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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2017-5790

2. Registrant Information.

Registrant Reference Number: ProPharma Group case #: 1-49853313

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.

26-SEP-17

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

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.

Active(s)

PMRA Registration No. 26980      PMRA Submission No.       EPA Registration No.

Product Name: VANQUISH HERBICIDE

  • Active Ingredient(s)
    • DICAMBA (PRESENT AS ACID, AMINE SALT, ESTER, OR SODIUM SALT)

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. - Out Home / Rés - à l'ext.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.

Data Subject

2. Demographic information of data subject

Sex: Female

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

3. List all symptoms, using the selections below.

System

  • Respiratory System
    • Symptom - Irritated nose
  • Skin
    • Symptom - Pruritus
  • Eye
    • Symptom - Irritated eye
  • Respiratory System
    • Symptom - Respiratory pain
  • Nervous and Muscular Systems
    • Symptom - Trembling
  • General
    • Symptom - Fatigue
  • Respiratory System
    • Symptom - Difficulty Breathing
  • Gastrointestinal System
    • Symptom - Nausea
    • Symptom - Stomach cramps
  • Nervous and Muscular Systems
    • Symptom - Dizziness
  • Eye
    • Symptom - Discharge eye
  • Ear
    • Symptom - Earache
  • Respiratory System
    • Symptom - Sinus pain
  • Gastrointestinal System
    • Symptom - Sore throat

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

Unknown

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.

Respiratory

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.)

1-49853313 - The reporter indicates an exposure to a pesticide containing the active ingredient dicamba (present as acid, amine salt, ester, or sodium salt). Six days before the day of initial contact with the registrant, the reporter indicated the product was sprayed outside her home. An unknown amount of time later, the reporter indicated she developed sinus pain, irritated nose, respiratory pain, difficulty breathing, pruritus, irritated eyes, discharge from the eyes, trembling, dizziness, fatigue, nausea, stomach cramps, sore throat, and earache all of which were occurring at the time of initial contact. The reporter indicated that she had not yet cleaned or ventilated the home. The reporter was advised to seek immediate medical attention, and also ventilate and clean the home. The reporter was told that the severity and persistence of the symptoms would not be expected. No additional information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.