG-17
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. 100-1074
Product Name: GRAMOXONE MAX HERBICIDE
- Active Ingredient(s)
- PARAQUAT
- Guarantee/concentration 43.8 %
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).
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: Unknown / Inconnu
3. List all symptoms, using the selections below.
System
- Nervous and Muscular Systems
- Symptom - Unconsciousness
- Skin
- Symptom - Lesion
- Specify - laceration
- Nervous and Muscular Systems
- Symptom - Memory loss
- Symptom - Other
- Specify - Traumatic brain injury
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
Occupational
8. How did exposure occur? (Select all that apply)
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.
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.)
1-49196501 - The reporter, a paramedic, indicates an exposure to a pesticide containing the active ingredient paraquat. On the day of initial contact with the registrant, the reporter indicated he was called to an accident scene where a farm worker was found unconscious in a puddle of the product which was the result of a vehicle rear-ending the tractor the farm worker was driving. The reporter did not know if the product was diluted or full strength. The farm worker had a laceration on his head, had no recollection of what happened, and a traumatic brain injury. The farm worker had been transported to a hospital and decontaminated, but no further information was available on his condition. The reporter indicated the doctor who was treating the farm worker was familiar with the product and did not need any further assistance. Follow-up calls were attempted on the first, second and third days after the day of initial contact and messages were left, but none were ever returned. No additional information is available.
To be determined by Registrant
14. Severity classification.
Major
15. Provide supplemental information here.
Note that the traumatic brain injury was a result of the vehicle rear-ending the tractor, not a result of exposure to the product.