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)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 100-1074

Product Name: GRAMOXONE MAX HERBICIDE

• Active Ingredient(s)
  • PARAQUAT
    • Guarantee/concentration 43.8 %

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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.